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Medical Staff and Telemedicine: Meeting CMS Conditions of Participation and the Joint Commission Standards

By - Laura A. Dixon, BS, JD, RN, CPHRM

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Any hospital that accepts Medicare and Medicaid payments must comply with the regulations known as Conditions of Participation. The Centers for Medicare and Medicaid Services (CMS) hospital CoPs have sections on all aspects of patient care including medical staff and telemedicine.
The medical staff section includes information on credentialing and privileging requirements, implementing Medical Staff (MS) bylaws and rules and regulations, hospitals in systems.

The Governing Body and Medical Staff sections in the Manual will be discussed in relation to medical staff requirements and oversight. There will also be a concurrent discussion of TJC standards for medical staff.
Although telemedicine has been a factor in healthcare for many years, COVID-19 gave it a larger role in diagnosis and treatment of patients. Every hospital and critical access hospital that participate in or utilize telemedicine should ensure compliance.

The regulations cover the credentialing and privileging process for physicians and practitioners providing telemedicine services to another hospital. This revised process is less burdensome for hospitals, so CMS allows hospitals to credential such providers by proxy. Hospitals are required to have a written agreement that meets certain criteria. This webinar will briefly cover important provisions that should be considered in a telemedicine contract.


  • Recall that hospitals can have a separate medical staff or a unified shared integrated medical staff
  • Describe the requirements for a medical staff under CMS Conditions of Participation and TJC standards
  • Describe the requirement that hospitals must have a written telemedicine agreement specifying the responsibilities of the distant-site hospital and entities to meet the required credentialing requirements
  • Recall that Joint Commission has standards on telemedicine

Detailed Outline

  • Introduction to the Manual
  • Deficiencies – Medical Staff and Telemedicine
  • Overlap of Governing Board and Medical Staff sections
  • Appointment of individuals to the MS
  • Unified and integrated staff
  • Eligibility and appointment
  • Periodic appraisals
  • Credentialing
  • Organization and accountability
  • Hospital systems
  • Medical Staff bylaws
  • Medical staff duties
  • History & physicals
  • Advanced practice providers and H&Ps
  • Critical Access Hospitals Medical staff
  • Professional and ancillary staff
  • Review of professional services
  • Additional considerations for medical staff
  • TJC Standards for Medical Staff
  • Telemedicine introduction and definitions
  • Distant site telemedicine hospital
  • Distant site entity (DTSE)
  • Requirement for written agreement for Telemedicine
  • Telemedicine privileges based on medical staff recommendations
  • Credentialing by proxy
  • Agreements with Medicare certified hospitals
  • Agreements with telemedicine entities
  • Adverse events and notification
  • Periodic appraisals
  • Complaints received about the distant site physician
  • Joint Commission telemedicine standards
  • Suggested content for telemedicine agreements
  • Telemedicine resources
  • Appendix & Resources

Who Should Attend?

  • Chief Medical Officer
  • Medical Staff leader
  • Credentialing and Privileging Professionals
  • Physicians
  • Medical staff office staff and coordinator
  • Teleradiology Professionals
  • Chief Nursing Officer
  • Chief Operating Officer
  • Risk manager
  • Compliance officer – CMS and/or TJC/DNV
  • Patient safety officer
  • Nurse educator
  • Accreditation Director
  • Director of Regulatory Affairs
  • Telemedicine director
  • Anyone involved or in contracting for telemedicine services

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Speaker Detail

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

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