Part 1: The Value Gain of Medical Staff Integration - CMS Compliance for Multi-Hospital Systems

In our symplr education webcast series, we’ve spoken to Rick Curtis, CEO of The Center for Improvement in Health Quality (CIHQ), who is a nationally recognized expert on the CoP (Conditions of Participation) and the Centers for Medicare & Medicaid Services (CMS) Certification and Survey Process. He recently spoke with us about the Medicare CoP and the new allowance for hospital systems to have a single organized, integrated medical staff.

We’ve organized Rick’s conversation into a two part blog series covering his main points. We start with the changes in allowance for medical staff integration and things to consider before restructuring.

Integrating the Medical Staff

The push to increase vertical hospital system integration is a movement that has been gaining momentum in recent years. It has brought more value into the quality of care received by patients, because it helps alleviate the high cost of investment in new technologies and facilities for leading practices and allows hospitals to diversify services.

The CoP for medical staff requires a single hospital staff for each hospital. Hospitals that belong to a health system have the option to integrate their medical staff amongst their entire network by following four main requirements for CMS compliance.

Four Main Medical Staff Requirements for CMS Compliance

  1. Staff majority vote = unified body
    The medical staff of each hospital within a network of hospitals must have a simple majority vote to become integrated into a unified body. The governing body of a hospital cannot force integration, and not all hospitals have to opt-in to have a unified medical staff with a network. For example, if 7 hospitals opt-in but 3 hospitals opt-out, then the 7 hospitals that opted-in will host the unified staff with the other 3 having their own separate staff.
  2. Unified by-laws
    There must be a process of integrating and unifying the by-laws of each hospital. It is important that governing bodies consider the special qualities of each hospital, as different hospitals may be fitted to serve unique communities.
  3. Defined departments, policies and procedures
    In addition to the by-laws, governing bodies must take into consideration the way individual hospitals organize and define their departments, established policies, and procedures.
  4. Notification system for raising concerns
    Governing bodies must have a mechanism in place that raises issues and concerns to the network’s board or leadership about network structures, policies, operations, and processes of the medical staff’s ability to meet local needs. This way, the unique needs of each hospital’s local populations and medical staff are addressed.

These four main requirements enable hospitals to operate while keeping the needs of their local communities in mind. These requirements were modified by the CMS and are what surveyors will be looking for, as well as any of other accrediting agencies (i.e. the CIHQ, The Joint Commission, DNV, URAC, or HFAP).

Since there are many unique configurations within a network of hospitals, CMS provides guidelines on how you can best structure things to make sure you are compliant. However, with older hospitals or networks who already practice staff integration, these structures may lead to inherent complications. To help smooth the structuring process, Rick talked through his 3 main areas of caution for integrating into a single medical staff.

Things to Consider When Structuring into a Single Medical Staff

  1. Payment Systems:
    Hospital systems that are paid through something other than the prospective payment system may jeopardize their payment status under Medicare when they go to integrate. If this is the case, those hospitals may have to avoid integration and maintain their own independent payment system in order to keep the network compliant.
  2. Integration Is Easier For Campuses:
    Hospitals with multiple campuses who are part of a health system may integrate all of their campuses in one motion. However, this only applies to hospitals with multiple campuses within a health system. Freestanding-Hospitals with interests in joining a health system may not integrate their medical staff in this way, regardless of system affiliation. They must go through the voting process.
  3. There Must Be Documentation:
    Hospitals that already have integrated medical staff prior to CMS initiating the requirements must go through the process of voting and documentation through a governing body. Although they may be integrated in practice, in order to be compliant with CMS, there must be a formal discussion, majority vote and documentation of opting-in.

Key Takeaway for Part 1:

While integration is ideal for modern hospital systems, acting in the interests of your local communities is key. CMS looks carefully into the quality of care provided to patients. If integration doesn’t enhance the quality of care, then it may not be a viable option. 

Coming Up Next!

The second part of our blog series will cover Rick’s expertise in by-law adjustments for networks and the process of creating a governing body over the unified medical staff.

For more information about CMS for Multi-Hospital Systems and Integrated Medical Staff Offices, listen to our symplr education series webcast with Rick Curtis. To learn more about simple and effective solutions for the credentialing process, schedule a Demo with symplr now!

MS for Multi-Hospital Systems & Integrated Medical Staff Offices


Melissa Outlaw

About the Author
Melissa Outlaw

Melissa Outlaw is a Vice President, Customer Success with symplr. Melissa and her team assist clients in learning and implementing our provider management software - credentialing, privileging, peer review, quality and event reporting applications. She supports clients in benchmarking current internal practices, identifying potential efficiencies, then driving the integration of technology with process improvement to reduce time of service and operating expenses. She works extensively with decentralized, multi-facility organizations in transitioning to a shared service center as well as assisting healthcare organizations bridge the gap between procedures performed by a provider and their privileges granted.

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