February 2021 Grand Rounds —
Forming A Unified Medical Staff – Process to Follow and Key Factors to Consider

February 2, 2021 - 1:00 pm to 2:00 pm (ET)


Susan Lapenta and Lauren Massucci

In 2012, the Centers for Medicare & Medicaid Services (“CMS”) took the position that while it was permissible for a multi-hospital system to have a single Governing Board, each hospital that was separately certified by Medicare had to have its own Medical Staff.  Fortunately, in 2014, CMS reversed its position and revised the Medicare Conditions of Participation to allow hospitals that are part of the same system and have the same Governing Board, to have a “unified and integrated” Medical Staff.  CMS has a number of procedural requirements that must be followed when establishing a unified medical staff as well as some ongoing requirements which must be satisfied once a unified medical staff has been established.  There are also a number of practical and operational issues that must be considered when structuring a unified medical staff such as:

      • How Medical Staff Officers are elected and whether there will be campus Medical Staff Officers as well.
      • Will departments be system-wide or will there be campus departments, or a mix of both.
      • Composition and duties of the System Medical Executive Committee.
      • Whether there will be campus Medical Executive Committees and how they will function.
      • Who has voting rights for campus issues and system issues.
      • Where Medical Staff members will fulfill their Medical Staff responsibilities such as on-call obligations.

Join Susan Lapenta and Lauren Massucci for this segment of HortySpringer’s 2021 Grand Rounds Audio Conference series in which they will walk you through CMS’ requirements for establishing and maintaining a unified Medical Staff and several of the key practical and operational issues that you need to consider when structuring a unified Medical Staff.

Learning Objectives

  1. Understanding CMS’ requirements for establishing and maintaining a unified Medical Staff.
  1. Understanding the key practical and operational issues that that should be considered when structuring a unified Medical Staff.

Education Credit

Instructions on how to obtain your Continuing Education certificate for audio conferences will be e-mailed to the contact person for your organization at the conclusion of this audio conference.

Category 1 CME

Joint Provider Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Pittsburgh School of Medicine and HortySpringer Seminars.  The University of Pittsburgh is an affirmative action, equal opportunity institution.  The University of Pittsburgh School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

The University of Pittsburgh School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

CEUs Credit

Other health care professionals are awarded 0.1 continuing education units (CEUs), which is equal to 1 contact hour.

NAMSS Continuing Education Credit

This course has been approved for National Association of Medical Staff Services (NAMSS) continuing education credit and NAMSS hereby awards 1.0 NAMSS continuing education credits for participation in this activity.  Accreditation of this educational content in no way implies endorsement or sponsorship by NAMSS.

HortySpringer Audio Conference Disclaimer


The information presented during an audio conference and any supplementary materials provided to registrants are intended for educational and informational purposes only. Nothing contained therein is to be considered as the rendering of legal advice for specific cases or circumstances.

No one should act or refrain from acting on the basis of any information presented during an audio conference without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer practicing as permitted by applicable laws, regulations or rules of professional conduct. No attorney-client relationship is formed by registration for an audio conference or the use of the supplementary materials.

About the Grand Rounds

The Grand Rounds 2021 Audio Conference Series consists of twelve audio conferences spread over the course of the year, with the goal of providing focused, manageable bites of education for Medical Staff leaders and those who support them.

  • Registration includes an MP3 containing the audio conference at no additional charge following each conference.
  • CME credit issued for live conference participation.
  • Register for the full series of 12 monthly audio conferences. Please contact us at 412-687-7677 or if you are interested in purchasing this series.

* Registration fee includes one phone line; you may add up to two additional lines to your order for $50 each line (per audio conference).

Designed for even the busiest hospital and medical staff leaders, registration for the year-long series is a quick and inexpensive way for Medical Staff Officers, members of the Medical Executive Committee, Department Chairs, Chairs of the Credentials and Peer Review Committees, and the Chairs of other key Medical Staff committees to have access to the most up-to-date health care information at their fingertips while obtaining valuable CME credits as well.


PLEASE NOTE: To help your staff and medical professionals adhere to social distancing guidelines, we will waive the extra line fee for up to 3 additional lines so others in your organization are able to safely listen from their home or office.

Audio Conferences/Grand Rounds Registration: $250 and includes:

      • 1 AMA PRA Category 1 Credit*
      • 1.0 NAMSS continuing education credit*
      • One MP3 recording to share with your staff throughout the year
      • Three phones lines. You may purchase additional lines for $50/line, per audio conference.

Can’t make the live audio conference? No problem! We offer single MP3 recordings for $250/audio conference.

*Not all audio conferences will be approved for continuing medical education credits.

Register Online