Making The Most Of Your Relationship With… Regulatory Bodies and Professional Associations

September 1, 2020 - 1:00 pm to 2:00 pm (ET)


Making The Most of Your Relationship With
Regulatory Bodies and Professional Associations

September 1, 2020


Rachel Remaley and Ian Donaldson


  • Do Medical Staff leaders need to comply with the CMS Conditions of Participation, accreditation standards (Joint Commission, DNV, HFAP, Commission on Cancer, ACE accreditation for PCI, etc.), the AMA Code of Ethics, or state hospital licensing laws when drafting Bylaws and conducting their affairs? Do those bodies have authority over the Medical Staff?
  • If the state has developed a standardized Medical Staff application form, must the Hospital and its Medical staff leaders utilize that form?
  • If the state medical association or state hospital association has adopted a “model” of Medical Staff Bylaws, must the Medical Staff leadership follow that “model” when drafting or revising Medical Staff Bylaws?
  • Should members of the medical association hold ex officio places on Medical Staff committees, to ensure that the Medical Staff’s affairs are informed by the medical association’s platform, information, and advocacy?
  • What role do Medical Staff leaders play in ensuring the Hospital satisfies its obligations under EMTALA to provide emergency on-call services by specialists?
  • Is the Hospital Board allowed to amend the Medical Staff Bylaws or other Medical Staff policies to comply with the laws governing hospitals if the Medical Staff does not – or will not – adopt the changes necessary for compliance with the law? For compliance with accreditation standards? To allow the Hospital to participate in quality measures or voluntary reimbursement programs? What process should be followed in these situations?
  • Are Medical Staff leaders required to use parliamentary procedures (Robert’s Rules of Order) when conducting meetings? Who sets the rules for how meetings are conducted, minutes are kept, notices are given, etc.?
  • Should Medical Staff leaders obtain education about regulatory and accreditation requirements affecting the Medical Staff’s functions? Who pays for that? Can the doctors obtain payment or CME for their time and efforts?

Learning Objectives

Upon completion of this audio conference, participants should be able to:

  1. Identify those regulatory and accreditation standards that the Medical Staff leadership must comply with, those it should comply with, and those that it may treat as advisory or ignore altogether.
  2. Articulate the Medical Staff’s role in working with the Hospital toward compliance with applicable laws and accreditation standards.

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 each 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 Grand Rounds

The Grand Rounds 2020 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.

This year’s series is focused on helping physician leaders utilize resources outside the Medical Staff in a manner that achieves the best results for patients and Medical Staff members.

  • Registration includes an MP3 containing the audio conference at no additional charge following each conference.
  • Register for the full series of 12 monthly audio conferences. Click here for more information.
  • CME credit issued for live conference participation.

* 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.


Registration for this audio conference (includes MP3):


Registration for the Grand Rounds 2020 Audio Conference Series:

Click here for more information

Mix and Match: 

$250/line* for participation in each 2020 Grand Rounds audio conference.

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