CMS Conditions of Participation

Governing Body and Medical Staff Responsibilities Under Medicare

Conditions of Participation

Feb. 27, 2024, 12 - 1:30 p.m.


This session will provide an overview of the regulatory requirements for the provision of surgical and anesthesia services in hospitals and critical access hospitals.

Learning Objectives

  • Describe governing-board responsibilities and specific responsibilities for patient rights, quality improvement and medical staff credentialing.
  • Describe minimum requirements for medical staff bylaws, rules and regulations and governing body oversight.
  • Explain the differences in medical staff credentialing regulations for telemedicine providers and onsite providers.
  • Describe hospital responsibilities for credentialing nonphysician staff in the hospital.¬†

Recommend to attend

This program is intended for all hospitals and health systems including general acute hospitals, critical access hospitals, and anyone involved with compliance regulations and standards, including but not limited to surgical nursing directors, perioperative nursing staff, post operative nursing staff, anesthesia providers, chief executive officers, chief medical officers, chief nursing officers, quality improvement staff, risk managers, compliance officers and legal counsel, regulatory readiness liaisons, safety officers, department directors, and other interested staff.

Continuing Education

This program has been designed to meet the Minnesota Board of Nursing continuing education requirements for a total of 1.5 contact hours.

Nursing Home Administrators: The content of this conference is being reviewed by the Board of Examiners for Nursing Home Administrators for clock hours. The quantitative value assigned will be indicated on the certificate of attendance awarded to participants who attend sessions. 


  • $60 for MHA member hospital and health systems
  • $60 for MHA associate members
  • $75 per person for nonmembers¬†

Registration deadline

Please register by noon on the day before the webinar to ensure timely delivery of access instructions.

If you have any questions, please reach out to

Log In to Register
When and Where
  • 2/27/2024 12:00 PM CST
  • 2/27/2024 1:30 PM CST
  • Zoom Webinar