Meeting the direct consultation requirement in a multi-hospital system

Q: Our system has one governing board for a multi-hospital system and an advisory board at each hospital. Which board must meet the CMS requirement for "direct consultation" with the individual who is assigned the responsibility for the organization and conduct of the medical staff?

A: The primary responsibility rests with the governing board. However, the CMS guidance allows this responsibility to be delegated to a board committee. Under the circumstances you describe, your advisory board at each hospital is probably a better choice, given its ongoing interaction with the medical staff. But it would be important, if not required, that at least one member of the advisory board also serve on the governing board in order to satisfy the requirement of a "direct" communication between the board and each medical staff.

If this responsibility is being delegated by the governing body, I would recommend that an appropriate board resolution or similar record be made to reflect this decision and the basis for doing so.