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Governing Board and C-Suite Responsibilities: CMS, TJC and DNV Requirements

March 15 @ 11:00 am - 12:00 pm MDT


The Centers for Medicare and Medicaid Services (CMS) has issued many citations related to the Governing Board and the C-Suite. This program will discuss the standards and responsibilities of the Governing Board and C-Suite members for hospitals under CMS Conditions of participation and hospitals accredited by The Joint Commission and DNV, which are closely cross-walked to the CMS CoPs.

The governing board of a hospital is responsible for operation and management of the hospital. Members of the C-suite are also involved with the operation of the hospital, as they are tasked with ensuring implementation and safe provision of care within the hospital.  All these sections have various responsibilities which are evaluated by CMS and the various accrediting organizations. 

This presentation will cover the requirements for the Governing Board and C-Suite of hospitals under the CMS Conditions of Participation and those accredited by the Joint Commission and DNV Healthcare.

  • Describe CMS, Joint Commission and DNV standards for Governing Board and management.
  • Explain that the Governing Board is responsible for operation of, and provision of care by the hospital.
  • Explain that C-Suite management is responsible to the Governing Board for implementation of policies and procedures and provision of safe care.
  • Recall that CMS requires that Board ensure all services, including contracted services, are reviewed as part of the QAPI process.
  • Governing Board members
  • C-Suite (CEO, CFO, CNO, CMO)
  • Director of Accreditation and Regulation
  • Hospital Attorneys
  • Risk Managers
  • Individuals responsible for contracted services
  • Quality improvement director
  • Department directors
  • Patient safety officer
  • Compliance officer
  • Joint Commission coordinator
  • Regulatory department directors

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.  Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.

Ms. Dixon’s legal experience includes medical malpractice defense and representation of nurses before the Colorado Board of Nursing. 

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa.  She is licensed to practice law in Colorado and California.

March 8; 5:00 p.m. MTN

Access instructions and materials will be emailed to the person completing the registration prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.


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IHA Member (0315tx)
$ 160.00


March 15
11:00 am - 12:00 pm MDT
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