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Hardenbergh Group

Webinar
Thought Leadership Series 2025

Navigating the New CMS Attestation Requirements

Wednesday, January 22, 2025
1-2pm Eastern Time

Effective in 2025, CMS has adopted the Patient Safety Structural Measure (PSSM) attestation requirements as a way to motivate hospital leaders to increase their investment and resources in their continuing efforts to improve patient care.

This session will present an overview of the new CMS Patient Safety Structural Measure, its five (5) Domains, and their associated Hospital Board attestation requirements.

The panelists will discuss the major pitfalls and gaps that organizations typically may experience when they audit their present situation and suggest concrete ways in which to achieve successful compliance with this new PSSM.

By attending this webinar, you will:

    1. Clearly identify the Five (5) domains of attestation that are required.
    2. Be able to identify at least one actionable item per domain.
    3. Identify how MSPs and Medical Staff leaders can communicate these requirements to Board Members.
    4. Gain an understanding of the role that Board Members, Medical Staff leaders, and MSPs must take in ensuring compliance with the new PSSM.

 

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Mark Smith, MD, MBA, FACS, CPHQ

Chief Medical Officer, The Hardenbergh Group

Dr. Smith brings 30 years of clinical practice and hospital management experiences to his work with physicians and hospitals across the United States. He is a Clinical Professor of Surgery (Voluntary) in the Vascular and Endovascular Surgery Section at the University of California, Irvine Medical Center. His area of interest is in treating patients with venous disorders.

Dr. Smith’s clinical practice as a surgeon and multiple roles in senior hospital administration make him uniquely qualified to assist clients develop solutions to their complex problems. He has expertise in system quality and performance improvement, peer review, ongoing and focused professional practice evaluation, management of deficient practitioner performance, criteria-based privileging, low volume practitioners, ED call and external focused review.

He is a fellow of the American College of Surgeons. He is a member of the American College of Healthcare Executives, the Society for Vascular Surgery, and the Southern California Vascular Surgical Society. He is serving on the Committee for Political Action of the Society of Vascular Surgery. He also holds a certification as a quality professional, CPHQ, from the NAHQ.

Dr. Smith is a graduate of Jefferson Medical College. He received his general surgery residency training at the University of Kansas Medical Center and had Cardiac and Vascular Surgery fellowships at the Hospital of the University of Pennsylvania. Dr. Smith holds an M.B.A. from the University of Phoenix.

Brock Bordelon, MD, FACS

Medical Director, The Hardenbergh Group

Dr. Bordelon is the Medical Director, Surgical Services, at Hardenbergh Group. He has practiced general and minimally invasive surgery in Colorado Springs since 1994, and has served as the Chief of Surgery, a member of the Medical Executive Committee, and the Citizenship Committee, among several other hospital medical staff functions.

Dr. Bordelon is certified by the American Board of Surgery and is a Fellow of the American College of Surgeons, the Society for Surgery of the Alimentary Tract, and the Society of American Gastrointestinal Endoscopic Surgeons, among other regional and national professional societies.

He attended the University of Texas Southwestern Medical School, followed by a general surgery residency at the University of Utah School of Medicine. While in Salt Lake City, he completed a fellowship in minimally invasive surgery.

Dr. Bordelon was a member of the Colorado Medical Board for four years and served as the chair of one of the board’s inquiry panels.

Michael R. Callahan, JD

Senior Consultant, The Hardenbergh Group

Michael R. Callahan brings an unparalleled level of healthcare consulting experience. Formerly a healthcare attorney for over 40 years, he provides consultative services, educational programs and thought leadership in his role as Senior Consultant. His areas of focus include hospital/physician relations, medical staff bylaws and policies, peer review policies and investigations, privileging and credentialing issues, National Practitioner Data Bank guidelines and reporting standards, EMTALA standards, accreditation compliance, medical staff integration and hospital/medical staff disputes.

In addition, he is recognized as a national expert involving all aspects of the federal Patient Safety and Quality Improvement Act of 2005.

Maggie Palmer, MHA, CPCS, CPMSM

Maggie Palmer is a healthcare administration professional with over 25 years of experience in medical staff professional services, and numerous other administrative areas of healthcare. Maggie is currently the Vice President, Medical Staff Professional Services & Regulatory Affairs at Parkland Health in Dallas, Texas. She is the President Elect for Texas Society of Medical Service Specialists (TSMSS).

Maggie holds a Master’s degree in Healthcare Administration from Central Michigan University.  She is dual certified through the National Association Medical Staff Services (NAMSS) since 2000.