CMO Message: July 2026

Trust but verify

This phrase got thrown around a lot not only during my time in the Army, but also during my training as an ObGyn resident (Fun Fact! This Russian proverb, which rhymes in Russian, was popularized by former President Ronald Reagan during Cold War negotiations with the Soviet Union in the 1980s). From inspecting soldiers’ uniforms and weapons, to repeating key portions of the physical exam and testing the suction before surgery, a quick double check here or there has always served me well. Similarly, in High Reliability Organizations (HROs), Validate and Verify is a critical two-part thinking technique required before any high-risk task is started. It involves both an internal check and an external check with an independent, credible source.

For July, I would ask your partnership to validate and verify a few very important items:

1. Verification and Validation of Privileges: You will receive a very important email in the next few weeks asking you to verify your privileges. Please check and double check… ensure that your current privileges reflect the current scope of your practice. This is important for a few reasons:
   1. We need to confirm that your currently approved clinical privileges are correct
   2. We need you to attest that your current practice aligns with your privileges
   3. We want to address and correct any discrepancies
   4. Understand the significance of knowingly practicing out of scope – this is a compliance concern and may have financial implications for physicians and patients in terms of billing and reimbursement.
   5. State Laws and CMS Conditions of Participation (CoPs) mandate that a facility’s’ governing body “exclusively credential and grant privileges to qualified practitioners” and that “practitioners are working within the scope of those granted and documented privileges."

2. Annual Compliance Training is due August 21, 2026. This training can be accessed via HealthStream. Please be sure to complete your training before August 21!

3. Thank you! The past few weeks have been challenging in several areas, and I want to thank you for your patience and understanding. Thank you for your support and professionalism during our recent unannounced Joint Commission survey at St. Peter! TJC Accreditation is another way we validate and verify compliance with accepted standards. While we will have some additional follow-up and work to do, it was generally a successful survey thanks to you! 

4. I promise to come back with more Length of Stay/Opportunity Days updates next month😉… so stay tuned!