Protocols, Standing Orders, Order Sets, and Preprinted Orders: Cracking the Code to the CMS Hospital CoP and TJC Requirements

Product Id : HE173
Instructor : Sue Dill Calloway
Oct 23, 2019 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

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Are you aware of the requirements on standing orders promulgated by CMS that all hospitals must follow? This will also cover the Joint Commission standards on standing orders and protocols. Did you know there are four separate CMS hospital condition of participation sections that hospitals must be aware of? This program will cover the interpretive guidelines and regulations required by the Center for Medicare and Medicaid Services (CMS) related to Order Sets, Protocols, Preprinted Orders, and Standing Orders.

This has been a very confusing area for hospitals and this program will demystify the requirements. Any hospital that accepts Medicare or Medicaid patients must be in compliance with these standards and for all patients. This area has generated a large number of questions.

CMS created a tag number to house the major section regarding standing order requirements in the medical record chapter under Tag 457. There are a total of four separate sections in the hospital CoP manual that regulate this issue. This has been confusing for hospitals because two of the sections did not link to the other requirements in the CMS manual. CMS also moved most of the standing order requirements from tag 405 into the new section on tag 457. Standing orders must address well defined clinical scenarios. Standing orders related to medications must be approved by the Medical staff and nursing and pharmacy leadership. There are many required radiology protocols and policies and these will be discussed.

The development of protocols and standing orders is best described as a journey. This program will provide the history of each of the four sections and what each section requires hospitals to do. This program will clarify this confusing area and make the requirements understandable for hospitals. This is especially important as hospitals move toward a complete electronic medical record. It is important that any order in the electronic medical record populate the entire order in the order section.

Learning Objectives:

  • Recall that hospitals must comply with the CMS CoP requirements if they accept Medicare or Medicaid reimbursement
  • Discuss that CMS has requirements for standing orders and protocols in four separate sections 
  • Describe that all protocols must be approved by the Medical Staff even if the protocols are department specific
  • Recall that the physician must sign off the standing order along with a date and time

Who Should Attend?

  • CEO and COO
  • Chief Nursing Officer, Staff Nurses, Nurse Managers, Nurse Supervisors
  • Chief Risk Officer
  • Chief Medical Officer
  • Hospital legal counsel
  • Radiology Director
  • Compliance and Regulatory Officer
  • Joint Commission liaison
  • Pharmacy Director and Pharmacist
  • Patient Safety Officer
  • Anesthesia Director and Anesthesiologist
  • Policy and Procedure Committee Members    
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

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