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

Session Overview

Unravel CMS Hospital Standing-Order Rules

Are you aware of the Centers for Medicare & Medicaid Services (CMS) requirements on standing orders that all hospitals must follow? Did you know that there are four separate CMS hospital Conditions of Participation (CoP) sections? If you aren’t fluent on these topics, you’re not alone: These have been confusing areas for hospitals and have generated a plethora of questions. Now you can get answers!

Join expert speaker Sue Dill Calloway, RN, MSN, JD as she gives you all the tools and knowledge you need to ensure your hospital is in compliance with CoP standards and the requirements related to standing orders. Learn the Joint Commission standards on standing orders and protocols, as well as the interpretive guidelines and regulations under CMS related to order sets, protocols, preprinted orders, and standing orders.

After attending this training session, you will have a solid understanding of CoPs and standing-order requirements. If your hospital accepts Medicare or Medicaid patients, you can’t afford NOT to be compliant with these standards — your payments are on the line!

Session Objectives

Here is a taste of what you will uncover:

• Learn the history behind the four CoP sections and the CMS requirements for standing orders and protocols.


• Understand why your medical staff must approve all protocols—even when the protocols are department-specific.


• How to implement a process for the physician to sign off on the standing order along with the date and time.


• Uncover the Joint Commission standards on standing orders and how they interact with CMS requirements.


• Learn about the crucial Tag 450 modifications (Don’t get left behind on these changes!)


• Discover the new Tag 457 for preprinted and electronic standing orders, and what you need to do to comply.

Session Agenda

Introduction

• Hospital CoP revisions


• How to locate a copy of the CoP


• CMS Memo on Standing Orders in Hospitals


• Access to hospital complaint data


• Updated deficiency data reports


• CMS order sets, protocols and standing orders


• Preprinted orders vs order sets


• ISMP guidelines for order sets


• Minimum requirements for standing orders


• Standing orders for vaccines website


• Vaccine standing order program


• Fínal federal register changes


• Radiology protocols


• Joint commission standards


• Protocols for suicidal patients in office


• WHO best practice protocols


• Survey and Certification website for changes


• CMS required radiology protocols

Who Should Attend?

Anyone involved in ensuring compliance with the CMS Hospital Conditions of Participation related to standing orders, protocols, order sets including the CEO, Chief Operating Officer, Chief Nursing Officer, Chief Risk Officer, Chief Medical Officer, Risk Management, Hospital legal counsel, Senior Leadership, Radiology director, PI staff, Compliance Officer, Regulatory Officer, Joint Commission liaison, Pharmacy Director, Nurse Educator, Pharmacist, Rehab and Respiratory Director and staff, Patient Safety Officer, MEC committee members, Infection Preventionist, OR Manager, Anesthesia Director, Anesthesiologist, Staff Nurses, Nurse Managers, Nurse Supervisors, IS Department staff, Policy and Procedure Committee Members, and anyone involved in standing orders, protocols, order sets and preprinted orders. This includes anyone who serves on a committee that reviews standing orders, order sets, and protocols.