New CMS CoPs Regulations: Standing Orders, Order Sets, Protocols & More?

Event Information
Product Format
Prerecorded Event
90 Minutes
Product Description

Understanding Hospital CoPs: Standing Orders, Order Sets and Protocols

This is an advanced workshop by Duane Abbey, PhD where he explores the process for making changes to hospital COPs including the Federal Register, the State Operations Manual and special memorandums from CMS. The process for making substantive changes occurs over the span of several years. A recent cycle for this process started with the May 16, 2012 Federal Register which was implemented on July 16, 2012. A corresponding update to the State Operations Manual (SOM) then followed along with survey procedures. The main changes in this cycle include standing orders, order sets and protocols.

In this session, Duane will answer pertinent questions such as:

  • Just what are these Conditions of Participation (CoPs)?
  • How important are these CoPs?
  • How does CMS go about updating the CoPs?
  • Do Critical Access Hospitals (CAHs) have the same CoPs?
  • What recent changes have been made in the CoPs?
  • How does the State Operations Manual (SOM) fit into the picture?
  • What should hospitals be doing relative to the CoPs changes?
  • Which departments of the hospital are most affected by these changes?
  • Does the hospital Medical Staff Organization (MSO) become involved in these changes?
  • How do we go about developing policies and procedures for standing orders, order sets and protocols?
  • How do we keep up-to-date with these directives from CMS?
  • Are there any implications for Electronic Health Record computer systems?

Training Objective:

  • To review the change process for hospital Conditions of Participation
  • To understand the multiple coordinated documents that CMS uses to make changes to the COPs
  • To appreciate the compliance implications with the COPs
  • To review changes with the use of standing orders
  • To understand the Emergency Department involvement with these changes
  • To appreciate the need for the Medical Staff Organization involvement
  • To review the State Operations Manual directives for standing orders, order sets and protocols
  • To appreciate the survey procedures
  • To appreciate the impact on hospital care paths and clinical pathways
  • To understand the need to develop written policies and implementing procedures
  • To appreciate the involvement of Electronic Health Record systems
  • To understand how these COP changes do or do not apply to CAHs

Teleconference/Webinar Outline/Agenda:

  • Change Cycle for Hospital Conditions of Participation
    • Federal Register Process
    • State Operations Manual
    • Survey Certification
    • Hospital Conformance
    • Compliance Considerations
    • Care Paths
    • Brief Review of Hospital CoPs
    • Critical Access Hospitals
  • Hospital Operational Impacts
    • Policy and Procedure Development
    • Emergency Department Impact
    • Medical Staff Organization Involvement
    • Other Hospital Departments
  • Standing Orders
    • Federal Register Discussion
    • State Operations Manual Directives
    • Action Steps for Hospitals
  • Order Sets
    • Federal Register Discussion
    • State Operations Manual Directives
    • Action Steps for Hospitals
  • Protocols
    • Federal Register Discussion
    • State Operations Manual Directives
    • Action Steps for Hospitals
  • Additional Issues and Concerns
    • Development of Policies and Procedures
    • Internal Audits of Policies and Procedures
    • Accreditation Implications
    • Electronic Health Record Implications
  • Case Studies and Exercises

Who Should Attend:

Compliance Officers, Nursing Staff, Medical/Surgical Nursing Staff, Nurse Managers, ED Nursing Staff, Utilization Review Personnel, Quality Assurance Personnel, Quality Assurance Personnel, Physicians, Coding Personnel, Billing and Claims Transaction Personnel, Charge-master Coordinators, Financial Analysts, Compliance Personnel, and Other Interested Personnel

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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
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