Standing Orders

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Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional Information

Provided by MHA Center for Education

Date & Time

Monday, May 15, 2017
9 - 11 a.m.

Register on or before Wednesday, May 10, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Additional phone line connections each will be charged a registration fee. Multiple participants on the same connection is encouraged. Get more value by inviting colleagues to join you!

This webinar is being offered at a reduced registration fee to MHA-member hospitals because of a contribution from MHA Management Services Corporation.


CEO, COO, CNO, CMO, chief risk officer, risk management, hospital legal counsel, senior leadership, radiology director, compliance officer, regulatory officer, TJC liaison, pharmacy director, nurse educator, pharmacist, rehab and respiratory director and staff, patient safety officer, infection preventionist, anesthesia director, anesthesiologist, staff nurses, nurse managers, nurse supervisors, policy and procedure committee members, and anyone involved in standing orders, protocols, order sets and preprinted orders

The following program content was provided by the speaker.


Are you aware of the requirements on standing orders promulgated by the Centers for Medicare & Medicaid Services that all hospitals must follow? This webinar will cover The Joint Commission standards on standing orders and protocols. Did you know there are four separate CMS hospital Conditions of Participation sections of which hospitals must be aware? This webinar also will cover the interpretive guidelines and regulations required by CMS related to order sets, protocols, preprinted orders, and standing orders.


  • 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 medical staff even if the protocols are department specific
  • discuss that the physician must sign off on the standing order along with a date and time


  • Introduction/History
    • What are the CoPs
    • How to locate a copy of the CoP
    • TJC standards on standing orders
    • CMS required radiology protocols
    • History and development
    • Tag 450 Changes
    • A new tag number 457 was created
    • Final interpretive guidelines
  • Tag 457
  • Tag 405
  • Tag 406
  • CMS Memo on Standing Orders in Hospitals
  • Tag 450


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway is a nurse attorney and president of Patient Safety and Healthcare Consulting and Education Company. Calloway was the past vice president of legal services at a community hospital, in addition to being the privacy officer and the compliance officer. Calloway served as the director of risk management and health policy for more than eight years at the Ohio Hospital Association. She also was the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus, Ohio, for five years. She frequently lectures on legal and risk management issues and writes numerous publications. Calloway is a 1996 recipient of PESI HealthCare’s Excellence in Education award.