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

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Start Time:12:00 AM
End Time:12:00 AM
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Provided by MHA Health Institute.
Health Institute

Date & Time

Tuesday, Oct. 29
9 - 11 a.m.

Register on or before Wednesday, Oct. 23, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional connection will be charged a registration fee. Get more value by inviting colleagues to join you on the one connection.

Can’t attend the webinar? Would you like to share the webinar with your department or team? No worries! Register now, and you will have access to the webinar recording for two weeks after the presentation.

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


CNOs; CMOs; senior leadership; physicians; nursing supervisors and managers; infection preventionists; nursing, pharmacy and radiology staff; performance improvement and patient safety personnel; compliance and regulatory officers; Joint Commission liaisons; educators; hospital legal counsel; and others who are involved in ensuring compliance

The following program content was provided by the speaker.


The development of protocols and standing orders is best described as a journey. This webinar will provide the history of each of the four sections along with the hospital requirements. As hospitals move toward a complete electronic medical record, understanding the requirements is especially important.

This webinar also will cover the interpretive guidelines and regulations required by the Centers for Medicare & Medicaid Services related to standing orders, protocols, order sets and preprinted orders. Regarding standing orders, Tag 457 will be discussed, including the four separate sections in the hospital Conditions of Participation manual that regulate this issue, as well as the requirements that have been moved from Tag 405 to Tag 457. Additionally, standing orders related to medication approval and radiology standards will be reviewed.


At the conclusion of this session, participants will be able to:

  • discuss why hospitals must comply with the CMS CoP requirements
  • give examples of the CMS requirements for standing orders and protocols
  • explain how all protocols must be approved by the medical staff even if the protocols are department specific
  • describe why a physician must sign off on the standing order along with the date and time


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

Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting, and previously was the chief learning officer for the Emergency Medicine Patient Safety Foundation.