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Standing orders and protocols are key to the operation of any healthcare facility, but abiding by CMS’ rules on these tools can be difficult, says Sue Dill Calloway, RN, AD, BA, BSN, MSN, JD, CPHRM, CCMSCP, president of Patient Safety and Healthcare Consulting and Education in Dublin, OH.
“Standing orders is the topic I am asked most often about lately,” Calloway says. “Hospitals use these a lot and in some situations the answer to what CMS expects is not always in the COP.”
Calloway recently worked with a hospital that does ambulatory surgery and wants to have extensive protocols for intravenous lines and other routine patient care, with the nurse implementing the protocol before having it signed by a physician. The COP does not clearly delineate that as a permitted use because standing orders are typically used in emergent conditions rather than for everyday care.
“It was not intended to take the place of having a physician or licensed independent practitioner review orders that are non-emergent, so there is a lot that the COP doesn’t tell us about when this use is and is not permitted,” she says.
Protocols are another frequent problem, Calloway says, with hospitals questioning what must be documented in the electronic record, among other questions. Calloway recently has counseled two hospitals and discussed the issue with CMS officials, and she says some of CMS’ expectations are becoming clearer.
“They don’t want you to write something in the electronic chart like ‘trauma protocol,’” she says. “It needs to state the elements of the protocol, like give this morphine dose, put a large bore needle in, just like in a paper chart would have had a page that says all the things you do rather than just saying ‘trauma protocol.”
Review of protocols also is causing some consternation. CMS requires that all protocols be reviewed regularly, but just how often you should do so is not clear. While an annual review is the minimum accepted by CMS, a hospital could opt to do more frequent reviews, Dill Calloway says.
A “periodic and regular review” is what CMS requires, but it is not clear exactly what that means. Under the minimum requirements section, the interpretive guidelines state “at a minimum, an annual review of each standing order would satisfy this requirement. However, the hospital’s policies and procedures must also address a process for the identification and timely completion of any requisite updates, corrections, modifications, or revisions based on changes in nationally recognized, evidence-based guidelines.”
Questions also have arisen lately about Patient Safety Initiative Surveys based on the three worksheets — Quality, Discharge Planning, and Infection Prevention — that were finalized last year. Some have wondered if CMS would be conducting focused surveys using these worksheets rather than incorporating them into existing survey processes. The answer apparently is yes.
Calloway recalls hearing from hospitals recently that CMS surveyors have shown up for surveys based on the worksheets.
“These were not complaint surveys, validation surveys, or certification surveys,” Calloway says. “They just showed up for two days and said, ‘We’re going to do these worksheets.’”
CMS also is citing hospitals for not having a trained infection preventionist. She heard from one hospital that recently was cited and wanted to appeal. The hospital was small and when its infection control director left, a nurse with no special training was given the responsibility. CMS did not approve.
She advised the hospital not to appeal because it would lose.
“It’s one of the first questions they ask. Do you have a trained hospital infection preventionist?” she notes. “Hospitals should make a priority of addressing this requirement.”
Calloway notes that, though not strictly required, CMS highly recommends completion of the three worksheets in advance as a self-assessment tool. The worksheets are available online at http://tinyurl.com/pa5dju3.