Complete Healthcare Compliance Manual

Document 

Type​

What It Does​

Vetting ​

Required 

Approvals​

Publication 

Method​

Housed​

Auditing

and

Monitoring​

Required 

Review​

Format 

Source​

Standards of 

Conduct/

Code of 

Conduct​

Establishes 

principles 

which apply to every employee as well as [Governing] 

Board​

[Governing]

 Board;​

Senior Leaders​

[Governing] Board;​

Senior Leaders​

​

Distribute to each new employee 

during 

Orientation; post on website in [vendor] area​

Post to 

websites​

​

Annually​

​

SOX​

​

US HHS OIG

 Corporate 

Integrity 

template​

Policy​

Establishes a System position; sets a minimum 

expectation​

Minimum one end user from 

affected 

[department]​

Compliance 

Committee, if compliance-related (CCO determines); Legal Department

 subject matter counsel;​

System Policy Committee​

​

CMS SOM  Appendix A​

Policy Email​

Policies and 

Procedures Management System​

Yes​

Annually if compliance-related; once every three years if not 

compliance-related​

​

​

CMS Hospital Conditions of Participation ​

​

State Law​

​

Federal Law or Regulation​

​

TJC, DNV or Other 

Accreditation 

Source​

​

Process​

​

​

Implements the policy; could be the same as a procedure but may not be​

​

CMS SOM  Appendix A​

​

​

​

​

​

CMS SOM  

Appendix A​

 ​

Procedure​

Implements the policy; could be the same as a process but may not be​

​

CMS SOM  Appendix A​

​

​

​

​

CMS SOM 

Appendix A​

Protocol, Standing Order​

“Hospitals have the flexibility to use standing orders to expedite the delivery of patient care in well-defined clinical scenarios for which there is evidence 

supporting the application of standardized 

treatment or interventions.” 

Source: CMS SOM Appendix A 

Interpretive 

Guidelines §482.24(c)(3) ​

​

​

CMS SOM  Appendix A​

​

​

​

​

Annual review of each order​

​

Update when 

underlying 

science 

changes​

CMS SOM Appendix A​

​

Tag A-0457​

42 CFR §482.24(c)(3) ​

​

​

Consider other resources for standard definitions and requirements, including:​

​

Organizations to consider:​

• ISO: International Organization for Standardization  http://www.iso.org/​

• Clinical Laboratory Improvement Amendments https://www.cms.gov/regulations-and-guidance/legislation/clia ​

• [insert other resources here]​

Types of Written Standards to consider:​

• Desk Reference​

• Job Aid​