2023 Acute Care Hospital Conditions of Participation - Part 4: Dec. 12

Time: 12:00 PM


Virtual - noon-2 p.m., CT


(Per Webinar)
IHA Members:
$195 per hospital or per health system office*
Non-IHA Members: $245 per organization*

*Please note: The registration fee includes an unlimited number of connections within the same hospital or within the hospital system corporate office. It cannot be shared among system hospitals.

Register Online

With a focus on improving quality, equity and patient outcomes, the Centers for Medicare & Medicaid Services (CMS) continues to modify the Conditions of Participation (CoPs) for hospitals.  Maintaining compliance can be challenging as the current manual for acute care hospitals, dated July 2023, consists of 559 pages of survey protocols, regulations and interpretive guidelines. A five-part IHA webinar series will guide hospital leaders and staff through the manual to boost your compliance efforts. Lena Browning-Calloway, a seasoned accreditation professional, will lead the series, providing essential compliance strategies and resources specific to CMS’ State Operations Manual Appendix A. You’ll learn about recent revisions and common standards surveyors cite to strengthen internal processes and avoid costly fines.

The webinar series will explore these frequently cited requirements:

  • Care in a safe setting (environmental safety, infection control, security)

  • Nursing care plans

  • Legibility requirements

  • Necessary policies and procedures

  • Nursing medication carts

  • Informed consent

  • History and physicals

  • Verbal orders

  • Medication administration

  • Medication security

  • Emergency preparedness


Part 4: Dec. 12, noon-2 p.m., CT


  • Quality assurance and performance improvement (QAPI)

  • Medical staff

  • Diagnostic imaging (radiology)

  • Laboratory

  • Food and dietary services

  • Utilization review

  • Physical environment and maintenance

  • Emergency preparedness 

Learning Objectives
At the conclusion of this program, participants will be able to:

  • Discuss strategies and leading practices to improve quality assurance and performance improvement compliance (QAPI).

  • Identify key regulatory issues for medical staff, diagnostic imaging, laboratory, and food and dietary services.

  • Outline the key components of emergency management standards.

  • Describe challenges to compliance with physical environment and maintenance standards.

Who Should Attend
This webinar is designed for hospital leaders and staff responsible for CoP compliance, including those in:

  • Hospital administration (CEOs, COOs, CMOs, CNOs)

  • Accreditation and compliance (including clinical and regulatory professionals)

  • Quality improvement

  • Medical staff

  • Radiology

  • Laboratory

  • Dietary

  • Facilities management

  • Emergency preparedness

  • Risk management

Professionals seeking to expand their understanding of current COPs are also encouraged to attend.


At the conclusion of the webinar series, participants will be able to:

  • Outline hospital Conditions of Participation and describe strategies to remain in compliance with them.

  • List some of the most challenging Conditions of Participation as identified by the Centers for Medicare and Medicaid Services (CMS).

  • Identify changes to CMS survey procedures and interpretative guidelines.

  • Describe recent Clinical Standards and Quality (QSO) updates and their impact on your organization.

Who Should Attend

This program is designed for hospital leaders and staff responsible for CoP compliance, including those in:

  • Administration (CEOs, COOs, CMOs, CNOs)

  • Compliance, accreditation and regulation

  • Quality improvement

  • Risk management

  • Facility management

  • Infection prevention

  • Radiology

  • Rehabilitation

  • Legal affairs

  • Health information management

  • Diagnostic imaging, laboratory, emergency department, outpatient care, rehabilitation (OT, PT, speech pathology and audiology), operating room and special procedures

  • Clinical leadership including physicians, nurses, pharmacists, social workers and dieticians


Lena Browning-Calloway, MHA, BSN, RNC-NIC, CSHA
A nurse leader and accreditation specialist, Browning has more than 25 years of clinical leadership in acute care settings. She is an expert in CMS, The Joint Commission and state regulations and has performed system-wide tracers for continuous readiness and patient safety. Browning has coordinated accreditation and regulatory surveys, chaired continuous readiness committees, and coached staff and leadership in effective compliance and performance improvement strategies. Throughout her career, she has demonstrated a commitment to improving patient safety by empowering staff and leadership to maintain continuous compliance and achieve excellence across healthcare settings.