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Webinar: Hospital Surgery and PACU Standards: Are You in Compliance?

This educational activity is jointly provided by AXIS Medical Education and the North Carolina Healthcare Association

December 11, 2018 @ 10:00 am - 12:00 pm

This webinar will review the CMS Hospital CoP standards for surgery, anesthesia, and PACU. This program will cover some of the important CMS memos that discuss medication management, IV, and safe opioid use as well as the current interpretive guidelines regarding pre and post-anesthesia evaluations and anesthesia services, including documentation requirements. Our speaker will also identify the types of deficiencies hospitals receive in the areas of informed consent, H&Ps, safe opioid use, safe injection practices, compounding and beyond-use dates.


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

    • Identify the policies and procedures required by CMS related to surgery and anesthesia services.
    • Discuss the section in the CMS manual that Addresses PACU requirements.
    • Identify  items listed in the CMS manual that must be included in the OR register.
    • Describe the information for an informed consent that should be on the chart before surgery.
    • Discuss the patient and outpatient 48 hour requirements for the post-anesthesia evaluation.

Target Audience

Hospital staff involved with CMS  surgery, anesthesia and Post-Anesthesia Care Unit (PACU) compliance regulations and guidelines, including, but not limited to CMOs, CNOs, anesthesiology personnel, physicians, nurses, patient safety officer, risk managers, compliance officers and legal counsel and any staff involved in assisting with cases of anesthesia and moderate sedation.

Featured Faculty

Sue Dill Calloway, President, Patient Safety and Health Care Education and Consulting

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 was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. She has conducted many educational programs for nurses, physicians, and other health care providers. Sue has authored over 100 books and numerous articles. She is a frequent speaker and is well known across the country in the areas of health care law, risk management, and patient safety. Sue has no real or perceived conflicts of interest that relate to this presentation.

Continuing Education Credits

Continuing Education
Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and The North Carolina Healthcare Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activities for 2.0 contact hours each.

Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

AXIS Contact Information
For information about the accreditation of this program please contact AXIS at info@axismeded.org.

Disclosure of Conflicts of Interest
AXIS Medical Education requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by AXIS for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

Name of Faculty or Presenter Reported Financial Relationship
Sue Dill Calloway, RN, MSN, JD, CPHRM, CCMSCP, President, Patient Safety and Health Care Education and Consulting  Nothing to disclose

The planners and managers reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

Name of Planner/Manager Reported Financial Relationship
Sue Dill Calloway, RN, MSN, JD, CPHRM, CCMSCP, President, Patient Safety and Health Care Education and Consulting Nothing to disclose

Holly M. Hampe, D.Sc., RN, MHA, MRM Nothing to disclose

Dee Morgillo, MEd., MT (ASCP), CHCP Nothing to disclose

James Hayes, PMP Nothing to disclose

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Requirements for credit:
• Attend/participate in the educational activities and review all course materials.
• Complete the CE Attestation forms online by 11:59 pm ET on December 30, 2018. Instructions will be provided. If you do not enter the online portal by the above date, you will not be able to retrieve your statement of participation.
• Upon successful completion of the online form, your statement of completion will be presented to you to print.

American College of Healthcare Executives
NCHA is authorized to award 2.0 hours of pre-approved ACHE Qualified Education credit for this program toward advancement or re-certification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credit should indicate their attendance when submitting application to the ACHE for advancement or re-certification.


$199 per connection. NOTE: Other participants may sit in on the same connection. For each additional connection there is a charge of $199. Recordings are available for purchase with the purchase of one connection.


James Hayes at jhayes@ncha.org or 919-677-4246



December 11, 2018
10:00 am - 12:00 pm
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NCHA Education Services
James Hayes, PMP
Education Project Manager

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