Resource: Sample Written Standards Matrix | COSMOS Compliance Universe

Resource: Sample Written Standards Matrix

By Sarah Campbell


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