The Centers for Medicare and Medicaid Services (CMS) and accrediting organizations such as The Joint Commission (TJC) and Det Norske Veritas (DNV) have certain elements required for informed consent. This program will review those standards and informed consent requirements.
There are three sections in the CMS CoPs manual regarding consent. All hospitals that receive Medicare and Medicaid reimbursement must comply with these regulations and interpretive guidelines. This webinar will discuss the CMS requirements for hospitals and critical access hospitals.
Hospitals must follow the consent regulations for all patients, not just Medicare and Medicaid patients. Failure to follow these regulations could result in the hospital being cited and/or excluded from the Medicare program. Hospitals should ensure that their policies and procedures reflect the CMS requirements and that their staff are educated on the informed consent interpretive guidelines. There are six mandatory elements and additional optional elements for hospitals to adopt. CMS requires the hospital to ensure that physicians are following these guidelines. Consent is a process and not just having a signed form.
Health care providers must also be aware of their specific state law on informed consent. Many professional organizations, such as the American College of Surgeons, American Society of Anesthesiologists, and the American Association of Nurse Anesthetists also have guidelines or position statements on informed consent.
Laura A. Dixon, BS, JD, RN, CPHRM
Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.
Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States
As a registered nurse and attorney, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
At the conclusion of this session, participants should be able to:
Recall that the CMS hospital CoPs regulations have three sections on informed consent.
Describe the six minimum requirements CMS now mandates must be on any informed consent form for surgery completed at a Medicare-certified hospital.
Discuss the CMS and accreditation organization standards applicable to your facility, which should be reflected in the hospital’s policies and procedures.
Identify that the medical staff must have a list of procedures and tests that will require an informed consent under federal regulations.
The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a). Approved for 2 contact hours.
By attending Informed Consent Update: CMS, Joint Commission, DNV and other Standards Webinar offered by Georgia Hospital Association, participants may earn up to 2 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.