WEBINAR: Informed Consent

Ever been confused about what standards and guidelines apply to informed consent?

This webinar will discuss the current CMS hospital Conditions of Participation (CoPs), the Joint Commission and DNV Healthcare standards on informed consent requirements. It will include some confusing CMS changes such as having a patient advocate sign the consent form when present even if the patient is competent. 

Webinar Objectives:
recall that the CMS hospital CoP interpretive guidelines has 3 separate sections on informed consent
explain that hospitals and critical access hospitals have a separate guideline from CMS on informed consent and they are very different
describe the six minimum requirements that are now mandatory to be in the informed consent form for surgery done at a hospital that receives Medicare reimbursement including that the name of the hospital must always be on the form
discuss that the CMS and accreditation standards applicable to your facility 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 form under federal regulations

Target Audience
CEO, Compliance officer, chief medical officer (CMO)  chief nursing officer (CNO), COO, Nurse Educator, Nurses, Nurse Directors, Nurse Supervisors, Nurse Managers, Board Members, Physicians, Medical staff coordinator, patient safety officer, senior leadership, hospital legal counsel, Risk Manager, Chief Risk Officer, PI director, Joint Commission or DNV coordinator, director of health information management, director of anesthesia, OR nurse director, nurses, Patient Safety Officer, Pastoral Care, Patient Advocates, Ethics Committee and others responsible for compliance with hospital regulations, and persons responsible for rewriting policy and procedure on informed consent

Webinar Topics:
Introduction to the Hospital CoP Informed Consent Requirements
CMS interpretive guideline on informed consent for hospitals
Three sections in hospital CoP
Update policies and procedures
Educate staff including medical staff
Consent from the patient who is not incapacitated and the patient representative
Consent when the patient is incapacitated
Patient advocate asked to sign consent even if patient is competent
Informed Decision Section 1 CMS Hospital CoPs
Informed consent as a process
Right to make informed decisions
Right to be informed of health care status
Right to refuse care
Evaluate patient rights 
Right to delegate right to another for informed decisions
Surrogate decision makers
Right to participate in plan of care after discharge
Right to receive understandable information 
Policies and procedures required
Survey procedure for surveyor
Surgical services Section 2 CMS Hospital CoPs
Consent form on chart before surgery
Emergency exception
Short and long term risks
Physician professional judgment
Surgery definition
Hospital must assure consent process
Anesthesia consent required
Surgery consent policy requirements
Documentation in medical record
Elements of well-designed consent process
Risks, benefits, alternatives etc.
Surgical residents, RNFA, surgical Pas
Important tasks related to surgery and disclosure
Surgical resident section
Moonlighting resident or fellow
MS must approve list of when consent is required
Surveyor to interview patients on process
Medical record review by surveyor
Medical Records-Section 3 CMS Hospital CoPs
Inpatients and outpatient requirement
Consent on chart prior to surgery
Minimum elements in informed consent
Name of hospital on consent form
Revised witness requirement
Material risk definition
Signature of patient on consent form required
Additional elements to consider on consent form
Surveyor review of six charts
Surveyor procedure
CMS Critical Access Hospital CoPs
2 separate sections in CAH manual
Consent requirements
Significant surgical tasks
Consent as a process
Mandatory and optional requirements
 Joint Commission Informed Consent Standards
Remember state law requirements
RI.01.03.01 and the EPs
Written policy requirements
Surgery and procedures requiring consent must be specified
Consent as a process
Risks benefits, and side effects
Elements not required by CMS
Exceptions to policy
Emergency surgery
Consent on chart required before surgery
Consent for photography
TJC tracer on consent
DNV Healthcare Standard on Informed Consent
Professional Organization Resources on Consent
HCFA Standard on Informed Consent
Sue Dill Calloway, RN, Esq. CPRHM, AD, BA, BSN, MSN, JD, Attorney at Law
President of Patient Safety, Healthcare Consulting and Education Company

Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Ms. Calloway has given many presentations locally and nationally to nurses, physicians and attorneys on medical and legal issues. She has authored numerous articles and over 1000 articles and 100 books, including the 2009 Joint Commission Leadership Standard (HCPro), Nursing and the Law (PESI, 1986 and 1987), Ohio Nursing Law (West Publishing), Nursing Ethics and the Law (PESI, 1986), Legal Issues in Supervising Nurses (PESI, 1988), Medicine Made Easy (PESI, 1992) and The Law for Nurses Who Supervise/Manage Others (PESI, 1993), Legal Issues in Obstetrics (PESI, 1997) and JC Leadership Standards (HCPro, 2004), and the Compliance Guide to the CMS and the Joint Commission Patient Rights Standards (HCPro, 2005), and the 2009 book on the Joint Commission Leadership Standards (HCPro). She often writes articles called the “CMS Corner” in Briefings on the Joint Commission. Ms Calloway is a 1996 recipient of PESI's Excellence in Education Award.

Nursing CEU Credits: 
Nursing participants: This program has been approved for 2.4 contact hours by the Iowa Board of Nursing Approved Provider Number 339. Completion of offering required prior to awarding certificate.
All other participants: Must attend the entire Webinar and complete a Webinar critique to receive a 2 Hour Attendance Certificate.
7/24/2017 9:00 AM - 7/24/2017 11:00 AM
United States


Monday, 24 July 2017

7/24/2017 9:00 AM
9:00 AM - 11:00 AM
7/24/2017 9:00 AM
9:00 AM - 11:00 AM
7/24/2017 9:00 AM
9:00 AM - 11:00 AM
7/24/2017 9:00 AM

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