Catalog Number : ncd1389
Title : CMS & JC Informed Consents
Speaker : Sue Dill

Webplay Recording Date : 2-22-2012
Webplay Price : $ 200 for two weeks viewing

Webinar Overview:

Ever been confused about what standards and guidelines apply to informed consent? This program will discuss the current CMS hospital Conditions of Participation (CoPs) on informed consent requirements. It will include the confusing changes that were effective October 7, 2011. This program will discuss the CMS requirements for both PPS hospitals and critical access hospitals since they are different. We will cover the 2012 Joint Commission informed consent standards. This program will also discuss standards on consent for research, and other organization’s consent requirements.

Consent is a process and not just having a form signed on the chart. Come join us for a fun session on making informed consent a little simpler to understand!

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 separate guidelines from CMS on informed consent
• 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
• 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 require an informed consent form under federal regulations

Webinar Agenda:

• 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
  • October 7, 2011 changes
  • Consent from the patient who is not incapacitated and the patient representative
  • Consent when the patient is incapacitated
• 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
  • Benefits
  • 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
• 2012 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
• AAAHC and AAAASF Standards on Consent
• DNV Healthcare Standard on Informed Consent
• AOA HCFA Standard on Informed Consent
• Professional Organization Resources on Consent
• Research Informed Consent Requirements

Target Audience:

• CEO
• Compliance officer
• Chief of Medical Staff
• Chief Nursing Officer
• COO
• Nurse Educator
• Nurse Managers
• Physicians
• Medical Staff Coordinator
• Patient Safety Officer
• senior leadership
• hospital legal counsel
• Risk Manager
• Chief Risk Officer
• PI Director
• Joint Commission Coordinator
• Director of Health Information Management
• Director of Anesthesia
• OR Nurse Director
• nurses
• Patient Safety Officer
• Pastoral Care
• Patient Advocates
• Ethics Committee
• others responsible for compliance with hospital regulations, and persons responsible for rewriting policy and procedure on informed consent

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.