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Informed Consent Update: CMS, TJC, and DNV Standards (W3047)

Tuesday, September 12, 2023
9:00 am11:00 am

Informed Consent Update: CMS, TJC, and DNV Standards (W3047)

Dates: Tuesday, September 12, 2023
Time: 9:00 a.m. – 11:00 a.m. CT

Laura Dixon, BS, JD, RN, CPHRM

Cost: $195 to NHA members (Per hospital, no charge for additional lines. Those individuals interested in viewing the recording must register separately at the Zoom link prior to the start of the webinar. Zoom will send each individual registered an email containing an access code to view the recording.)

Course Curriculum
This program will discuss the current Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation (CoPs) on informed consent requirements. CMS notes that informed consent is a commonly cited deficiency.
CMS has three sections in the hospital CoPs manual regarding consent. All hospitals that receive Medicare and Medicaid reimbursement must comply with these regulations and interpretive guidelines. This program will discuss the variances between CMS requirements for hospitals and critical access hospitals. Hospitals in systems should be familiar with these differences.
The hospital must follow the consent regulations for all patients, not just those who receive Medicare and Medicaid assistance. 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. CMS requires that hospitals ensure that physicians are following these guidelines. Consent is a process that must be implemented and adopted and is more than simply 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.

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 that are now mandatory to be 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.
• Understand that the medical staff must have a list of procedures and tests that will require an informed consent under federal regulations.

Who Should Attend:
Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel

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.
This speaker has no real or perceived conflicts of interest that relate to this presentation.