What You Need To Know
Following a two year-long process involving feedback and support from a multidisciplinary team of leaders, a new network wide informed consent policy will go into effect on May 15, 2024.
Why?
Informed consent is foundational to our commitment to provide high-quality health care to our patients, foster trust and support shared decision making. It is both an ethical and legal obligation to ensure our patients are educated on the risks, benefits, and alternatives of a procedure or intervention. The new harmonized policy standardizes practices across the network, helping to achieve a safe environment for our patients and each other.
What?
The new “Informed Consent Policy for Surgery or Non-Operative/ Invasive Procedures, Anesthesia Services, Sedation, and Blood Transfusions" harmonizes informed consent for adult and minor patients. The policy applies to all HMH entities, including acute care hospitals, HMH physician practices, private physician practices and ambulatory care areas. The Informed Consent policy and four related informed consent forms have been harmonized. All existing informed consent policies and forms will be retired by May 15, 2024, when the new policy and forms are live in PolicyStat. Note, the new policy contains practice changes for some hospitals.
Substantive changes to the policy include:
- Applies to adults and minors;
- For guidance regarding appropriately including minors in healthcare decision making, including situations where minors may make their own medical decisions, please see the newly harmonized policy Involving Minors in Clinical Care Decision Making, Including Minor Assent and Informed Consent.
- Time validity for informed consent form for surgery and non-operative procedures is 90 calendar days with exceptions;
- Time validity for informed consent form for anesthesia is 30 days;
- Written informed consent is required for anesthesia services and a separate Informed Consent Form for Anesthesia Services must be signed by both the patient and Anesthesiologist;
- Critical Care and Emergency Medicine Sedation and Analgesia for Procedures form to be used In these settings by the non-anesthesiologist physician;
- Existing DNAR Orders are not automatically suspended, but rather require the Responsible Practitioner and Anesthesiologist, as part of the Informed Consent process, to discuss the status of existing DNAR and Airway Management Orders with the patient or surrogate prior to procedure;
- One RN Witness. ONLY verbal informed consent and telephone informed consent must be witnessed by one (1) individual. The witness must be a registered nurse;
- Includes a separate Consent or Refusal for Blood and/or Blood Products form;
- Leapfrog required elements have been incorporated into the policy and forms.