July 2016
Upcoming Webinars
Building a robust
credentialing, privileging,
and peer review process
July 13
Creating an "Aha" moment in
quality improvement
September 14
Want more on Informed
Consent? Watch for an
announcement of a November
2 webinar.
Education programming
in DC this fall
Achieving Accreditation will
be “picturing excellence”
Informed consent
“Informed consent” is the name given to the idea
that a patient has a legal and ethical right to direct
what happens to his/her body. Even though the
term specifically appears in a limited number of
AAAHC Standards* it is the philosophical basis for
positioning patient rights first among the
requirements for accreditation.
The goal of informed consent is that a patient has the
opportunity to be an active participant in his/her health care
decisions. This means that the provider has a responsibility to
disclose the nature of the proposed treatment or procedure,
the relevant associated risks, and any options—along with the
attendant risks of those alternatives.
These disclosures represent only the first (and perhaps the
simplest) step in a process. There is often an inherent power
imbalance in the provider-patient relationship that can easily
become coercive. Patients may be vulnerable and reluctant
to, or incapable of, asking clarifying questions about the
information that has been provided. They don’t know what
http://www.e-affect.com/aaahc-email/email-7-16/email.html[6/30/2016 1:03:43 PM]
September 23-24 at the
Marriott Marquis, Washington
DC
The AAAHC program is for
surgical and primary care
organizations. Register here.
A concurrent AAHHS-HFAP
program is for acute care
hospitals (with separate health
care and physical environment
tracks) and laboratories.
Register here.
Come meet the family and
learn the whole range of
programs we offer!
Chapter 17: Behavioral
Health Services
Revised Standards for
behavioral health services were
approved by the AAAHC board
after publication of the 2016
handbook. The new Standards
become effective for surveys
taking place on or after August
1, 2016.
The chapter is viewable as a
stand-alone document here.
A webinar on the new
they don’t know.
For this reason, the provider must confirm patient
understanding, (or that of his or her representative) prior to
seeking consent to ensure that the consent is voluntary and
intentional. It may help to frame the issue as a decisionmaking partnership. The provider will certainly share a
recommendation, but the patient must have ample
opportunity to participate in the decision to proceed. Including
a consent form among a stack of papers to sign could reduce
an individual’s agency and unfairly shifts responsibility to the
patient to ask rather than on the provider to explain.
With regard to the expectations of an accreditable
organization, here are some questions that have arisen with
regard to issues of consent.
Combining consents
Q: An organization with an integrated medical and behavioral
health service uses a single "consent to treat" for the whole
health center. Is this acceptable?
A: A single consent may be used, but the consent must cover
all services provided in sufficient detail that the patient/client
is able to make an informed decision. To address behavioral
health services, it may be appropriate for the consent to
include items such as treatment expectations and parameters,
and potential risks and protections related to treatment. The
organization might also wish to consider ensuring that
instances of limited confidentiality are clearly articulated,
reviewed with the client, and acknowledged by signature. It
may also be desirable to obtain consent for the coordination
of care with family members and/or significant others who
play a role in the plan of care or treatment of the client.
Q: For a surgical procedure, can a single consent form cover
both the anesthesia and the procedure?
A: Again, the heart of the issue is voluntary, informed patient
consent. If the provider(s) have fully communicated the
options, risks, recommended course of action, and assessed
the patient’s understanding and willingness to proceed, it is
acceptable to use a single consent document. In cases where
the anesthesia provider and the surgeon are individually
discussing their roles with the patient, it is more usual to see
separate forms. In settings where a surgeon is supervising
anesthesia provided by a CRNA, a single consent form is
more common.
Consent for a procedural service
Q: Can documentation that the proposed procedure was
discussed with the patient or the patient’s parents/guardian,
and that they consented to the procedure be included in the
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Standards was presented on
May 18. You can still register
for access to the recording
here.
AAAHC Contact
Information
Accreditation Association for
Ambulatory Health Care
5250 Old Orchard Road
Suite 200
Skokie, IL 60077
P: 847.853.6060
F: 847.853.9028
info@aaahc.org
www.aaahc.org
medical notes rather than being documented on a separate
form?
A: Some states require a written consent; many do not.
However, beginning in 2016, AAAHC Standard 10.H is quite
specific on this:
Informed consent for the proposed procedure is obtained.
1. There is documentation that the necessity of the
proposed procedure or surgery, as well as alternative
treatment techniques, have been discussed with the
patient.
2. The organization obtains written informed consent from
the patient or the patient’s representative before the
procedure or surgery is performed.
Written informed consent has always been required in
Medicare-certified ASCs, and the Standard now requires it in
other surgical/procedural settings as well. To apply 10.H.2 in
primary care settings, surveyors will ask for the organization’s
policies or guidelines regarding when written vs. verbal
consents are required, assess the rationale of those
guidelines, and then confirm compliance through the review of
clinical records. The intent is that in primary care settings,
some procedures such as cryotherapy of warts, removal of
skin tags, etc. are sufficiently benign that they will not require
separate written, signed consents. In this case, a note in the
clinical record is sufficient.
*Informed consent is specified in Standards relating to anesthesia (9.F),
surgical services (10.H), dental services (14.I.H), behavioral health
services (17.J), research activities (19.E), and radiation oncology
services (24.G). Standards cited refer to the identifiers in the 2016
edition of the Accreditation Handbook for Ambulatory Health Care.
If you have questions or comments about Connection, please contact Angela FitzSimmons at
afitzsimmons@aaahc.org.
© 2016 AAAHC. All Rights Reserved.
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