CMS, TJC, DNV and Other Standards on Informed Consent: Maneuvering the Maze

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Start Time:12:00 AM
End Time:12:00 AM
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Provided by MHA Health Institute
Health Institute

Date & Time

Thursday, June 27
9 - 11 a.m.

Register on or before Thursday, June 20, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional phone line connection will be charged a registration fee. Get more value by inviting colleagues to join you!

This webinar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation.


CEOs, CNOs, CMOs, COOs, compliance officers, nurse directors and supervisors, and clinical staff, including nurses and physicians, patient safety officers, legal counsel, risk managers, and TJC and DNV coordinators

The following program content was provided by the speaker.


This program will discuss the current CMS hospital Conditions of Participation, including the critical access hospital, The Joint Commission and Det Norske Veritas Healthcare standards on informed consent requirements. All hospitals that receive Medicare and Medicaid reimbursement must comply with these interpretive guidelines.

Hospitals should ensure that their policies and procedures reflect the CMS, TJC and DNV requirements and that their staff is educated on these informed consent interpretive guidelines. For CMS, there are six mandatory elements for hospitals to adopt and guidelines for physicians to follow. Consent is a process beyond just having a form signed. Health care providers also must be aware of their specific state laws on informed consent. Many professional organizations like 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 will better understand the CMS Infection Control Worksheet and will be able to:

  • identify the three sections on informed consent in the CMS hospital CoP interpretive guidelines
  • list the six minimum requirements that are now mandatory to be on the informed consent form for surgery
  • discuss the CMS and accreditation standards, applicable to your facility, that should be reflected in the hospital's policies and procedures
  • identify the list of procedures and tests to be used by medical staff that will require informed consent under federal regulations


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and previously was the chief learning officer for the Emergency Medicine Patient Safety Foundation.