Informed Consent

Informed Consent

In order to ensure that patients understand the risks associated with recommended procedures and alternatives, hospitals must have a robust informed consent process in place. This measure assesses whether a hospital's informed consent process includes all the following elements: 

1. A training program on informed consent that tailors different training topics to different staff roles and has made the training required for newly hired staff and existing staff who were not trained
2. A process to ensure that clinicians explain expected difficulties, recovery time, pain management, and restrictions after a test, treatment, or procedure, and give the patient an opportunity to ask questions
3. Consent forms that include the name of the clinician performing the test, treatment, or procedure, in addition to information regarding whether the clinician is expected to be absent, and whether any assistants or trainees will be involved
4. Consent forms written at a 6th grade reading level or lower
5. A process to ensure that prior to conducting the informed consent discussion, hospital staff identify the patient/legal guardian’s preferred language and provides a medical interpreter, and has a place in the consent form that indicates whether an interpreter was used
6. Clinicians that use the “teach back method” with patients/legal guardians to ensure that patients/legal guardians understand what will be done, why it will be done, and what are the primary risks

Reporting Period

• 2024

Patients Included in the Measure

• Inpatients (Patients who are admitted to the hospital for at least one overnight stay)
• Outpatients (Patients who are admitted and discharged on the same day)
• Adults and Children