One shortcut to ensuring staff share their surgery center’s work ethic is a credo, or guiding principle. Building a credo into the organization’s foundation is very important, says Barbara J. Holder, RN, BSN, LHRM, CAPA, quality officer at Andrews Institute Ambulatory Surgery Center in Gulf Breeze, FL.

Andrews Institute, named for James Andrews, an orthopedic surgeon who works with athletes, offers a credo for its employees. It is short enough to fit on a business card. “It’s encouraged you have it on you and periodically take it out and read it so it becomes instilled in our culture,” Holder says. The credo touches on the organization’s mission to provide compassionate care, highest quality care, and access to the latest technologies. These words also inform how employees handle informed consent. ASC employees know they must provide fully informed consent to attain their credo’s ideals. Informed consent is another foundation because it is so important to the patient’s experience, Holder says.

“If the patient has an understanding of the procedure, risks, benefits, [and] treatment ... it makes their experience so much better, and it makes our job easier, too,” she explains. “Informed consent should not be initiated on the day of surgery.” The surgery center follows regulations closely when providing informed consent. CMS requires informed consent before all treatment and procedures. 42 CFR 416.50(e), the standard for the exercise of rights and respect for property and person, says patients have the right to be “fully informed about a treatment or procedure and the expected outcome before it is performed.”

Andrews Institute’s informed consent rules go beyond the CMS regulations, outlining exactly what should be listed in the informed consent, including descriptions of the procedure, risks, benefits, treatment, and other items, Holder says. The informed consent process consists of questions and answers, giving patients time to absorb information and come up with questions.

“The physician or staff has to present it in a way that the patient understands,” Holder says. “It can be written, verbal, a combination, a video. I’ve seen a lot of different ways doctors have done this.”

Patients should learn what type of anesthesia is used and what types of alternative treatments are available. “When informed consent is done correctly, the patient will have all questions answered,” Holder says.

An ASC can ensure informed consent is performed correctly though audits.

“We audit 100% of charts here for 6,000 surgeries a year,” Holder says. “That’s part of what I do.”

Auditors look for completeness and follow these checklist questions regarding informed consent:

  • Is the physician’s office informed consent on the chart?
  • Was the patient asked if the surgeon discussed the surgery to be performed?
  • Was the patient asked if the surgeon explained the procedure to the patient’s satisfaction and understanding?
  • Was the patient asked if the surgeon answered all the patient’s questions?
  • Was the patient asked if there were any additional questions?

“When we audit charts, we audit for completeness and also gathering of charts for documents for peer review,” Holder says.

In addition to thorough chart audits, the ASC spot checks verbal informed consent audits.

“We have a checklist and observation tool we use so that everyone who performs the spot check is on the same page,” Holder notes. “It’s not fair to judge one person one way and another a different way.”

Auditors meet to agree on how the spot checks will be conducted. Spot checks are conducted for handwashing, informed consent, and safe injection practices. When an audit reveals a problem, Holder will meet with the employee and review policies and procedures. Often, staff will ask Holder for feedback. Checking for documentation of informed consent is the first priority in any audit or spot check. “We’re not responsible for the informed consent, but we are responsible for ensuring it takes place,” Holder says.