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Leaders, Are you Risking an RFI with your the Informed Consent Process?


By Salome Chitavi, PhD, Project Director

Who oversees informed consent in your hospital? Do patients understand what they are consenting to when they sign a form? Do health care providers (i.e. physicians, nurses, allied health professionals) know their role in the process?

Informed consent is the process of communication between a clinician and patient that results in the patient’s decision of whether or not to undergo a specific medical intervention. It is important that a patient fully understand the nature, risks, benefits and alternatives of their treatments and make an informed choice before a physician or other health care professional begins a treatment, test, or procedure. This is an area that some hospitals are struggling to comply with. In 2016, Joint Commission surveyors identified compliance issues related to informed consent in more than 500 hospital surveyed.

What is concerning is that research has shown that the process of obtaining informed consent is all too frequently minimized to a signature on a form. That’s unfortunate because this can result in a situation where a patient provides authorization for care but may not have an understanding of the care they are consenting to receive.

To improve the informed consent process, the Agency for Healthcare Research and Quality (AHRQ) engaged The Joint Commission and Abt Associates to provide guidance through development of free online courses for hospital leadership and other health care professionals. Improving the informed consent process may help to improve physician-patient communication and patient empowerment.

The on-demand courses consist of two modules:

  • The Leadership Module reviews each topic that an informed consent policy should address and provides examples from a fictional hospital of what each part of the policy could look like. The module also outlines strategies and system changes for hospitals to create a culture that supports a high-quality policy of informed consent and illustrates how to launch an informed consent quality improvement initiative. The course provides downloadable worksheets and 34 resources.
  • The Healthcare Providers Module provides strategies and tools to improve the informed consent process through effective communication and patient engagement. The concept of informed consent as a team process and tips on adequate documentation are also presented.  

An implementation guide and other resources are available on the AHRQ website. Hospitals that do not participate in The Joint Commission’s LMS may obtain the courses for their own LMS from AHRQ by emailing .