Revisions to RI chapter requirements address informed consent, audiovisual information

Effective July 1, 2022, The Joint Commission has approved revisions to the Rights and Responsibilities of the Individual (RI) chapter for hospitals, critical access hospitals, ambulatory health care organizations, behavioral health care and human services organizations, home care organizations, and nursing care centers.

These revisions were made after an internal review and address a written policy on informed consent and organizational use of images, films, and recordings of patients.

The Joint Commission added a new bullet to Standard RI.01.03.01, Element of Performance (EP) 1, that requires organizational policies to include who is qualified under law and regulation to conduct informed consent discussions. The informed consent discussion is an opportunity to establish a mutual understanding between the patient and the licensed practitioner about a proposed procedure or treatment and the risks, benefits, and side effects of the proposed and alternative procedures or treatments.

In addition, for ambulatory health care organizations, the bullet stating, “Circumstances that would allow for exceptions to obtaining informed consent” will be deleted from RI.01.03.01, EP 1, because organizational policies that relate to informed consent should sufficiently address all procedures or treatments performed in the organization.

The Joint Commission also is deleting Standard RI.01.03.01, EP 3, that requires organizations to obtain patients’ informed consent prior to making and using recordings, films, or other images of patients. This requirement will be replaced with a new EP at Standard RI.01.01.01 that more broadly addresses issues related to protecting patients’ rights.

The Joint Commission recognizes that the ease of capture and portability of audiovisual information can potentially pose risks to patient privacy. However, such information also can be beneficial for treatment, payment, and health care operations, such as education and internal performance improvement. This new EP will require health care organizations to comply with applicable laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), when making and using recordings, films, or other images of patients. The Joint Commission will continue to evaluate compliance with applicable federal and state requirements.

View the prepublication standards.