UCLA takes hard look at admission consent form
Project leads to examination of larger issues
A query to legal counsel about the ramifications of patients refusing to sign a clause on the conditions of admission form has mushroomed into a revamping of the form and a comprehensive reexamination of informed consent issues throughout the University of California at Los Angeles (UCLA) Medical Center.
UCLA Medical Center, like many other teaching hospitals, asks patients to consent to having interns participate in their care and having the results of their treatment used in research projects, explains Cynthia Frizelle, RN, acting director of admissions and registration. Those requests are on a list of consent items that patients are asked to sign before they’re admitted to the hospital or treated as an outpatient.
"In the past, we simply refused to see patients who didn’t sign the clause," Frizelle explains. "Now there’s so much competition, we’re having to rethink that stance. It’s a public relations issue."
Task force looks at consent process
A discussion with the medical center’s legal counsel about how to handle a refusal to sign the consent for research clause led to the formation of a task force to look at the entire consent for admission form, she says. This includes such issues as form content, how it impacts various departments, who should authorize changes and explain them to the patient, and, if alterations are made, how to disseminate that information.
In addition to Frizelle, the task force includes representatives from patient relations, risk management, legal counsel, research programs, and ambulatory services.
"We decided to look at each of the [form’s] components step by step, to see what we eeded to do with that component," she says. "The research clause brought this to light, but we thought we might as well look at everything. Every time you reprint [a form], it’s a major deal."
With as many as 2,300 admissions a month, even a small percentage of consent problems can be time-consuming and confusing, she notes. And even though outpatients are required to sign only one consent per year, those can get complicated when the usual insurer isn’t responsible for a visit as when a person is injured on the job and therefore covered by workers’ compensation.
"It doesn’t happen that often, but when that one conflict comes about when patients refuse to sign or want to scratch out or alter parts of the form it may take hours," Frizelle explains. "Many people get involved, and it’s labor-intensive as well as being a public relations issue. We felt it was important to provide guidelines and do preventive work so issues wouldn’t come up later."
All patients over age 18 and emancipated minors must sign the Terms and Conditions of Service upon admission or registration, according to UCLA Medical Center policy. If a patient refuses to sign the document, only emergency care can be provided, backed by physician documentation to support emergency care services.
If a patient is unable to sign, the policy states, the patient’s representative with legal power of attorney for medical care may sign on his or her behalf.
The task force has proposed a revised policy specifying that if a patient wishes to alter the Terms and Conditions of Service in any way, approval must be obtained from the following administrative personnel:
• admissions and registration director or designee (both inpatients and outpatients);
• practice plan chief administrative officer (outpatients only);
• patient relations manager (both inpatients and outpatients);
• ambulatory care assistant director (outpatients only);
• director of risk management (both inpatients and outpatients);
• medical center associate directors, deputy director or directors (both inpatients and outpatients).
The proposed guidelines for altering sections of the consent form subject to the approval of the above personnel are as follows:
1. Medical consent.
This section, by which patients consent to medical treatments or procedures by the attending physicians assigned to their care, may not be altered under any circumstances. Patients who won’t sign the form because of this clause may be provided only with emergency services.
2. Teaching institution clause.
This section which was the impetus for the form revision provides that residents, interns, medical students, and students of other health care professions may participate, under the supervision of the attending physician, in patient care as part of the institution’s medical education program.
The revised policy specifies the following in regard to this clause:
A. If the patient is consulting with a private attending physician on a one-day visit only, the matter should be discussed with the attending. If the attending physician agrees not to include residents or students, that portion of the conditions of admission (COA) "The COA must be valid for consultation visit only (specific date)" may be crossed out.
B. If the patient is being seen by a "service," this section of the COA cannot be altered because the institution cannot guarantee that residents or students will not be involved in patient care.
3. Release of information.
This section authorizes UCLA Medical Center to furnish information from the patient’s medical record to the referring physician and others in connection with a claim for aid, insurance, or medical assistance. It also authorizes the medical center to release information to a collection agency to which the patient’s account may be referred. It can’t be altered under any circumstances, the policy states.
4. Financial agreement.
This section, which requires the patient to pay for medical center and physician services, cannot be altered under any circumstances.
5. Medicare benefits.
With this section, the patient certifies that information given in applying for payment under Title XVIII of the Social Security Act is correct, authorizes the release of information needed for a Medicare claim to the Social Security Adminis-tration, and requests that payment of authorized benefits be made on his or her behalf to the medical center. According to the revised policy, this section may be stricken if the patient is not eligible or covered under Medicare and pays cash for services in advance.
6. Research institution.
With this section, the patient agrees that any data or specimens obtained during treatment may be used in research which may or may not be related to the treatment or condition, and that the patient has no property or ownership interest in such specimens.
The proposed changes to the form include the elimination of this clause. Until then, the policy states, any questions or proposed changes must be referred to approved administrative personnel as described above.
7. Home care.
This section states that requests for home care services and equipment are referred to the UCLA home care program unless otherwise ordered or requested. The task force determined that there’s no need for this clause and that it should be removed from the form at next printing.
8. Personal valuables.
This section, which states that the medical center won’t be held liable for patients’ money or valuables unless they’re put in the its fireproof safe, can’t be stricken under any circumstances.
The form contains a section on "Insurance Assignments" that authorizes payment of insurance benefits directly to UCLA Medical Center. Under the proposed revisions, this section may be stricken if an end date is specified or if the words "for this admission only" or "for this visit only" are included on the form and if the patient pays for all services in cash and in advance.
Normally, a mechanism in the medical center’s admission, discharge, and transfer system puts an expiration date of six months from the present on the consent form. If the consent form is altered however, the expiration date is changed to the next day, and the patient gets a new COA form on his or her next visit, Frizelle explains.
The task force looking at the Terms and Conditions of Service expects to wrap up its mission soon, with a new document that will be sent to the hospital forms committee for review.
More consent issues uncovered
However, in the process of reviewing the COA form, other informed consent issues were uncovered and are now being examined by a larger committee, Frizelle says. That group is trying to determine how many types of consent forms are in use at the medical center and is reviewing procedures associated with them.
These include consents for surgical and radiology procedures and for various research protocols, Frizelle says. The committee "has identified 13 consents so far, and the consultant who’s working with us said he wouldn’t be surprised if we came up with between 40 and 60 when the search is done."
The larger consent committee, she says, is looking at such issues as whether the consent process is handled the same way by different physicians performing the same procedure, and the potential impact of inconsistencies in the process.
In examining the consent process, the com-mittee has identified some unnecessary steps, Frizelle says. For example, when a patient who is unable to sign a consent arrives, the facility requires that two physicians sign a piece of paper attesting to the need for treatment and the patient’s inability to sign.
"The consultant said he had never heard of that and asked why we were doing it," she says. "California law requires only that it be mentioned in the notes [in the patient’s file] that it was an emergency situation."
The requirement, which she describes as "very labor-intensive," probably will be eliminated, Frizelle adds.
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