The Joint Commission: Patient Rights

TELNET 2447 November 18, 2008 10-11:30 am EST

What every hospital should know.

Speaker
By: Sue Dill Calloway RN, Esq. AD, BA, BSN, MSN, JD Attorney at Law Director of Hospital Patient Safety OHIC Insurance Co. The Doctors Company 155 E. Broad Street Columbus, Ohio 43215 614 255-7163 sdill@thedoctors.com

RI Chapter
Rights and responsibilities of the Individual (RI), A copy of the Joint Commission (TJC) patient rights chapter is available at http://www.jointcommission.org/AboutUs/Co ntactUs/ Not called JCAHO anymore, There is an outline, chapter, and history tracking form forward and backwards,

CMS Patient Rights

Remember that most hospitals accept Medicare and as such must follow the CMS Hospital CoPs, So hospital must follow these also and for all patients not just Medicare or Medicaid patients, Include both in your P&Ps, Exception is the CAH (critical access hospitals) do not have a patient rights section CMS has a patient rights section, Includes 50 pages of restraints interpretive guidelines,

The Conditions of Participation

Regulations first published in 1966 and revised and most current edition is April 11, 2008, First published in the Federal Register-42 CFR Part 482. Federal Register available at http://www.gpoaccess.gov/fr/index.html Then CMS takes and adds their directions on how to survey these in the Interpretive Guidelines, All changes at http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list. asp, Should check this website once a month,

The Revised Hospital CoPs

Memo 08-18 issued April 11, 2008 is the advance copy of the interpretive guidelines-sit behind the restraint memo,
Go to http://www.cms.hhs.gov/SurveyCertificationGenInf o/PMSR/list.asp ,
or go directly to http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/itemdetail.a sp?filterType=dual,%20date&filterValue=7|d&filterByDID=1&sortByDID=4&sortOrder=ascending&itemID=CMS1209698&intNum PerPage=10

CMS Patient Rights Standards 0115

CMS Patient Rights include: Right to notification of rights, Exercise of rights, Privacy and safety, Confidentiality of medical records, and Restraint issues. Tag 0116-214, These establish minimum protections and rights for patients,

TJC Patient Rights

Amended in 2009 as part of the Standards Improvement Initiative (SII), There are 14 (from 24) standards in the TJC RI chapter, There are 92 elements of performance, TJC is committed to protecting the rights and dignity of all patients, Must treat patients as individuals with unique personal and health needs, They need to be actively encouraged to be involved with decisions about their care, And to accept or refuse specific treatment or participate in clinical research, Hospital must protect confidentiality of information,

TJC Know Your Rights Brochure

3 FAQs on Ethics, Rights and Responsibilities

Filming And Recording FAQ

Q: Standard RI.2.50 (01.03.03), EP 7 states; "Anyone who engages in recording or filming (who is not already bound by the hospital's confidentiality policy) signs a confidentiality statement to protect the patient's identity and confidential information. Does this mean that we need to have media sign a confidentiality agreement even if the patient has consented to be filmed/recorded?

Filming And Recording FAQ

A: No. EP 7 is only applicable in those circumstances in which filming/recording intended for external use is being done without patient consent. In that situation, the party filming the images should sign a confidentiality agreement indicating that they will not show the film/photos until consent is obtained from the patient. If consent is not obtained, the identity of the patient will be masked or the film will be destroyed. If the patient has specifically consented to being filmed/recorded prior to the commencement of filming, the media or party doing the filming does not need to sign a separate confidentiality agreement.

Organ Donation FAQ (now in TS chapter)

Q: Are hospitals required to ask patients about their wishes concerning organ donation? A: No, hospitals and CAH are not required to ask patients about their organ donation wishes unless it is required by law/regulation, organization policy/procedure or OPO agreement. . If organ donation is specified in the patient's advance directive or verbally expressed by the patient, there should be documentation of the patient's wishes according to the organization's policy and procedure. The organization must honor the patient's wishes within the limits of the law or hospital capacity. Some organizations may not be capable of fully honoring the patient's wishes since they do not have the capability of sustaining life. The patient may need to be transferred and this should be in accordance with law/regulation and any applicable OPO agreement.

Consent When Videotaping or Filming

Q: Can staff or their designated agent film or videotape patient care activities in the Emergency Department? (Yes; see full answer following below) , A: Yes. It is appropriate to film or videotape patient care activities in the emergency room, provided patients -- or their family members or surrogate decision makers -give informed consent.

Patients Have the Right

Patient Rights are one of 14 Priority focus areas, Right to an appropriate level of care or service, Right to receive safe care, Respect for cultural values and religious beliefs, Privacy, Confidentiality of information, Recognition and prevention of potential abuse situations,

Patients Have the Right to

Notification of unanticipated outcomes, Involvement in care decisions, Information on risks and benefits of investigational studies, End of life care, Advance directives, Organ procurement,

Patients Have the Right

A right to have advance directives and to have them followed, Freedom from unnecessary restraints, Informed consent for various procedures, The right to refuse care, Right to have their pain believed and relieved, Communication with administration, And education,

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Individual Tracers Patient Rights

Staff discussion and observation on communication between shifts and departments, Education of patient needs with culture and language diversity, physical and cognitive challenges, Use of R&S, Process when patient refuses care, Patient and family understanding of AD, end of life decisions, right to register a complaint, and patient safety and privacy of health information,

AHA Patient Rights

New document replaces the AHA's Patients' Bill of Rights, It is a plain language brochure that informs patients about what they should expect during their hospital stay with regard to their rights and responsibilities. The brochure is available in multiple languages, http://www.aha.org/aha/ptcommunication/partners hip/index.html

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AHA Patient Rights Booklet

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RI.01.01.01 Respecting Patient Rights

The standard: The hospital respects the patient rights, EP1 There are written P&P on patient rights, EP2 Patients are informed of their rights, EP4 Patients are treated in a dignified and respectful manner, EP5 The patients rights to and need for communication must be respected,

RI.01.01.01 Respecting Patient Rights

EP6 Patients cultural and personal values, beliefs, and preferences are respected, EP7 Right to privacy is respected, See also IM.02.01.01, EP1-5, requires hospital to protect the privacy of health information, to have a P&P on this, and to disclose information only as permitted by law,

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RI.01.01.01 Respecting Patient Rights

EP8 Right to pain management is respected, EP9 Patient right to religious and spiritual service is respected by the hospital, EP10 Patients are allowed to access, request amendment, and obtain information on disclosures about their health information, As allowed by law and regulation,

RI.01.01.01 Respecting Patient Rights

Previously RI.2.10, 2.20, 2.100, 2.130, and 2.160. CMS in the hospital CoPs also has a section on patient rights, Make sure you have a written P&P on patient rights, Give patients a written copy of their rights, Can include patient rights on back side of general consent form and notice of privacy practice that all patients sign on admission or for outpatient treatment,

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What does this standard mean?

Form can say I hereby acknowledge that I have received a written copy of my patient rights, Accommodate the right to pastoral or other spiritual services, Resources to recognize and address pain, Educate staff and providers about pain, Document pain assessment and relief of pain, HIPAA requires hospitals to have a policy and procedure in which a patient can request an amendment of their medical record if they believe there is a mistake,

RI.01.01.03 Right to Receive Information

Standard: The patient had the right to receive information in a manner she will understand, EP1 The information provided to the patient needs to be tailored in a way the patient can understand considering age, language and their ability to understand, EP2 Interpreting and translation services need to be provided, EP3 Communication with patients with vision, speech or cognitive impairment is done in manner that meets the patients needs,
Previously RI.2.100,

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What does this standard mean?

Patients need to receive information in a manner they can understand and use, Issue of low health literacy, Written material should be appropriate to age and understanding of patient, Need to address needs of those with vision, speech, hearing or language problems, Post sign for interpreting services in different languages,
Interpreting services need to be provided and be sure to document,

RI.01.02.01 Right to Participate in Decisions

Standard: the patient has a right to participate in decisions about their care and treatment, EP1 Patient is involved in decision making about their care and treatment, EP2 Patient is provided with written information on their right to refuse care as allowed by law, EP3 hospital respects the patients right to refuse care as allowed by law, EP6 Surrogate decision maker is use if patient is unable to make decisions about care and treatment,

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RI.01.02.01 Right to Participate in Decisions

EP7 When surrogate decision maker is responsible for care the hospital must involve them in the decision making process, EP8 Family is involved in care when permitted by the patient or the surrogate decision maker, as allowed by law, EP20 Patient is provided information about outcomes of care that the patient needs in order to participate in their current and future health care decisions,

RI.01.02.01 Unanticipated Outcomes UO

EP21 Patient or surrogate decision maker is informed about unanticipated outcomes of care and treatment related to the TJC reviewable SE, There is a SE chapter, EP22 LIP responsible for managing patients care, or their designee, informs the patient about the UO related to SE when patient is not aware of the occurrence or Where further discussion is needed, Previously RI 2.30, 2.70, 2.80, and 2.90,

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What does this standard mean?

Document patient involvement in decisions about their care, CMS has a similar provision in allowing patients to participate in decisions about their care, Patients give informed consent, are involved in pain management decisions, and in formulating advance directives, Competent adults can refuse care but needs to be educated right so they know the risks and benefits, Recommend you get it in writing,

What does this standard mean?

Parent usually consents for minor child, If patient is incompetent document legal guardian or DPOA, Surrogate decision maker steps into shoes of incompetent patient, Have P&P on unanticipated disclosure, Educate all staff on P&P, Consider disclosure coaches, Document discussion with patient,

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National Patient Safety Foundation

Talking to patients about Health Care Injury. Available at http://www.npsf.org, When a health care injury occurs, the patient and the family or representative is entitled to a prompt explanation of how the injury occurred and its short and long-term effects. When an error contributed to the injury, the patient and the family or representative should receive a truthful and compassionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients.

ASHRM 4 documents
20 page document titled "perspective on disclosure of unanticipated outcome information, Provides examples of UO Policy and procedures, Has additional 3 documents, Disclosure: What works now and what can work even better, Disclosure: Creating an effective patient communication policy, and. Disclosure: the next step in better communications with patients,
At http://www.ashrm.org/ashrm/resources/monograph.html TDC website also has resources available at www.thedoctors.com,

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RI.01.03.01 Informed Consent

Standard: the hospital must honor the patients right to give or withhold informed consent, EP1 need written P&P on informed consent, EP2 policy identifies the care or treatment that requires informed consent as required by law, EP3 written policy describes exceptions to getting consent, EP4 policy describes the process used to get consent,

RI.01.03.01 Informed Consent

EP5 P&P describes how consent is to be documented (in form, progress note, or elsewhere), EP6 P&P describes when surrogate decision maker can give consent, References RI.01.02.01, EP 6 EP7 consent process includes discussion about the care and treatment

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RI.01.03.01 Informed Consent

EP9 Consent includes discussion of potential benefits, risks, and side effects of the proposed care, The likelihood of the patient achieving her goals, and Any potential problems that might occur during the recuperation, EP11 Consent process includes discussion about reasonable alternatives, and the risks, benefits, and side effects of the alternatives,

RI.01.03.01 Informed Consent

EP12 consent process included discussion of any circumstances under which information about the patient must be disclosed or reported, Would include reports to the department of health or the CDC regarding cases of HIV, TB, viral meningitis, or other things required,

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What does the standard mean?

CMS has 3 sections on informed consent in the hospital CoPs, Remember your state law on consent, Have a written P&P on consent, Make sure staff are aware of policy, Need list of all surgeries and procedures with yes or no if consent needed, Make sure documented in medical record, Consent on chart before surgery except in emergencies,

What does the standard mean?

Policy must include exceptions, Policy must include when surrogate decision maker signs (incompetent patient and guardian or DPOA), Make sure includes all required elements from TJC, CMS, and state law (alternatives, risks, benefits, etc.) Make sure staff and physicians understand and document conversation with patients about mandatory reporting laws (HIV, STD, TB, viral meningitis etc.)

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RI.01.03.03 Recordings and Consent

Standard: Patient has the right to give or withhold consent to use films, photographs, recordings, video, or other images for purposes other than his care, (previously RI 2.50) EP1 Hospitals may occasionally make a recording or film or other image of a patient for internal use other than for identification or diagnosis, Such as for PI or education, Need to obtain and document consent prior to producing this,

RI.01.03.03 Recordings and Consent

EP2 When photograph, filming etc is used for external use you need the patients consent before you do this, Consent must include a discussion of how the photo or film is going to be used, These are commercial filming, TV programs, or marketing material,

EP3 If patient unable to give consent for filming then it may occur as permitted by your written P&P, Which is established thru an ethical mechanism like the ethics committee and that might include community input,

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RI.01.03.03 Recordings and Consent

EP4 If the patient is unable to give consent then the film or photograph is held in the hospitals possession and not used for any purpose until consent is obtained, EP5 The hospital must destroy the film or photograph if the patients consent can not be subsequently obtained when the patient is unable to give the consent,

RI.01.03.03 Recordings and Consent

EP6 Patient needs to be informed of the right to stop production of the recording or film, EP7 Anyone who is not bound by the hospitals confidentiality policy must sign a confidentiality statement, This is done to protect the patients identity and confidential information, This must be done before the filming or production starts,

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Sample Consent Form for photography

The American Health Information Management Association (AHIMA) has a practice brief on Patient Photography, Videotaping and other Imaging. It is available at http://library.ahima.org/xpedio/groups/public/docu ments/ahima/bok2_000585.hcsp?dDocName=bo k2_000585

AHIMA.org

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Sample Consent

RI.01.03.05

Research

Standard: Patients rights during research, investigation, and clinical trials is protected, (previously RI 2.180) EP1 Research protocols must be reviewed, This includes weighing the risks and benefits to the patient participating in the research, EP2 The patient must be provided with the following to decide whether to participate or not in the research; Explanation of the purpose of the research, Expected duration or how long it will last, Description of the procedures to be followed,

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RI.01.03.05 Research
Statement of the potential benefits, risks, discomforts, and side effects, Alternatives that might be advantageous, EP3 Patient is informed that refusing to participate or discontinuing participation will not jeopardize his access to care unrelated to the research, EP4 The following must be documented in the consent form, That the patient received information to help determine whether to participate or not,

RI.01.03.05 Research
EP 6 The name of the person who provided the information and the date the form was signed must be documented, EP7 Consent form describes right to privacy, confidentiality and safety, EP9 Hospital keeps all information given to the patient in the medical record or research file along with the consent forms,

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RI.01.04.01 Persons Responsible for Care

Standard: patient has a right to information about the individuals responsible for providing care and treatment, (previously RI 2.60), EP1 patient is informed of the name of the physician and other practitioners who have primary responsibility of the patients care, EP2 patient is informed of the name of the physician or other practitioners who will provide their care,

What does the standard mean?

Patients have the right to know the name of their physician or LIP, Introduce yourself to the patient at the first interaction, Name tags or name embroider on lab coat, If the patient is incompetent then information can be given to the surrogate decision maker, parent, guardian, DPOA,

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RI.01.05.01 End of Life Care

Standard: patient decisions are addressed about care that will be received at the end of life, previously RI 2.20 and 2.80, EP1 Must have P&P on advance directives, foregoing or withdrawing life sustaining treatment, and withholding resuscitation, Must be in accordance with law or regulation, EP4 The hospital has a written P&P on whether they will honor AD in the outpatient setting, Must decide if will honor in any of the OP settings,

RI.01.05.01 End of Life Care

EP5 hospital must implement its AD P&Ps, EP6 patients are provided information in writing about AD, foregoing or withdrawing life sustaining treatment and withholding resuscitation, EP8 hospital provides information to the patient upon admission to the extent the hospital is able and willing to honor advance directives, EP9 must document if patient has AD, EP 10 hospital refers patient to resource to assist in formulating ADs upon request,

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RI.01.05.01 End of Life Care

EP11 staff and LIPs must be aware of whether or not the patient has an AD, EP12 hospital honors patients right to review or revise their AD, EP13 hospital honors AD in accordance with law and regulation, EP15 must document patients wishes regarding organ donation when she makes her wishes know or when required by hospitals P&P,

RI.01.05.01 End of Life Care

EP16 hospital honors organ donation wishes of patient within hospitals capabilities and in accordance with law and regulation, EP17 Existence or lack of an advance directive does not in any way affect the patients right to acess care and treatment, EP19 policy on AD in the outpatient setting must be communicated upon request or when warranted by the care or service provided, EP20 hospital refers outpatients to assistance to make an AD upon request,

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What does the standard mean?

Document that you ask all patients if they have an AD, Secure a copy and place on chart, Have an AD documentation sheet to collect all required information, Include if they want to make any changes to the document, Use sticker in front of chart so other departments are aware such as radiology,

Stamp or sticker on front of chart

Name:______________________________ Medical Record Number:_______________ Date:_______________________________ This patient has the following advance directives; ___ Living Will ___ Durable Power of Attorney ___ Organ donor card ___ Mental health declaration ___ DNR

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What does the standard mean?

Educate all staff on AD during orientation and if changes made (CMS CoP requirement also), Educate staff on end of life issues, Make sure you give patient this right in writing about their right to accept or refuse care including to withhold or withdrawal life sustaining treatment when allowed by law, Do medical record audit on this. Know who can fill out an AD for the patient if they dont have one and want one,

What does the standard mean?

Need to work with OPO and honor patient wishes to be an organ donor, Document one call rule to OPO (CMS requirement also), In outpatient setting need to communicate to patient what your policy is, Include in patient rights, May want to honor if presented to staff at each outpatient encounter (lab, x-ray, outpatient department, PT, etc.)

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RI.01.06.03
Standard; the patient has the right to be free from neglect, exploitation or abuse while receiving care or treatment, (Previously RI 2.150) EP1 Hospital determines how it will protect the patient from neglect, exploitation or abuse while the patient is receiving care or treatment, EP2 Must evaluate all allegations, observations, or suspected case that occur in the hospital, EP3 Must report these to appropriate authorities based on the evaluations of the suspected events, or as required by law,

What does the standard mean?

Have a policy and make sure staff is aware of it, Include definitions from both TJC and CMS CMS also has standard and requires ongoing education on abuse and neglect, Policy needs to address how it will protect patients and investigation should be through and comprehensive, Refer to board of nursing, etc. if indicated, This is a very important issues with both the Joint Commission and CMS!

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TJC defines as follows:

abuse is an intentional maltreatment of a patient which may cause injury, either physical or psychological. mental abuse includes humiliation, harassment, and threats of punishment or deprivation. physical abuse includes hitting, slapping, pinching, or kicking. Also includes controlling behavior through corporal punishment. sexual abuse includes sexual harassment, sexual coercion, and sexual assault,

RI.01.06.05 Pleasant Environment

Standard: patient has the right to an environment that preserves dignity and contributes to a positive self-image, (previously RI 2.100, 2.130, 2.140),
EP1 Hospital EOC supports patients positive self image and dignity, EP2 The number of patients in a room is based on patient ages, developmental levels, clinical conditions, and diagnostic needs for hospitals that provide long term or more than 30 days,

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RI.01.06.05 Pleasant Environment

EP4 Patient can keep and use or personal clothing and possessions unless it infringes on other rights, or Is medically or therapeutically contraindicated, EP15 Patients are provided telephones and mail based on the population setting, EP16 Must provide access to phones for patients who need a private phone conversation in a private space, based on population and setting,

RI.01.06.05 Pleasant Environment

EP17 if visitors, mail, phone calls or other forms of communication are restricted, the restriction are determined with the patients participation in LTC, EP18 these restrictions have to be justified and documented in the medical record, EP19 these restrictions have to be evaluated for therapeutic effectiveness,

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What does the standard mean?

Patients who enter the hospital have a right to a environment that is conductive to care, Unit or room becomes their home especially in LTC unit, Sufficient storage to hand clothes and possessions, Can keep personal clothing and possessions unless infringes on right, Protect confidentiality and privacy of health information,

RI.01.07.01 Complaints
Standard: patient and or her family has the right to have a complaint reviewed, (RI 2.120 previously), EP1 Hospital must establish a complaint resolution process, See also MS.09.01.01, EP1, EP2 Patient and family is informed of complaint process, EP4 Complaints must be reviewed and resolved when possible,

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RI.01.07.01 Complaints
EP6 Hospital acknowledges receipt of complaints that are recognized as significant, Hospital must notify the patient of follow up to the complaint, EP7 Must provide the patient with the phone number and address to file the complaint with the relevant state authority, EP10 The patient is allowed to voice complaints and recommend changes freely with out being subject to discrimination, coercion, reprisal, or unreasonable interruption of care,

What does the standard mean?

CMS has more stringent section on grievances in hospital CoP, Include TJC and CMS requirements in one policy, Need a formal process, CMS requires grievance committee, Do as part of your PI, Make sure patients rights tells patient who to contact if concerns or comments about their care, Include that reports can be made to QIO, TJC, or state department of health along with phone numbers,

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RI.01.07.013 Protective Services

Standard: Patient has a right to protective and advocacy services, (previously RI 2.170) EP1 Resources must be provided to help families and the court to determine the patients needs for services, When the hospital serves a population of patient that need these protective services, Such as guardianship, child or protective services, and advocacy services

RI.01.07.013 Protective Services

EP2 The hospital must maintain a list of names, addresses, and phone numbers of patient advocacy groups, such as the state authority and the protection and advocacy network, EP3 The hospital gives the list of patient advocacy groups to the patient when requested,

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What does the standard mean? The list is given to patients when requested, Hospital should have P&P, P&P should reflect your state law, For example how to get a guardianship for a patient,

RI.02.01.01 Patient Responsibilities

Standard: the patients are informed about their responsibilities related to care, treatment, and services, (previously RI 3.10), EP1 must have a written P&P that defines the responsibilities of the patients, This must include, but not be limited to, providing information, asking questions, accepting consequences, following rules and regulations,

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RI.02.01.01 Patient Responsibilities

Showing respect and consideration, Acknowledging that they do or do not understand the treatment course, And meet their financial obligations, EP2 The patients are informed of their responsibilities in accordance with the hospital P&P, Patient responsibilities should be shared with patients verbally, in writing, or both,

What does the standard mean?

The patients rights statement also contains responsibilities of the patient, These need to be in writing and given to the patient, Need P&P and should include how this information is provided to the patient such as giving separate Rights and Responsibility document, Or listed on back of consent form, Sample language for responsibilities following the end slide,

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The End Are you up to the challenge?

Patient Responsibilities
Asking questions.

Patients and their families are expected to ask questions when they do not understand something. Hospitals staff sometime talk using medical lingo. Physicians and staff may try to keep the discussion at a level the patient can understand, but it is up to the patient to tell them if they are confused.

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Patient Responsibilities
Meeting financial needs. Patients and their families should ask questions and talk with the business office about their financial obligations. They are responsible to make sure the hospital has the correct billing information and answer and assist the hospital in getting their bill paid.

Patient Responsibilities
Showing respect and consideration. Patients and families need to behave in a specific manner and decorum. Patients need to be considerate of the hospitals staff and property. They also need to be considerate of other patients and their property. Patient who plays loud music at 2am would be disruptive to his room mate or other patients,

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Patient Responsibilities
Accepting consequences. Patients and their families are accountable and responsible for the outcomes if they follow the recommended treatment recommended by the physicians and other staff. Patients who leave without being seen or leave against medical advice are responsible for the outcome that results from not following the recommended treatment plan. (cont on next page)

Patient Responsibilities
Healthcare professionals often make recommendations such as smoking cessation, reduction of weight, or dietary recommendations that are based on the medical evidence of providing positive outcomes and which are in the best interest of the patients. It is not fair to the healthcare provider to not follow their advice and expect the provider to be responsible.

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Patient Responsibilities
Following rules and regulations. All healthcare facilities have rules and regulations that must be followed. Rules and regulations are necessary for a variety of reasons including infection control and patient safety considerations. Restriction of minors visiting certain areas, or use of cell phones next to critical care equipment to patients wearing gowns in the operating rooms are all example of typical rules that patients and their families must follow for the safety of all,

Patient Responsibilities
Following instructions. All patients must follow instructions that are provided by their physicians and staff. Patients need to follow their plan of care and treatment. Hospitals make every effort to adapt the plan to the specific needs of the patient. If adaptation to the care, treatment, and service plan are not followed, then the patient is informed of the consequences of what can happen if they dont,

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Patient Responsibilities
Providing information. Patients need to provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health. Patients should answer all questions truthfully. Patients can help the hospital by also providing honest feedback about their services and expectation.

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