joint commission patient rights what every hospital should know

Joint Commission Patient Rights

What every hospital should know.

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Speaker

Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD

President Patient Safety and Healthcare Education 5447 Fawnbrook Lane Dublin, Ohio 43017

614 [email protected]

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Patient Rights Will discuss the following:

CMS patient rights guidelines

TJC brochure on patient rights

TJC tracer questions on patient rights

Patient rights as one of the 14 priority focus areas

TJC standards on patient rights

TJC has 3 FAQs on patient rights

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RI Chapter Rights and responsibilities of the Individual and

abbreviated RI Chapter

The Joint Commission

Will refer to as TJC and not called JCAHO anymore

Patient rights is important with both TJC and CMS and TJC has made changes

TJC eliminates RI.01.06.05 EP1 July 1, 2010

New change 2011 on patient centered communication which was previously called patient provider communication

CMS has a patient rights chapter which is extensive

Patient Provider Communication RI.01.01.01

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Jan 1, 2011 Patient Centered Communication

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CMS CoP Hospital Patient Rights Remember that most hospitals accept Medicare

and as such must follow the CMS Hospital CoPs

So hospital must follow these 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 except will add visitation and QIO/State agency notification

CMS has a patient rights section Includes 50 pages of restraints interpretive guidelines

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The Revised Final CoPs Final interpretive guidelines were published June 5,

2009 Anesthesia ones changes December 30, 2009 and February 5, 2010,

May 21, 2010 and February 14, 2011

Respiratory and Rehab orders updated October 1, 2010

Visitation regulations effective Jan 18, 2011 but interpretive guidelines not out yet

Has section on grievances, patient rights, and advance directives

Every hospital should have a copy of this!!! www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf

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www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf

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The Conditions of ParticipationFirst 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 and some have survey procedures,

Should check the below website once a month to check for changes

Changes on Survey and Certification website at www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

Also some changes at Transmittals at www.cms.gov/Transmittals/01_overview.asp

CMS Survey & Certification Website

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www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/

list.asp

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CMS Patient Rights Standards 0116-214

CMS Patient Rights include:

Right to notification of rights and exercise of rights

Privacy and safety

Confidentiality of medical records and

Restraint issues

QIO and state agency notification

Visitation rights

These establish minimum protections and rights for patients

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TJC Patient Rights Many changes in 2009 as part of the Standards

Improvement Initiative (SII) which continue into 2011

There are 14 (from 24) standards in the TJC RI chapter

There are 91 elements of performance (one deleted July 2010 and one added 2011

TJC is committed to protecting the rights and dignity of all patients

Must treat patients as individuals with unique personal and health needs

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TJC Patient Rights Overview

Patients need to be actively encouraged to be involved with decisions about their care

Empowered patients ask more questions and develop better relationships with their caregivers

The acknowledgement of patient rights helps patients feel more supported by the hospital and staff involved with their care

Patients have an obligation to take on certain responsibilities

These are defined and relayed to the patients

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TJC Patient Rights Overview

TJC, unlike CMS, has patient obligations and responsibilities

Mere list of rights does not itself guarantee those rights

Hospital must show its support of patient rights in the actions it takes

Hospitals need to make sure patients are informed of their rights

Hospitals must help patient to understand their rights and exercise their rights

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TJC Rights Include

The right to effective communication

The right to participate in care decisions

The right to informed consent

The right to know care providers

The right to participate in end-of-life decisions

Individual rights of patients

Patient responsibilities

Overview of TJC RI Chapter

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TJC Revised Requirements

Recall discussion that Mar 26, 2009 TJC issues 27 pages of changes to the TJC hospital manual that continue into 2010,

Will discuss the changes made

TJC has a flier on the speak up program encouraging patients to know their rights at www.jointcommission.org/PatientSafety/SpeakUp/,

,

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TJC Changes to Comply with CMS CoPs

RI.01.01.01.01 when patients request access to medical record information, hospital need to provide as quickly as record keeping system allows

RI.01.02.01 patient has a right to have family member notified of admission to hospital and to have own physician notified (even if not the admitting physician)

RI.01.05.01 the hospital defines how it obtains and documents permission to perform an autopsy,

RI.01.07.01 Grievances and now 20 EPs

TJC Know Your Rights Brochure

TJC has a flier on the speak up program encouraging patients to know their rights at

http://www.jointcommission.org/speakup.aspx

It is called “Speak Up Know Your Rights”

Issued March 15, 2011

Discusses questions for patients to ask their doctor

Discusses what are the patient’s rights

Discusses having a patient advocate to stay with them, consent, how to file a complaint etc.

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TJC Know Your Rights Brochure

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www.jointcommission.org/speakup.aspx

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FAQ on Patient Rights

TJC has 3 topics under FAQs on RI

Organ donation one but this standard is now in the Transplant chapter

Filming and recording

Patient rights and informed consent when videotaping or filming

All revised November 24, 2008

– at www.jointcommission.org/standards_information/jcfaq.aspx

3 FAQs on Rights and Responsibilities

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These will be covered under the standards

http://www.jointcommission.org/standards_information/jcfaq.aspx

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Filming And Recording FAQ

Q: Standard RI.01.03.03 EP 7 states;

Before engaging in recording or filming anyone 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?

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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.

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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 ED, provided patients or their family members or surrogate decision makers give informed consent.

FAQ on Videotaping and Consent

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Patients Right is One of 14 PFAs

TJC has 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 and confidentiality of information

Recognition and prevention of potential abuse situations

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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

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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

To chose their visitors

And education

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Individual Tracers Patient Rights

Not a hospital program specific tracer like patient flow or suicidal prevention

However, TJC 2011 Survey Guide states patient rights tracer is done as part of the individual tracer

When surveyor interviews patients and families

Things surveyor may look at or observe

Staff discussion and observation on communication between shifts and departments,

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Individual Tracers Patient Rights Surveyor to talk with staff about the following and

to observe these during the survey process;

Communication between shifts and departments

Education within the confines of patient needs, physical and cognitive challenges, culture and language diversity

Use of restraint and seclusion

Process when a patient refuses care

Process to inform family, surrogate, or another physician of admission when requested by patient

Individual Tracers Patient Rights

Surveyor is instructed to interview the patient and the family to determine their understanding of the following;

Rights, prior to receiving or discontinuing care

This includes advanced directive and end of life decisions

Patient safety and personal and health information privacy

Hospital would want to make sure that white boards with things such as patient names and diagnosis are not visible to the public

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AHA Patient Rights A different AHA document replaces the AHA's

Patients' Bill of Rights

It is called “The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities”

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 eight languages

http://www.aha.org/aha/issues/Communicating-With-Patients/index.html

AHA Patient Rights Brochure

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http://www.aha.org/aha/issues/Communicating-With-Patients/index.html

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AHA Patient Rights Booklet

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AHA Patient Rights Expectations

High quality care

Clean and safe environment

Discussing your medical condition

Information about medically appropriate treatment choices

Discussing your treatment plan

Right to get information from the patient

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AHA Patient Rights Expectations

Understanding who can make decisions if you can not

Involvement in your care

Protection of patient privacy

Help with bill and filling insurance claims

Preparing for discharge

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RI.01.01.01 Respecting Patient Rights

The standard: The hospital respects, respects and promotes 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 effective communication must be respected

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EP6 Patients cultural and personal values, beliefs, and preferences are respected

EP7 Right to privacy is respected

Discusses personal right to privacy

See also IM.02.01.01, EP1-5 which requires the 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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EP8 Right to pain management is respected

EP9 Patient right to religious and spiritual service is accommodated 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,

New EP 28 and 29 in 2011 on patient centered communication

RI.01.01.01 Respecting Patient Rights EP 28 A family member,friend, or other individual to

be allowed to be present with the patient for emotional support during the course of stay

Unless the presence infringes on others' rights, safety

Unless it is medically or therapeutically contraindicated

The person may or may not be the patient's surrogate decision-maker or legally authorized representative

EP 29 Discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression is prohibited

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RI.01.01.01 Respecting Patient Rights These first new EPs will not be counted against the

hospital until January of 2011 and the visitation one became effective July 1, 2011

CMS has passed a federal regulation effective January 19, 2011

The regulation requires you to give the patient, in writing, information about visitation

This must be documented in the medical record

For example, if you limit visitors in the ICU to two, this would be permitted, but patient gets to pick the two people such as a same sex partner or best friend

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2011 Changes MR Must Contain New in 2011 to improve patient centered

communication

Qualifications for language interpreters and translators will be met through proficiency, assessment, education, training, and experience

Hospitals need to determine the patient’s oral and written communication needs and their preferred language for discussing health care under PC standard

Hospital will communicate with patients in a manner that meets their communication needs

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2011 Changes MR Must Contain

Hospitals required to collecting race and ethnicity data under RC.02.01.01 EP1

Patients should self report so patient states she is white and Albanian

Collecting language data under RC.02.01.01 EP1

The patient’s communication needs, including preferred language for discussing health care

If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the MR

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RI.01.01.01 Respecting Patient RightsCMS 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

Communication with patient is important

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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


Hospitals and other healthcare facilities will encounter more patients with language barriers as our country becomes more diverse

Hospitals must have language access services for translators and interpreters to meet the communication needs of patients

Communication is a critical part of patient safety and risk management

This is what lead the Joint Commission to adopt five standards in four different chapter on patient centered care to ensure patient provider communication

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RI.01.01.03 Respecting Patient Rights Communication is the cornerstone of patient safety

and quality

Effective communication allows the patient to participate more fully in their care

Good communications prevent medical errors

Communicating is critical during the informed consent

There are 50 million people in this country whose English is not their primary language

Low health literacy is another important issue54


Many patients way require alternative communication methods

Patients who speak other languages than English

Patients with limited literacy in any language (LEP)

Patient with visual or hearing impairments or on ventilators

Hospitals needs interpreters and translated written material

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Interpreters Are Required by Law Title VI of Civil Rights Act

Executive Order 13166

Policy guidance from the Office of Civil Rights regarding compliance with Title VI, 2004

Title III of the Americans with Disabilities Act, 1990

State laws (many states have laws and regulations that require the provision of language assistance) and the American Medical Association Office Guide to Limited English Proficiency (LEP) Patient Care

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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 Language interpreting and translation services are provided by the hospital

EP3 Information is provided to the patient who has vision, speech, hearing, or cognitive impairments

This must be provided in a manner that meets the patient’s needs

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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 and that they are available at no charge

Interpreting services need to be provided and be sure to document in the medical record

What are Surveyors Looking For? The hospital has a P&P on language access

services

That staff are oriented and trained in the P&P

That language access is used at the critical times or points of care and staff know how to access these

That staff and physicians understand the patient has the legal right to interpreting and translation services

How the hospital designed the program and addition to their demographics with the population served

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What are Surveyors Looking For? Surveyors will observe if staff follow the P&P to make

sure patients communication needs are met

May do as part of a tracer and select a patient who does not speak English

What is the hospital’s plan for language access, accessibility and that it is in good working order

Make sure bilingual staff have training on how to be an interpreter

Do not use a child to interpret and family members Exception for family members if patient insists, get it in writing, use

interpreter to obtain, make sure knows at no expense to the patient

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What are Surveyors Looking For?

Will make sure patients are informed about their rights and consider posting sign

Will verify there is documentation about the use of an interpreter

Will verify that there is documentation about the patient’s preferred language for discussing health care

That race and ethnicity data is collected in the MR

Will assess if the patient uses any assistive devices and these were used to help the patient

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What are Surveyors Looking For? Consider providing patient rights materials in

multiple language along with other important documents for patient population served

Understand when person is qualified and when certified to be an intepreter

Identify patient cultural, religious, or spiritual beliefs and practices that influence care

The Roadmap for Hospitals has a number of excellent recommendations for ensuring a quality interpreting and translation program

This is available at no charge62

Advancing Effective Communication Roadmap

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals is a monograph developed by TJC

To help hospitals incorporate concepts from the communication, cultural competence, and patient- and family-centered care fields into their facility

The Roadmap will help hospitals to comply with the patient-centered communication standards

Has educational tools

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Communication Roadmap

Includes information on the law

Includes model policies

Includes a self assessment guide

Provides examples for each standard

Roadmap Updated August 2010

See also Hospitals, Language, and Culture A Snapshot of the Nation

See One Size Does Not Fit All: Meeting the Healthcare Needs of Diverse Populations

Available at http://www.jointcommission.org/patientsafety/hlc/64

Study Finds Few Hospitals in Compliance

Study published February 14, 2011 finds few hospitals in compliance with the TJC standards on patient centered communication

Lack of compliance with language access requirements for limited English proficiency (LEP)

Communication breakdowns are responsible for 3,000 unexpected death every year

Standards to improve patient provider communication and ensure patient safety "The New Joint Commission Standards for Patient-Centered Care," report

can be found at http://www.languageline.com/jointcommission2011report

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Topics Covered in the White Paper

Language challenges that impact healthcare

Why language services are critical

The unfortunate truth: most hospitals are not compliant

The origins of medical interpreting

Patient/provider understanding and acceptance

Joint Commission mandates for training and certification

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Topics Covered in the White Paper

The standards that apply to language access services

The consequences of non-compliance

Developing a system-wide language services program

The Joint Commission is serious

Hospitals CAN prepare themselves

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TJC R3 Report

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http://www.jointcommission.org/R3_issue1/

OIG Examines Provisions of Language Services

Medicare Improvements for Patients and Providers Act of 2008 requires survey of hospitals and others with high number of limited English proficient individuals (LEP)

Only 2/3 of hospitals use the Office of Civil Rights four factor assessment to determine which language services are appropriate for a patient

Only 33% of providers offered services consistent with the Office of Minority Health's Culturally and Linguistically Appropriate Services in Health Care voluntary standards

Report OEI-05-10-00050 issued July 2010 at www.oig.hhs.gov

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TJC Video Improving Patient-Provider Communication

The Joint Commission and the HHS Office of Civil Rights has a resource that hospitals should be aware of at www.jointcommission.org

It is a 31 minute video on how to improve patient-provider communication

It is available at no charge

Initially standard referred to as patient-provider communication

More recently referred to as patient-centered communication

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www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/ecinfo.html

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www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/index.html

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RI.01.02.01 Right to Participate in Decisions

Standard: the patient has a right to participate in decisions about their care and treatment

Right is not to be construed as mechanism to demand medically unnecessary care (DS)

EP1 Patient is involved in decision making about their care and treatment

Including right to have own physician notified promptly upon admission

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EP2 Patient is provided with written information on their right to refuse care as allowed by law

EP3 Hospital respects the patient’s right to refuse care as allowed by law

EP6 Surrogate decision maker is used if patient is unable to make decisions about care and treatment

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EP7 When surrogate decision maker is responsible for care the hospital must respect their decision to refuse care (changes)

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

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RI.01.02.01 Unanticipated Outcomes

EP21 Patient or surrogate decision maker is informed about unanticipated outcomes (UO) of care that related to reviewable sentinel events TJC sentinel event chapter has definition of reviewable

sentinel event

EP22 LIP is responsible to manage patient care and inform about UO related to sentinel event if patient is not already aware of this

Where further discussion is needed

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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 get 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

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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.

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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 patientsAt http://www.ashrm.org/ashrm/resources/monograph.html

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RI.01.03.01 Informed Consent

Standard: the hospital must honor the patient’s 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

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EP4 Policy describes the process used to get consent

Remember informed consent is a process

It is not just a form

EP5 P&P describes how consent is to be documented

Documentation must be in a form, progress note, or elsewhere in the medical record

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RI.01.03.01 Informed ConsentEP6 P&P describes when surrogate decision maker can give consent

References RI.01.02.01, EP 6

For example patient is incompetent and has a guardian appointed or a durable power of attorney for healthcare

Parents make decisions for their two year old child

EP7 Consent process includes discussion about the proposed care and treatment

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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

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RI.01.03.01 Informed ConsentEP12 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

EP13 Consent is obtained in accordance with Hospital P&P prior to surgery unless an emergency

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What Does This 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

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What Does This 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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Consider List of Procedures

Procedure Name Requires Informed Consent

Ablations Yes

Amniocentesis Yes

Angiogram Yes

Angiography Yes

Angioplasties Yes

Arthrogram Yes

Arterial Line insertion (performed alone) Yes

Aspiration Cyst (simple/minor) No

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Informed Consent Manual

One hospital (Providence Everett Medical Center) has their informed consent manual on the Internet1

It has an excellent list of which procedures need informed consent

List can be used by others to determine which procedures they want to have informed consent

Link with MS Office on what procedures are being done in your facility

Remember procedures with reasonable known risks should be considered

1 http://www.lucidoc.com/cgi/doc-gw.pl/ref/pemc_p:10127

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Informed Consent Forms Need for all surgeries except in emergencies

All inpatients and outpatients

For all procedures specified

Needs to reflect a process

Form must follow policies

Must include state or federal requirements

Must contain minimum requirements (mandatory)

CMS has 6 mandatory issues for consent and optional ones called well designed

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Resources

A site for consent forms that list the risks, and complications, and alternatives of many procedures (provided by the Queensland Government.)1

They have forms for pediatrics, orthopedics, vascular, urology, surgical, renal, plastic surgery, psychiatry, ophthalmology, maxillofacial, medical imaging, neurosurgery, ear, nose and throat and many more.2

1 http://www.health.qld.gov.au/informedconsent/ConsentForms/14025.pdf

2 http://www.health.qld.gov.au/consent/html/for_clinicians.asp

http://www.health.qld.gov.au/consent/

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www.health.qld.gov.au/consent/

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www.health.qld.gov.au/consent/

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www.mnpatientsafety.org/index.php?option=com_content&task=view&id=85&Itemid=69

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www.hhs.gov/forms/HHS-687.pdf

So What’s In Your Policy?

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So What’s In Your Policy?

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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

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

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RI.01.03.03 Recordings and Consent EP2 When photograph, filming etc is used for external use

you need the patient’s 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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EP4 If the patient is unable to give consent then the film or photograph is held in the hospital’s possession

And it is not used for any purpose until consent is obtained

EP5 The hospital must destroy the film or photograph if the patient’s consent can not be subsequently obtained when the patient is unable to give the consent

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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 hospital’s confidentiality policy must sign a confidentiality statement

This is done to protect the patient’s identity and confidential information

This must be done before the filming or production starts

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EP8 The organization accommodates the patient's right to rescind consent before the recording, film, or image is used

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/documents/ahima/bok2_000585.hcsp?dDocName=bok2_000585

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AHIMA.org

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Sample Consent

Be Aware of Your Hospital Policy

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RI.01.03.05 Research Standard: Patient’s rights during research,

investigation, and clinical trials is protected

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,

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EP5 The hospital documents the following in the research consent form:

That the patient was informed that refusing to participate in research, investigation, or clinical trials

or discontinuing participation at any time will not jeopardize his or her access to care

treatment, and services unrelated to the research

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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

EP1 Patient is informed of the name of the physician and other practitioners who have primary responsibility of the patient’s care

EP2 Patient is informed of the name of the physician, clinical psychologist, or other practitioners who will provide their care

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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

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

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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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EP11 Staff and LIPs must be aware of whether or not the patient has an AD

EP12 Hospital honors patient’s right to review or revise their AD

EP13 Hospital honors AD in accordance with law and regulation and the hospital's capabilities

EP15 Must document patient’s wishes regarding organ donation when she makes her wishes know or when required by hospital’s P&P

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RI.01.05.01 End of Life Care EP16 Hospital honors organ donation wishes of

patient within hospital’s capabilities and in accordance with law and regulation

EP17 Existence or lack of an advance directive does not in any way affect the patient’s right to access 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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EP 21-For hospitals that use Joint Commission accreditation for deemed status (DS) purposes

The hospital defines how it obtains and documents permission to perform an autopsy

CMS CoP requirement

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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

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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 This Standard Mean? Educate all staff on AD CoP requirement also)

Educate staff on en during orientation and if changes made (CMS d 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 don’t have one and want one

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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.)

Know Your Hospital Policy on DNR

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128

RI.01.06.03 Neglect and AbuseStandard; the patient has the right to be free from neglect, exploitation or verbal, mental, and sexual abuse

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

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What Does This 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

Make Sure Policy has TJC, CMS, & State Law

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RI.01.06.05 Pleasant EnvironmentStandard: patient has the right to an environment that preserves dignity and contributes to a positive self-image Hospitals that provide longer term care

EP1 Hospital EOC supports patient’s positive self image and dignity (eliminated July 1, 2010)

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

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RI.01.06.05 Pleasant Environment The following are for patients who are inpatients for

more than 30 days

EP17 If visitors, mail, phone calls or other forms of communication are restricted, the restriction are determined with the patient’s 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 This 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 possession,

Can keep personal clothing and possessions unless infringes on right

Protect confidentiality and privacy of health information

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RI.01.07.01 Complaints & Grievances

Standard: Patient and or her family has the right to have a complaint reviewed TJC calls it complaints and CMS calls it grievances

EP1 Hospital must establish a complaint resolution process

See also MS.09.01.01, EP1

EP2 Patient and family is informed of the complaint resolution process

EP4 Complaints must be reviewed and resolved when possible

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RI.01.07.01 Complaints & Grievances EP6 Hospital acknowledges receipt of a complaint

that cannot be resolved immediately

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

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RI.01.07.01 Complaints and Grievances

EP 17 Board reviews and resolves grievances unless it delegates this in writing to a grievance committee (eliminated but still CMS requirement)

EP 18 Hospital provides individual with a written notice of its decision which includes (DS)

Name of hospital contact person

Steps taken on behalf of the individual to investigate the complaint

Results of the process

Date of completion of the grievance process

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RI.01.07.01 Complaints and Grievances

EP19 Hospital determines the time frame for complaint review and response(DS)

EP20 Process for resolving grievances includes a timely referral of patient concerns regarding quality of care or premature discharge to the QIO (DS)

EP21 Board approves the C&G process (eliminated but still CMS standard)

Note that CMS has detailed section on grievances starting at tag number A-0118

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QIOQIO or Quality Improvement Organizations are CMS contractors

Charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting

QIOs to make beneficiaries aware of fact they have a complaint regarding the quality of care, disagree with coverage decision or wish to appeal a premature discharge

Patient can ask that complaint be forwarded to the QIO by the hospital

List of QIOs at http://www.qualitynet.org/dcs/ContentServer?pagename=Medqic/MQGeneralPage/GeneralPageTemplate&name=QIO%20Listings

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CMS Definition of Grievance A-0118

Definition: A patient grievance is a formal or informal written or verbal complaint

when the verbal complaint about patient care is not resolved at the time of the complaint by staff present

by a patient, or a patient’s representative, regarding the patient’s care, abuse, or neglect, issues related to the hospital’s compliance with the CMS CoP

or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489

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What Does This Standard Mean? CMS has similar 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.01.07.03 Protective Services

Standard: Patient has a right to protective and advocacy services

EP1 Resources must be provided to help families and the court to determine the patient’s 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

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RI.01.07.03 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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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.01.07.07 Long Term Psych Services

Standard: The hospital protects the rights of patients who work for or on behalf of the hospital for psychiatric hospital settings that provide longer term care (more than 30 days)

EP1 Have a written P&P that addresses situation in which patients would be allowed to work for the hospital

EP2 Hospital must follow or implement this P&P

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RI.01.07.07 Long Term Psych Services

EP3 Patients must be paid for work on behalf of the hospital as in accordance with law and regulation

EP4 Must incorporate the work performed on behalf of the hospital into the plan of care

EP5 Patients have the right to refuse to work for or on behalf of the hospital

New standards

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RI.02.01.01 Patient Responsibilities

Standard: The patients are informed about their responsibilities related to care, treatment, and services To support consistent responsibilities of patients

To support communication with patients

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

Supporting mutual consideration and respect by maintaining civil language and conduct

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

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What Does This 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 Questions?

Sue Dill Calloway RN, Esq. CPHRM

AD, BA, BSN, MSN, JD

Additional resources on Consent for research

CMS visitation rights for those who want more information

Sample language for patient responsibilities and billing practices

Information on who is qualified or certified to be an interpreter

152152

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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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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.

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Showing respect and consideration.

Patients and families need to behave in a specific manner and decorum. Patients need to be considerate of the hospital’s 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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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. (con’t on next page)

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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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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,

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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 don’t,

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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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Patient Friendly Billing Project

Project spear headed by HFMA to promote clear and concise patient friendly financial communication,

Addresses patient’s rights to understand and prepare for their financial obligation

Patients want to know what they will be expected to pay

www.hfma.org/library/revenue/PatientFriendlyBilling/

TJC HR.01.02.01 Pt Centered Communication

Standard: The hospital defines staff qualifications

Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training and experience

Hospital has flexibility to define the qualifications for their interpreters and translators

– The use of qualified interpreters and translators is supported by the ADA, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964

– The federal laws will be discussed later

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HR.01.02.01 Examples

Someone who is fluent in Spanish and has attended a minimum 40 hour education class is qualified to be an interpreter

There is no current national certification specifically for healthcare interpreters

However, two organizations were formed to meet the needs for providing certification of professional competence that meet national standards of knowledge, skill, and performance for healthcare interpreters

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HR.01.02.01 Examples There are now two organization that provide

certification of professional competence in Spanish

First one in September 2009

– Certification Commission for Healthcare Interpreters CCHI

Second one effective January of 2011

– It is an oral and written exam from National Board of Certification

– So now this person is qualified and certified

– Offered only in Spanish but other languages forthcoming

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Education Content of Programs CCHI

166

Qualifications to Take Exam CCHI

Healthcare Interpreters must meet the following eligibility requirements before they can apply for the examination. Minimum age of 18 years.

At least one year of experience working as a healthcare interpreter.

Have a minimum of U.S. high school diploma (or GED) or its equivalent from another country.

Have at least 40 hours of healthcare interpreter training (academic or non-academic program).

Have linguistic proficiency in English and the target language(s).

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HR.01.02.01 How to Meet the Standard

HR should be aware of the certification status

Current confusion around issue of certification

ATA has program for translators of documents but current passage rate is only about 20%

Certification exists for American sign language (ASL) for the deaf

New emerging area for interpreters for standards for new interpreters education

Many formal programs and colleges adding this to their curriculum

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Certification and Meeting the Standard HR should make sure medical interpreters have formal

education and be trained and assessed in medical interpretation and experience

HR should maintain a file on all interpreters regardless of their employment status

Same level of documentation with remote telephone or video language service providers

American Sign Language (ASL) interpreters may receive national certification through a joint program of the Registry of Interpreters for the Deaf (RID) and the National Association of the Deaf

The ASL interpreter certifications is not specific to health care169

Certification CHI AHI CMI QMI SMI National Council on Interpreting in Health Care and

CCHI or the Certification Commission for Healthcare Interpreters (CCHI Associate Healthcare Interpreter credential and has two credentials)

CHI stands for Certified Healthcare Interpreter (best)

AHI stands for Associate Healthcare Interpreter

The National Board of Certification for Medical Interpreters

CMI or Certified Medical Interpreter, Qualified Medical Interpreter (QMI) or Screened Medical Interpreter (SMI)

Question contact [email protected]

Two Credentials of CCHI

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www.healthcareinterpretercertification.org/

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Certification for Interpreters Many people use this term “certified interpreter”

when they only attended an education program

Participants will receive a certification of attendance or participation which has been confused with being certified Certification is a formal process by which a governmental,

academic or professional organization attests to an individual’s ability to provide a particular service.

Certification calls for formal assessment, using an instrument that has been tested for validity and reliability, so that the certifying body can be confident that the individuals it certifies have the knowledge, skills and abilities needed to do the job.

173

Certification for Interpreters

Initial work done in a pilot program by the Massachusetts Medical Interpreters Association (MMIA, now the IMIA)

Funded by the U.S. Office of Minority Health

Done in collaboration with the California Healthcare Interpreters Association (CHIA) and the National Council on Interpreting in Health Care (NCIHC)

The Certification Commission for Healthcare Interpreters is continuing their mission to develope certification for health care interpreters

174

Proposed National Training Standards

175

Certification for Translators However, ATA or the American Translators

Association, has a general certification program to enable individual translators to demonstrate that they met professionals standards

ATA certification is awarded to candidates who pass an open book exam

Is a testament to translator’s competence in translating one specific language to another

Source: A Guide to Understanding Interpreting and Translation in Health Care by NCIHC

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Guide to Understanding Interpreting

A Guide to Understanding Interpreting and Translation in Health Care is an excellent resource for HR staff

Has requisite skills and qualifications of a translator and an interpreter

Discusses certification for interpreters and translators

Discusses how to hire an interpreter or translator

Discusses standards of practice for an interpreter and a translator

What skills are needed for interpreters and translators178

www.ncihc.org/mc/page.do?sitePageId=57022

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http://www.ncihc.org/mc/page.do;jsessionid=EC5D32E43B90F9742B4E5C91472A5142.mc1?sitePageId=50909

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How to Hire an Interpreter

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182

Research US Dept of Health and Human Services (HHS) and

several other federal agencies, such as Dept of Education, and the National Science Foundation

Have regulations on research which are commonly referred to as the common rule

To protect human subjects involved in research

Institutional Review Boards (IRB) reviews research proposals even if informed consent is obtained, IRB can waive consent requirement

See Title 46 Protection of Human Subjects at www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm

187

Research Consent Research investigator needs informed consent from

research subject

Must be in plain language

Must include a statement that the study involves research

Explanation of the purpose of the research

Expected duration of the subject’s participation

Description of procedures to be followed

Identification of any procedure considered to be experimental

188

Research Elements of Consent

Description of any reasonable foreseeable risks or discomforts to the subject

Disclosure of any benefits to the subject and others which may be expected

Disclosure of appropriate alternative procedures or courses of treatment

Statement to which confidentiality of records identifying the subject will be maintained

189

Research Elements of Consent Cont.

Contact information for answers to questions about the research

Also to include information on patient’s rights in case of a research related injury

Statement that participation is voluntary and refusal to participate involves no penalty or loss of benefits

Subject can discontinue participation at any time without penalty or loss of benefits

190

www.hhs.gov/ohrp/informconsfaq.html

192

AHRQ Toolkit to Facilitate Consent

AHRQ toolkit to facilitate the process of obtaining informed consent

Also information on the HIPAA authorization for potential research subjects

Available at http://www.ahrq.gov/fund/informedconsent/

Visitation Law in a Nutshell

Require all hospitals that accept Medicare or Medicaid reimbursement

To allow adult patients to designate visitors

Not legally related by marriage or blood to the patient

To be given the same visitation privileges as an immediate family member of the patient

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Visitation Rights for All Patients CMS issued proposed changes to the CAH and

PPS hospital conditions of participation (CoPs)

Published in the June 28, 2010 Federal Register (FR) with comments until August 27, 2010

Had 7,600 comments but 6,300 were form letters

CMS publishes the final rule in the November 18, 2010 FR

Regulation effective January 18, 2011

Applies to all hospitals that accept Medicare and Medicaid reimbursement

This includes all critical access hospitals196

Patient Visitation Right This rule revises the hospital CoPs to ensure

visitation rights of all patients including same sex domestic partners

Hospitals are required to have policies and procedures (P&P) on this

P&P must set forth any clinically necessary or reasonable restrictions or limitations

Hospitals will have to train all staff

Hospitals will be required to give a written copy of this right to all patients in advance of providing treatment

197

Final Rule FR Effective January 18, 2011

198

Visitation Rights for All Patients

The new final rule implements the April 15, 2010 Presidential memo1

The President gave HHS (Health and Human Services) the task of requiring any hospital that receives Medicare reimbursement to preserve the rights of all patients to choose who can visit them

Patients or their representative have a right to visitation privileges that are no restrictive than those for immediate family members

1 http://www.whitehouse.gov/the-press-office/presidential-memorandum-hospital-visitation

2 http://www.access.gpo.gov/su_docs/fedreg/a100628c.html (June 28, 2010 Federal Register)

199

Final Language on Patient Visitation Rights

Standard: Patient visitation rights

A hospital must have written P&P regarding the visitation rights of patients

This includes setting forth any clinically necessary

Or reasonable restriction or limitation that the hospital may need to place on such rights

And the reasons for the clinical restriction or limitation

200


A hospital must meet the following 4 requirements:

1.Inform each patient (or support person, where appropriate) of his or her visitation rights

Including any clinical restriction or limitation on such rights

When he or she is informed of his or her other rights under this section (previously mentioned)

For CAH hospitals the last bullet is absent and it says to do this in advance of furnishing patient care

Note CAH do not have a pre-exisitng patient rights section

201


2. Inform each patient (or support person, where appropriate) of the right

Subject to his or her consent

To receive the visitors whom he or she designates

Including, but not limited to, a spouse, a domestic partner (including a same sex domestic partner),

Another family member, or a friend, and his or her right to withdraw or deny such consent at any time

202


3. Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability

4. Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences

So what does this mean??

203

Patient Visitation Rights

All hospitals would have to inform all patients of their visitation rights in writing in advance of care furnished

This includes the right to decide who may and may not visit them

Some hospitals may give a one page sheet to each patient upon admission

Hospitals would want to amend their patient rights statement to include this information– Example: written patient rights given to patients on admission and

could have also brochure in admission packet204


Competent patients can verbally give this information on admission

There is no requirement that this has to be in writing if a competent patient gives oral confirmation as to who he or she would like to visit

Some patients may sign a written patient visitation advance directive

Some patients may add a section to their advance directive adding a section on who they would like to visit or deny visitation

205


CMS does suggest that this be documented in the medical record for future reference

Reading of the Federal Register helps to provide an understanding of what it means and how to implement it

Federal Register (FR) summarizes the comments and publishes a response

CMS will eventually add this to the hospital CMS interpretive guidelines

206

207

Research References

US Department of Health and Human Services. “Protection of Human Subjects.” Code of Federal Regulations, 2002. 45 CFR, Part 46

Office for Civil Rights. “Medical Privacy—National Standards to Protect the Privacy of Personal Health Information.” Section “Research”1

US Department of Health and Human Services. “Food and Drugs.” Code of Federal Regulations, 2002. 21 CFR, Part 56, Section 102

1 www.hhs.gov/ocr/hipaa/privacy.html

CMS

Thought it would only take hospitals 15 minutes to update their P&P

Estimated the cost to provide the patient with a one page printed disclosure form detailing visitation rights on admission would be 2 cents a page

Would anticipate this form would be put in admission packet so would reduce cost

Make sure P&P includes any clinically necessary or reasonable restrictions or limitations and reasons for these

208

Resources

Rosenberg CE. The Care of Strangers: The Rise of America's Hospital System. Baltimore, Md: Johns Hopkins University Press; 1987

A challenge accepted: open visiting in the ICU at Geisinger, www.ihi.org

Marfell JA, Garcia JS. Contracted visiting hours in the coronary care unit: a patient-centered quality improvement project. Nurs Clin North Am. 1995;30:87-96 at http://www.ncbi.nlm.nih.gov/pubmed/7885927?dopt=Abstract

209

Resources

Gurley MJ. Determining ICU visitation hours. Medsurg Nurs. 1995;4:40-43 at http://www.ncbi.nlm.nih.gov/pubmed/7874220?dopt=Abstract

Krapohl GL. Visiting hours in the adult intensive care unit: using research to develop a system that works. Dimens Crit Care Nurs. 1995;14:245-258 at http://www.ncbi.nlm.nih.gov/pubmed/7656767?dopt=Abstract

Simon SK, Phillips K, Badalamenti S, Ohlert J, Krumberger J. Current practices regarding visitation policies in critical care units. Am J Crit Care. 1997;6:210-217 http://ajcc.aacnjournals.org/cgi/content/abstract/6/3/210?ijkey=e4ebfadff6f205451545c622736f88ef98f36485&keytype2=tf_ipsecsha

210

211

http://ccn.aacnjournals.org/cgi/content/full/25/1/72

Breaking Down Barriers

Document states that lesbian, bisexual, gay, and transgender (same sex) families face discrimination when attempting to access healthcare system

Includes visitation access and medical decision making during emergencies and end of life care

Human Rights Campaign Foundation administers the Healthcare Equity Index of healthcare policies and procedures and identifies best practices and policies with equal treatment

213

Recommendations

First establish a definition of permitted visitors

Then enumerate restrictions on visitor access such as restriction to sensitive areas such as behavioral health unit or OB (infant security issues)

Health concern restrictions such as preventing ill visitors

Definition of family is critical and must be broad and encompass concept of family

Provides a sample definition of family and recommendation for what should be in the P&P

216

Definition of Family Family means any person who plays a significant role in an

individual’s life.

This may include a person not legally related to the individual.

Members of family include spouses, domestic partners, and both different-sex and same-sex significant others.

Family includes a minor patient’s parents, regardless of the gender of either parent. Solely for purposes of visitation policy, the concept of parenthood is to be liberally construed without limitation as encompassing legal parents, foster parents, same-sex parent, step-parents, those serving in loco parentis, and other persons operating in caretaker roles.

36 Kaiser Permanente hospitals implemented them in June 2010

217

Sample Visitation Authorization

218

American Hospital Associations

220

http://www.putitinwriting.org/putitinwriting_app/index.jsp

Visitation Expanded in the ED

221

The Joint Commission

222

One Size Does Not Fit All: Meeting the Health Care Needs of Diverse PopulationsSelf-Assessment Tool – Accommodating the Needs of Specific Populations

So What’s in Your Policy?

223

So What’s in Your Policy?

224