Joint Commission Patient Rights What every hospital should know.

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Joint Commission Patient Rights What every
hospital should know.
2
Speaker

• Sue Dill Calloway RN, Esq.
• CPHRM
• AD, BA, BSN, MSN, JD
• President
• Patient Safety and Healthcare
• Education
• 5447 Fawnbrook Lane
• Dublin, Ohio 43017
• 614 791-1468
• sdill1_at_columbus.rr.com

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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

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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 PPs
• 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_Appendice
  stoc.pdf

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www.cms.hhs.gov/manuals/downloads/som107_Appendice
stoc.pdf
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The Conditions of Participation

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

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CMS Survey Certification Website
www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/li
st.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

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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

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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 patients 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
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/j
  cfaq.aspx

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3 FAQs on Rights and Responsibilities
These will be covered under the
standards http//www.jointcommission.org/standard
s_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.

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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

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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-P
  atients/index.html

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AHA Patient Rights Brochure
http//www.aha.org/aha/issues/Communicating-With-P
atients/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 PP 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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RI.01.01.01 Respecting Patient Rights

• 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 PP 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 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

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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 patients 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 patients 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 Rights

• CMS in the hospital CoPs also has a section on
  patient rights
• Make sure you have a written PP 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

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RI.01.01.03 Respecting Patient Rights

• 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 issue

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RI.01.01.03 Respecting Patient Rights

• 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
  patients 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

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What are Surveyors Looking For?

• The hospital has a PP on language access
  services
• That staff are oriented and trained in the PP
• 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 PP 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 hospitals 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
  patients 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 charge

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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/patien
  tsafety/hlc/

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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/jointcommission2011rep
  ort

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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
http//www.jointcommission.org/R3_issue1/
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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/specialtopic
s/hospitalcommunication/ecinfo.html
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www.hhs.gov/ocr/civilrights/resources/specialtopic
s/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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RI.01.02.01 Right to Participate in Decisions

• 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 used 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 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 PP on unanticipated disclosure
• Educate all staff on PP
• 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 patients
• At http//www.ashrm.org/ashrm/resources/monograph.
  html

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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 PP 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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RI.01.03.01 Informed Consent

• EP4 Policy describes the process used to get
  consent
• Remember informed consent is a process
• It is not just a form
• EP5 PP 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 Consent

• EP6 PP 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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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

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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
• EP13 Consent is obtained in accordance with
  Hospital PP 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 PP 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

92
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

93
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

94
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/informedcons
  ent/ConsentForms/14025.pdf
• 2 http//www.health.qld.gov.au/consent/html
  /for_clinicians.asp
• http//www.health.qld.gov.au/consent/

95
www.health.qld.gov.au/consent/
96
www.health.qld.gov.au/consent/
97
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98
www.mnpatientsafety.org/index.php?optioncom_conte
nttaskviewid85Itemid69
99
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100
www.hhs.gov/forms/HHS-687.pdf
101
So Whats In Your Policy?
102
So Whats In Your Policy?
103
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

104
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
  PP
• Which is established thru an ethical mechanism
  like the ethics committee and that might include
  community input

105
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 it is 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

106
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

107
RI.01.03.03 Recordings and Consent

• 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?dD
  ocNamebok2_000585

108
AHIMA.org
109
Sample Consent
110
Be Aware of Your Hospital Policy
111
RI.01.03.05 Research

• Standard Patients 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

112
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,

113
RI.01.03.05 Research

• 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

114
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

115
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 patients care
• EP2 Patient is informed of the name of the
  physician, clinical psychologist, or other
  practitioners who will provide their care

116
What Does This 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

117
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 PP 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 PP on whether
  they will honor AD in the outpatient setting
• Must decide if will honor in any of the OP
  settings

118
RI.01.05.01 End of Life Care

• EP5 Hospital must implement its AD PPs
• 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

119
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 and the hospital's capabilities
• EP15 Must document patients wishes regarding
  organ donation when she makes her wishes know or
  when required by hospitals PP

120
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
  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,

121
RI.01.05.01 End of Life Care

• 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

122
What Does This 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

123
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

124
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 dont have one and want one

125
What Does This 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.)

126
Know Your Hospital Policy on DNR
127
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128
RI.01.06.03 Neglect and Abuse

• Standard 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

129
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!

130
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

131
Make Sure Policy has TJC, CMS, State Law
132
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133
RI.01.06.05 Pleasant Environment

• Standard 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 patients 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

134
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

135
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 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

136
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

137
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

138
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

139
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

140
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 CG process (eliminated
  but still CMS standard)
• Note that CMS has detailed section on grievances
  starting at tag number A-0118

141
QIO

• QIO 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/Cont
  entServer?pagenameMedqic/MQGeneralPage/GeneralPag
  eTemplatenameQIO20Listings

142
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 patients representative,
  regarding the patients care, abuse, or neglect,
  issues related to the hospitals compliance with
  the CMS CoP
• or a Medicare beneficiary billing complaint
  related to rights and limitations provided by 42
  CFR 489

143
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,

144
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 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

145
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

146
What Does This Standard Mean?

• The list is given to patients when requested
• Hospital should have PP
• PP should reflect your state law
• For example how to get a guardianship for a
  patient

147
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 PP that addresses situation
  in which patients would be allowed to work for
  the hospital
• EP2 Hospital must follow or implement this PP

148
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

149
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 PP 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

150
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
  PP
• Patient responsibilities should be shared with
  patients verbally, in writing, or both

151
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 PP 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,

152
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

152
152
153
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.

154
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.

155
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,

156
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)

157
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.

158
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,

159
Patient Responsibilities

• Following instructions.
• All patients must follow instructions that are
  provided by their physicians and staff. Patients
  need to follow their plan