Joint Commission Patient Rights What every hospital should know. - PowerPoint PPT Presentation

1 / 227
About This Presentation

Joint Commission Patient Rights What every hospital should know.


Joint Commission Patient Rights What every hospital should know. – PowerPoint PPT presentation

Number of Views:584
Avg rating:3.0/5.0
Slides: 228
Provided by: TDC1


Transcript and Presenter's Notes

Title: Joint Commission Patient Rights What every hospital should know.

Joint Commission Patient Rights What every
hospital should know.
  • Sue Dill Calloway RN, Esq.
  • AD, BA, BSN, MSN, JD
  • President
  • Patient Safety and Healthcare
  • Education
  • 5447 Fawnbrook Lane
  • Dublin, Ohio 43017
  • 614 791-1468

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
  • TJC standards on patient rights
  • TJC has 3 FAQs on patient rights

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
  • CMS has a patient rights chapter which is

Patient Provider Communication RI.01.01.01
Jan 1, 2011 Patient Centered Communication
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

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,
  • Respiratory and Rehab orders updated October 1,
  • 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!!!

The Conditions of Participation
  • First published in the Federal Register-42 CFR
    Part 482.
  • Federal Register available at http//www.gpoaccess
  • 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
  • Also some changes at Transmittals at

CMS Survey Certification Website
CMS Patient Rights Standards 0116-214
  • CMS Patient Rights include
  • Right to notification of rights and exercise of
  • 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

TJC Patient Rights
  • Many changes in 2009 as part of the Standards
    Improvement Initiative (SII) which continue into
  • There are 14 (from 24) standards in the TJC RI
  • 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

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
  • These are defined and relayed to the patients

TJC Patient Rights Overview
  • TJC, unlike CMS, has patient obligations and
  • 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

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
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,
  • ,

TJC Changes to Comply with CMS CoPs
  • RI. when patients request access to
    medical record information, hospital need to
    provide as quickly as record keeping system
  • 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//
  • It is called Speak Up Know Your Rights
  • Issued March 15, 2011
  • Discusses questions for patients to ask their
  • Discusses what are the patients rights
  • Discusses having a patient advocate to stay with
    them, consent, how to file a complaint etc.

TJC Know Your Rights Brochure
(No Transcript)
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

3 FAQs on Rights and Responsibilities
These will be covered under the
standards http//
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?

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
  • 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
  • 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

(No Transcript)
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.

(No Transcript)
FAQ on Videotaping and Consent
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

Patients Have the Right To
  • Notification of unanticipated outcomes
  • Involvement in care decisions
  • Information on risks and benefits of
    investigational studies
  • End of life care
  • Advance directives
  • Organ procurement

Patients Have the Right
  • A right to have advance directives and to have
    them followed
  • Freedom from unnecessary restraints
  • Informed consent for various procedures
  • The right to refuse care
  • Right to have their pain believed and relieved
  • Communication with administration
  • To chose their visitors
  • And education

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
  • When surveyor interviews patients and families
  • Things surveyor may look at or observe
  • Staff discussion and observation on communication
    between shifts and departments,

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
  • 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

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
  • 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//

AHA Patient Rights Brochure
AHA Patient Rights Booklet
AHA Patient Rights Expectations
  • High quality care
  • Clean and safe environment
  • Discussing your medical condition
  • Information about medically appropriate treatment
  • Discussing your treatment plan
  • Right to get information from the patient

AHA Patient Rights Expectations
  • Understanding who can make decisions if you can
  • Involvement in your care
  • Protection of patient privacy
  • Help with bill and filling insurance claims
  • Preparing for discharge

(No Transcript)
(No Transcript)
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

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

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

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,
  • Unless it is medically or therapeutically
  • The person may or may not be the patient's
    surrogate decision-maker or legally authorized
  • 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

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

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

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

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
  • 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

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

RI.01.01.03 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

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
  • There are 50 million people in this country whose
    English is not their primary language
  • Low health literacy is another important issue

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
  • Patient with visual or hearing impairments or on
  • Hospitals needs interpreters and translated
    written material

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,
  • 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

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
  • This must be provided in a manner that meets the
    patients needs

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

What are Surveyors Looking For?
  • The hospital has a PP on language access
  • 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

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
  • Make sure bilingual staff have training on how to
    be an interpreter
  • Do not use a child to interpret and family
  • Exception for family members if patient insists,
    get it in writing, use interpreter to obtain,
    make sure knows at no expense to the patient

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

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
  • The Roadmap for Hospitals has a number of
    excellent recommendations for ensuring a quality
    interpreting and translation program
  • This is available at no charge

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
  • The Roadmap will help hospitals to comply with
    the patient-centered communication standards
  • Has educational tools

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//

(No Transcript)
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
  • 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

Topics Covered in the White Paper
  • Language challenges that impact healthcare
  • Why language services are critical
  • The unfortunate truth most hospitals are not
  • The origins of medical interpreting
  • Patient/provider understanding and acceptance
  • Joint Commission mandates for training and

Topics Covered in the White Paper
  • The standards that apply to language access
  • The consequences of non-compliance
  • Developing a system-wide language services
  • The Joint Commission is serious
  • Hospitals CAN prepare themselves

(No Transcript)
TJC R3 Report
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

(No Transcript)
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
  • 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

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

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

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

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

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
  • Recommend you get it in writing

What Does This Standard Mean?
  • Parent usually consents for minor child
  • If patient is incompetent document legal
    guardian or DPOA
  • Surrogate decision maker steps into shoes of
    incompetent patient
  • Have PP on unanticipated disclosure
  • Educate all staff on PP
  • Consider disclosure coaches
  • Document discussion with patient

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

ASHRM 4 Documents
  • 20 page document titled "perspective on
    disclosure of unanticipated outcome information
  • Provides examples of UO Policy and procedures
  • Has additional 3 documents, Disclosure What
    works now and what can work even better,
  • Disclosure Creating an effective patient
    communication policy, and
  • Disclosure the next step in better
    communications with patients
  • At http//

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

RI.01.03.01 Informed Consent
  • EP4 Policy describes the process used to get
  • 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

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
  • EP7 Consent process includes discussion about the
    proposed care and treatment

RI.01.03.01 Informed Consent
  • EP9 Consent includes discussion of potential
    benefits, risks, and side effects of the proposed
  • The likelihood of the patient achieving her
    goals, and
  • Any potential problems that might occur during
    the recuperation
  • EP11 Consent process includes discussion about
    reasonable alternatives, and the risks, benefits,
    and side effects of the alternatives

RI.01.03.01 Informed Consent
  • EP12 Consent process included discussion of any
    circumstances under which information about the
    patient must be disclosed or reported
  • Would include reports to the department of health
    or the CDC regarding cases of HIV, TB, viral
    meningitis, or other things required
  • EP13 Consent is obtained in accordance with
    Hospital PP prior to surgery unless an emergency

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

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.)

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

Informed Consent Manual
  • One hospital (Providence Everett Medical Center)
    has their informed consent manual on the
  • 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//

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

  • A site for consent forms that list the risks, and
    complications, and alternatives of many
    procedures (provided by the Queensland
  • 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//
  • 2 http//
  • http//

(No Transcript)
(No Transcript)
So Whats In Your Policy?
So Whats In Your Policy?
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

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

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
  • 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

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

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
  • It is available at http//

Sample Consent
Be Aware of Your Hospital Policy
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

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

RI.01.03.05 Research
  • 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

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

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

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
  • 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

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

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
  • 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

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

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,

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

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
  • Use sticker in front of chart so other
    departments are aware such as radiology

Stamp or sticker on front of chart
  • Name______________________________
  • Medical Record Number_______________
  • Date_______________________________
  • This patient has the following advance
  • ___ Living Will
  • ___ Durable Power of Attorney
  • ___ Organ donor card
  • ___ Mental health declaration
  • ___ DNR

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

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.)

Know Your Hospital Policy on DNR
(No Transcript)
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

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
  • Refer to board of nursing, etc. if indicated
  • This is a very important issues with both the
    Joint Commission and CMS!

TJC defines as follows
  • Abuse is an intentional maltreatment of a patient
    which may cause injury, either physical or
  • 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
(No Transcript)
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

RI.01.06.05 Pleasant Environment
  • EP4 Patient can keep and use or personal clothing
    and possessions unless it infringes on other
    rights, or
  • Is medically or therapeutically contraindicated
  • EP15 Patients are provided telephones and mail
    based on the population setting
  • EP16 Must provide access to phones for patients
    who need a private phone conversation in a
    private space, based on population and setting

RI.01.06.05 Pleasant Environment
  • 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

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
  • Sufficient storage to hand clothes and
  • Can keep personal clothing and possessions
    unless infringes on right
  • Protect confidentiality and privacy of health

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
  • 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

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

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
  • 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

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
  • 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

  • QIO or Quality Improvement Organizations are CMS
  • 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//

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

What Does This Standard Mean?
  • CMS has similar section on grievances in hospital
  • 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

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

RI.01.07.03 Protective Services
  • EP2 The hospital must maintain a list of names,
    addresses, and phone numbers of patient advocacy
  • 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

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

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

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
  • 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

RI.02.01.01 Patient Responsibilities
  • Standard The patients are informed about their
    responsibilities related to care, treatment, and
  • To support consistent responsibilities of
  • 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

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

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
  • 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,

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
  • Sample language for patient responsibilities and
    billing practices
  • Information on who is qualified or certified to
    be an interpreter

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.

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

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

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

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

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

Patient Responsibilities
  • Following instructions.
  • All patients must follow instructions that are
    provided by their physicians and staff. Patients
    need to follow their plan
Write a Comment
User Comments (0)