Joint Commission Patient Rights What every hospital should know.

1. 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@columbus.rr.com

3. 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

4. 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

5. Patient Provider Communication RI.01.01.01

6. Jan 1, 2011 Patient Centered Communication

7. CMS CoP Hospital Patient Rights • Remember that most hospitals accept Medicare and as such must follow the CMS Hospital CoPs • So hospital must follow these for all patients not just Medicare or Medicaid patients • Include both in your P&Ps • Exception is the CAH (Critical Access Hospitals) do not have a patient rights section except will add visitation and QIO/State agency notification • CMS has a patient rights section • Includes 50 pages of restraints interpretive guidelines

8. The Revised Final CoPs • Final interpretive guidelines were published June 5, 2009 • Anesthesia ones changes December 30, 2009 and February 5, 2010, May 21, 2010 and February 14, 2011 • Respiratory and Rehab orders updated October 1, 2010 • Visitation regulations effective Jan 18, 2011 but interpretive guidelines not out yet • Has section on grievances, patient rights, and advance directives • Every hospital should have a copy of this!!! • www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf

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

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

11. CMS Survey & Certification Website www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

12. 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

13. 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

14. 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

15. 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

16. 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

17. Overview of TJC RI Chapter

18. 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 atwww.jointcommission.org/PatientSafety/SpeakUp/, ,

19. 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

20. TJC Know Your Rights Brochure • TJC has a flier on the speak up program encouraging patients to know their rights at • http://www.jointcommission.org/speakup.aspx • It is called “Speak Up Know Your Rights” • Issued March 15, 2011 • Discusses questions for patients to ask their doctor • Discusses what are the patient’s rights • Discusses having a patient advocate to stay with them, consent, how to file a complaint etc.

21. TJC Know Your Rights Brochure www.jointcommission.org/speakup.aspx

23. FAQ on Patient Rights • TJC has 3 topics under FAQs on RI • Organ donation one but this standard is now in the Transplant chapter • Filming and recording • Patient rights and informed consent when videotaping or filming • All revised November 24, 2008 • at www.jointcommission.org/standards_information/jcfaq.aspx

24. 3 FAQs on Rights and Responsibilities These will be covered under the standards http://www.jointcommission.org/standards_information/jcfaq.aspx

25. 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?

26. 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.

28. 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.

30. FAQ on Videotaping and Consent

31. 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

32. 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

33. 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

34. 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 communicationbetween shifts and departments,

35. 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

36. 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

37. AHA Patient Rights • A different AHA document replaces the AHA's Patients' Bill of Rights • It is called “The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities” • It is a plain language brochure that informs patients about what they should expect during their hospital stay with regard to their rights and responsibilities • The brochure is available in eight languages • http://www.aha.org/aha/issues/Communicating-With-Patients/index.html

38. AHA Patient Rights Brochure http://www.aha.org/aha/issues/Communicating-With-Patients/index.html

39. AHA Patient Rights Booklet

40. 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

41. 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

44. RI.01.01.01 Respecting Patient Rights • The standard: The hospital respects, respects and promotes patient rights • EP1 There are written P&P on patient rights • EP2 Patients are informed of their rights • EP4 Patients are treated in a dignified and respectful manner • EP5 The patients rights to and need for effective communication must be respected

45. 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 P&P on this, and to disclose information only as permitted by law

46. 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

47. 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

48. 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

49. 2011 Changes MR Must Contain • New in 2011 to improve patient centered communication • Qualifications for language interpreters and translators will be met through proficiency, assessment, education, training, and experience • Hospitals need to determine the patient’s oral and written communication needs and their preferred language for discussing health care under PC standard • Hospital will communicate with patients in a manner that meets their communication needs

50. 2011 Changes MR Must Contain • Hospitals required to collecting race and ethnicity data under RC.02.01.01 EP1 • Patients should self report so patient states she is white and Albanian • Collecting language data under RC.02.01.01 EP1 • The patient’s communication needs, including preferred language for discussing health care • If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the MR