S02_Attachment_7_Patient_Rights_and_Organizational_Ethics.docx

MEDICAL CENTER POLICY MEMORANDUMS

NUMBER/TITLE OF POLICY:

00-06 Patient Rights and Organizational Ethics

Changes from Previous MCM:

Changes are:

Formatted policy for 508 Compliance

Updated Point of Contact

4.a. Replaced core values trust and commitment with integrity and advocacy.

Added the following verbiage from the 14 General Principles:

4.b.(1)(b) All employees must put forth an honest effort in the performance of their duties.

4.b.(1)(f) An employee must act impartially and must not show favoritism or give preferential treatment to any private organization or individual including vendors, sales representatives, Veteran’s or their family members.

4.b.(1)(g) An employee must protect and conserve Federal property and must not use it for other than authorized purposes.

4.b.(1)(h) An employee must comply with all laws and regulations governing Federal employees.

4.b.(3)(a)1. An employee must not engage in financial transactions using nonpublic Government information or allow the improper use of such information to further any private interest.

4.b.(3)(a)2. An employee must not knowingly make unauthorized commitments or promises of any kind that would bind the Government.

4.b.(3)(e) An employee must disclose waste, fraud, abuse, and corruption to the appropriate authorities.

4.b.(3)(f) An employee must satisfy in good faith their obligations as citizens, including all financial obligations that are imposed by the law (i.e. Federal, state or local taxes).

4.b.(3)(m) An employee must make every effort to avoid any actions creating the appearance that they are violating the law or the standards set forth in the Standards of Ethical Conduct as determined from the perspective of a reasonable person with knowledge of the revelant facts.

Added the the following verbiage from expired VAMC Bulletin 2007-048, Organizational Ethics:

4.b.(1)(i) An employee must endeavor to maintain professional boundaries with the patient both on duty and off duty. Examples of breaches in ethical conduct or behavior involving patients include:

1. Dating a patient under your care.

2. Dating a patient under your care.Developing a romantic, intimate or sexual relationship with a patient who is under your care.

3. Socializing (off duty or after hours personal contact) with a patient or patients who are under your care.

4. Entering into financial relationships with a patient, to include borrowing or lending money, or selling items of value while on duty.

5. Soliciting or recruiting VA patients into your private practice or private business for treatment, service or supplies.

4.b.(1)(j) A supervisor must maintain professional boundaries with an employee under their supervision. Examples of breaches in expected ethical conduct or behavior by supervisors include:

1. Dating employees under your supervision.

2. Sharing information about one employee with another employee under your supervision.

3. Entering into any type of business or contractual relationship with an employee who reports directly to you for supervision.

4. Demonstrating overt favoritism to an individual employee.

Added verbiage under ethical conduct or behavior by supervisor. 4.b.(1)(j)5. Soliciting subordinates for a gift, monetary contribution or the purchase of an item.

Updated policy numbers for 00-05 and 00-73 to coincide with the correct policy title.

Added Ethical Boundaries in the Patient-Clinician Relationship: A Report by the National Ethics Committee of the Veterans Health Administration, July 2003 as a reference.

4.a.(1).uPatients have the right to know the full names of the caregivers as well as any staff member who they encounter in the course of receiving services as related to their healthcare

Point of Contact for Further Information: Theresa Chan x 7540 and Brenda Johnson ext. 7522.

Attachment 7 – 36C24919R0003

POLICY MEMORANDUM

VA Medical Center 1030 Jefferson Avenue Memphis, TN 38104

Number: 00-06

Dated: June 29, 2015

Expires: June 30, 2018

Title: PATIENT RIGHTS AND ORGANIZATIONAL ETHICS

1. PURPOSE: To outline the principles of patient rights and organizational ethics in recognition of our responsibility to patients, staff, physicians, volunteers and the community we serve.

2. POLICY: This code of ethics addresses the ethical relationship of the medical center and its staff members, including volunteers, to patients, community, other health care providers, educational institutions, and payers. Every employee and volunteer is expected to act in a manner that is consistent with the intent of the organization’s code of ethics and the medical center’s mission, vision, values, strategic plan, and supporting policies. Every employee will ensure the patient’s right to treatment or service is respected and supported.

Definition: Code of Ethics is defined as a statement of principles and standards concerning the conduct of those who subscribe to the code, as in a code of ethics that defines proper professional behavior and practices. Codes of ethics are distinguished from licensure laws or practice acts in that they are a form of collective self-regulation rather than of regulation by external bodies.

3. RESPONSIBILITY:

a. Employees and volunteers are expected to act in a manner that is consistent with this policy. It is the responsibility of all employees, including management and medical staff, to notify their supervisor that a potential conflict of interest might exist.

b. Supervisors will inform all employees of this policy on ethical issues.

c. Service chiefs will ensure implementation of this policy as outlined.

d. The Associate Medical Center Director and Assistant Medical Center Director are responsible for ensuring ethical behavior in all purchasing, contract, or related business activities.

e. The Chief of Staff and Associate Medical Center Director, Nursing will ensure ethical behavior in all patient care and related clinical activities.

f. The Medical Center Director will establish adequate direction and control to ensure that this policy is appropriately enforced.

4. PROCEDURE:

a. Principles. VAMC Memphis is guided by the dedication to the principle that all patients, employees, volunteers, students and visitors deserve to be treated within the core values it champions: integrity, compassion, advocacy, respect, and excellence.

(1) Patient Rights.

(a) VAMC Memphis is committed to providing quality medical care in an atmosphere in which the human needs and concerns are met and individual rights and interests are protected. The medical center respects the patient’s right for effective communication which is tailored to the patient’s age and preferred language. The medical center will provide information in a manner appropriate to the physical and cognitive abilities of the patient. Patients will receive a written copy of their rights.

(b) Patients have the right to be treated with courtesy and respect. Care will be provided in a courteous, concerned and compassionate manner that supports the patient’s dignity.

(c) Patients have the right to be informed about the care they will receive. The patients and their family, or significant others, will be informed in their preferred language about the known therapeutic alternatives as well as the benefits and risks associated with them, and be involved in decisions or dilemmas regarding their care, to the maximum extent possible and practical.

(d) Patients have the right to know when something goes wrong with their care. The patient and their family, or significant others, to the extent possible, will be informed about the outcomes of care, including unanticipated outcomes or adverse events.

(e) Patients and their family, or significant others, have the right to be treated in a manner giving reasonable thought and consideration to their background, culture, spirituality, religion, heritage, and personal beliefs and values. Pastoral care and other spiritual services are available in the medical center for all patients.

(f) Patients who are provided the opportunity to perform work as a therapeutic intervention have the right to refuse such assignments. Patients who do agree are ensured it is appropriate to their needs and therapeutic goals; information is documented in their plan of care to include a description of the work to be performed and information regarding payment for services.

(g) Patients will be cared for by staff that has been educated about patient rights and their roles in supporting the patient’s rights. All staff will assist in meeting the security and privacy needs of patients.

(h) Patients who have mail, visitors and telephone use restricted have the right to be provided with a full explanation of the reasons. Such restrictions will be evaluated for therapeutic effectiveness.

(i) Patients have the right to appropriate assessment and pain management.

(j) Patients have the right to safe care and access to protective services.

(k) Patients will receive a copy of their rights and responsibilities upon admission to the medical center.

(l) Patients have the right to care that is free from discrimination. Patients will not be treated differently because of: patient’s culture, race, age, gender, sexual orientation, gender identity or expression, ethnicity, spiritual beliefs, physical or mental disability, socioeconomic status and language.

(m) Patients have the right to make decisions about their care. Patients have the right to have expression of choice related to service delivery, release of information, concurrent services and composition of service delivery team.

(n) Patients have the right to have access to legal entities through the referral processes provided by the Risk Manager or Social Worker upon request of the person served.

(o) Patients have the right to have a personal representative, also called an advocate, with them during their care for emotional support. The advocate is a family member or friend of their choice. Patients will have access to self-help and advocacy support services through various medical center processes/services including, but not limited to, patient education, social work services, Veteran services organizations, etc.

(p) Patients have the right to get information in a manner that meets their needs, if they have vision, speech, hearing or mental impairments. Patients will have access to their patient information in sufficient time to facilitate decision-making. Patients will be involved in making decisions about their care, treatment, and services.

(q) Patients have the right to access information related to reporting a safety or patient care concern to medical center leadership and/or The Joint Commission if not addressed or resolved.

(r) Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation.

(s) Patients have the right to refuse care. When patients are unable to make decisions about their care, the hospital involves the surrogate decision makers which could include the decision to refuse care on behalf of the patients.

(t) Patients have the right to know the full names of the caregivers as well as any staff member they encounter in the course of receiving services as related to their healthcare

(u) Patients have the right to get a list of all their current medicines.

(v) Patients have the right to be listened to.

(2) Patient Responsibilities.

(a) Patients, family members, and/or advocates will provide, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to the patients’ health. Advocates can be any person designated by the patient, regardless of the relationship..

(b) Patients, their family members, and/or advocates will report perceived risks in the patients’ care.

(c) Patients, their family members, and/or advocates will ask questions when they do not understand what they have been told about their care or what they are expected to do.

(d) Patients, their family members, and/or advocates will follow the care, service, or treatment plan developed.

(e) Patients, their family members, and/or advocates will be accountable for outcomes, if they do not follow the care, service, or treatment plan.

(f) Patients, their family members, and/or advocates will follow hospital rules and regulations concerning patient care and conduct to support a safe environment for all individuals in the hospital.

(g) Patients, their family members, and/or advocates are expected to be considerate of the hospital's personnel and property.

(h) Patients, their family members, and/or advocates will promptly meet any financial obligation agreed to with the hospital.

(3) Informed Consent.

(a) Every patient or legally responsible designee has the right to as much information as needed, or available, to make an informed decision regarding his or her care including withholding resuscitative services and withdrawal of life-sustaining treatment.

(b) Except in emergency situations, practitioners must inform patients of the purpose and description of any diagnostic procedures/treatments, expected results of both consenting to and foregoing proposed procedures, significant risks, and alternative treatments in language that is understandable to the patient.

(c) All patients involved in research protocols will be accorded the protection described in VHA Handbook 1200.05, Requirements for the Protection of Human Subjects in Research, Para 15, General Requirement for Informed Consent

(d) Consent in medical emergencies, consent from a patient's surrogate decision maker and other situations are obtained following Medical Center Policy Memorandum 11-11, Informed Consent.

(e) The process for obtaining advance directives from patients will adhere to Medical Center Policy Memorandum 11-09, Advance Healthcare Planning (Advance Directives).

(f) The process for obtaining consent for organ donations will adhere to Medical Center Policy Memorandum 11-10, Organ and Tissue Donation Procedures.

(g) The patient has the right to end-of-life planning to include appropriate treatment, management of pain, sensitivity regarding issues such as autopsies and organ donations, respect of values, religion and philosophy, involvement of family in all aspects of care, and responding to psychological, social, emotional, and cultural concerns.

(4) Confidentiality, Privacy and Patient Safety.

(a) Staff recognizes a responsibility to respect patient privacy and maintain patient and other information in a confidential manner. In accordance with Federal laws and regulations patient information will be shared only with proper authorization; information from patient records both manual and computerized will be released only when appropriate authorization has been received.

(b) Patient privacy is to be respected when conducting physical examinations and interviews. Professional discussion of a patient or their condition in public places (i.e. , elevators, lobbies, canteen, and public bathrooms) is to be avoided at all times.

(c) Sensitive information concerning personnel and management issues will be maintained in strict confidence and utilized only by those individuals to review and act upon such information.

(d) The medical center is committed to deliver service free from patient abuse, exploitation, retaliation, humiliation, or neglect.

(e) All patients have the right to expect that patient safety issues will be given a high priority for all patient care processes, functions, or services.

(5) Resolution of Conflict.

(a) Occasionally, conflicts will arise among those who participate in hospital and patient care decisions. Regardless if this conflict involves members of the administration, medical staff, employees, or patient care givers and the patient or the patient’s family/significant other(s), all conflicts will be resolved fairly, objectively and at the level most directly involved with the conflict in a timely manner.

(b) Every employee is expected to assist in resolving a concern/complaint reported by a patient. The complaint/resolution process includes five steps. If a satisfactory resolution cannot be reached in an individual step then you should proceed to the next. The steps are as follows: 1. Notify a member of your healthcare team. 2. Request to speak with a Service Advocate in the area where you are receiving care. 3. Ask to speak with the area supervisor. 4. Ask to speak with the Service Chief. 5. Speak with a Patient Advocate. For additional information, please refer to Medical Center Policy Memorandum 00-73 , Customer Service Program-Putting Veteran’s First

(c) All patients have the right to investigation and resolution of alleged infringement of their rights through (5) (b) above.

(6) Fair Billing and Procurement Practice.

(a) The medical center has an obligation to recover the cost of medical care provided to certain patients. The Federal Medical Recovery Act, (Public Law 87-693), Veteran Health Care Amendment Act of 1986, and the Omnibus Budget Reconciliation Act of 1990 authorizes the Department of Veterans Affairs to recover from liable third parties or Veterans the cost of hospital, medical care and medications furnished to patients who meet certain criteria. In compliance with these existing Federal regulations and public law, the VA Medical Center may bill non-Veterans, Veterans and/or third party insurers for care provided for non-service connected conditions and will provide assistance to persons seeking to understand the cost relative to their care.

(b) Veterans may be required to pay a pharmacy co-payment for medications received for their non-service connected conditions. Questions will be referred to the local or area Medical Care Cost Fund (MCCF) representative who will resolve questions and/or complaints in a tactful, courteous, and timely manner in the best interest of the patient and the government.

(c) During any Federal agency procurement of property or service activities, each procurement official is required to follow all procurement integrity standards as stipulated in Section 27 (b) of the Office of Federal Procurement Policy Act (41 U.S.C. 423).

(7) Outreach/Public Information.

(a) Staff of the medical center will promote, assist, and support both the flow of, and access to, information that will serve to communicate an understanding of this Medical Center’s mission and the services it provides.

(b) Policy will be communicated with the public and involved organizations in an honest and forthright manner that minimizes confusion and broadens both individual and public understanding.

(8) Integrity of Clinical Decision-Making: Access, eligibility, admission, transfer, discharge, and protective services.

(a) All eligible Veterans reporting to the VAMC Memphis requiring inpatient care will be admitted or will be transferred to another hospital for the appropriate level of care.

(b) Any patient requiring emergency hospitalization will be admitted regardless of eligibility as clinically appropriate.

(c) Any patient being transferred to another hospital (VA or non-VA) will be treated to stabilize their medical condition and to minimize further compromise of that condition. Ineligible Veterans and non-Veteran patients who require non-emergency hospitalization will be transferred to a non-VA hospital for that care as soon as possible. The patient, or legally responsible person acting on the patient’s behalf, must give informed consent to transfer.

(d) Patients will not be transferred until accepted by another physician. Responsibility for the patient remains with this Medical Center during transfer.

(e) All pertinent medical information will accompany the patient.

(f) Patients will be discharged from the hospital on completion of acute medical care or upon stabilization of a chronic condition.

(g) Discharge planning will be a collaborative and coordinated process with patients and families to ensure appropriate provisions are made prior to discharge in order to meet the patient’s and family’s bio-psychosocial continuing care needs. Arrangements for any needed continuing medical care will be made in a timely manner prior to discharge.

(h) Patients considered to be vulnerable adults (i.e., those unable to care for or advocate for themselves due to neglect, abuse or exploitation) will be accorded access to community protective services as soon as the need is identified and appropriate.

b. Employee Practice.

(1) Employee Behavior.

(a) New employees will be provided information which describes their responsibilities associated with Federal employment.

(b) All employees must place loyalty to the public trust above anyone’s private gain in order to prevent conflict of interest or the appearance of conflict of interest.

(c) All employees must put forth an honest effort in the performance of their duties.

(d) All employees must abide by all Federal rules and regulations governing the acceptance or giving of gifts (5 C.F.R. 2635), and Medical Center Policy Memorandum 05-53, Standards of Ethical Conduct. As a rule, no Government employee may solicit or accept, directly or indirectly, any gratuity, gift, favor, entertainment, loan, or anything of any monetary value from anyone who:

1 . Has or is seeking to obtain Government business with the employee's agency.

2 . Conducts activities that are regulated by the employee’s agency or has interests that may be substantially affected by the performance of the employee’s official duties (i.e., patient’s gifts).

(e) An employee must not use his or her position, including official time, information, property, or endorsements, for personal gain or the private gain of anyone.

(f) An employee must act impartially and must not show favoritism or give preferential treatment to any private organization or individual including vendors, sales representatives, Veteran’s or their family members.

(g) An employee must protect and conserve Federal property and must not use it for other than authorized purposes.

(h) An employee must comply with all laws and regulations governing Federal employees.

(i) An employee must endeavor to maintain professional boundaries with the patient both on duty and off duty. Employees must be alert to situations that may motivate behavior that violates the Standards of Ethical Conduct. Examples of breaches in ethical conduct or behavior involving patients include:

1. Dating a patient under your care.

2. Dating a patient under your care.Developing a romantic, intimate or sexual relationship with a patient who is under your care.

3. Socializing (off duty or after hours personal contact) with a patient or patients who are under your care.

4. Entering into financial relationships with a patient, to include borrowing or lending money, or selling items of value while on duty.

5. Soliciting or recruiting VA patients into your private practice or private business for treatment, service or supplies.

(j) A supervisor must maintain professional boundaries with an employee under their supervision. Examples of breaches in expected ethical conduct or behavior by supervisors include:

1. Dating employees under your supervision.

2. Sharing information about one employee with another employee under your supervision.

3. Entering into any type of business or contractual relationship with an employee who reports directly to you for supervision.

4. Demonstrating overt favoritism to an individual employee.

5. Soliciting subordinates for a gift, monetary contribution or the purchase of an item.(2) Conflicts of Interest: VA Medical Center employees may not:

(a) Hold financial interest that conflicts with the conscientious performance of duty.

(b) Use public office for private gain.

(c) Engage in outside employment or activities that conflict with official Government duties and responsibilities.

(3) Ethical Business Practices:

(a) Any employee who participates personally or substantially in any procurement action (i.e., requests for equipment, supplies, or services) must abide by all applicable regulations governing procurement.

1. An employee must not engage in financial transactions using nonpublic Government information or allow the improper use of such information to further any private interest.

2 . An employee must not knowingly make unauthorized commitments or promises of any kind that would bind the Government.

(b) Transactions relating to the expenditure of public funds require the highest degree of public trust and an impeccable standard of conduct. Any conflict of interest is to be strictly avoided in Government-contractor relationships.

(c) Government business will be conducted in a manner above reproach, and except as authorized by statute or regulation, with complete impartiality.

(d) Honest and mutually beneficial relationships will be fostered with affiliated educational institutions, patients/customers, suppliers, other healthcare institutions, third party payers, and the community.

(e) An employee must disclose waste, fraud, abuse, and corruption to the appropriate authorities.

(f) An employee must satisfy in good faith their obligations as citizens, including all financial obligations that are imposed by the law (i.e. Federal, state or local taxes).

(g) The organization will provide a work environment that is free of discrimination and harassment.

(h) All employees will be provided equal employment opportunities.

(i) All employees will be provided a mechanism for defining their rights.

(j) The organization and its staff will disclose information regarding rights, responsibilities, cost of services, discharge, and complaint process to patients and their families/significant others.

(k) The organization and its staff will bill only for those services rendered, when appropriate.

(l) The organization and its staff will be truthful in information dissemination at all times.

(m) An employee must make every effort to avoid any actions creating the appearance that they are violating the law or the standards set forth in the Standards of Ethical Conduct as determined from the perspective of a reasonable person with knowledge of the revelant facts.

5. REPORTING REQUIREMENTS: None.

6. RESPONSIBLE OFFICE: Medical Center Director (00).

7. REFERENCES: CARF Medical Rehabilitation Standards Manual; Joint Commission Comprehensive Accreditation Manual for Hospitals; VHA Handbook 1200.05, Requirements for the Protection of Human Subjects in Research, Appendix C-1, The Informed Consent; Federal Medical Recovery Act, (Public Law 87-693); Veteran Health Care Amendment Act of 1986; Omnibus Budget Reconciliation Act; Section 27 (b) of the Office of Federal Procurement Policy Act (41 U.S.C. 423); Medical Center Policy Memorandum 11-11, Informed Consent; 05-53, Standards of Ethical Conduct; 11-10, Organ and Tissue Donor Procedures; 11-09, Advance Health Care Planning (Advance Directives); 00-73, Customer Service Patient Satisfaction Program– Putting Veterans First; 00-05, Public Affairs Program; VHA Handbook 1050.01, VHA National Patient Safety Improvement, and Ethical Boundaries in the Patient-Clinician Relationship: A Report by the National Ethics Committee of the Veterans Health Administration, July 2003.

8. RESCISSION: Medical Center Policy Memorandum 00-06, dated January 25, 2013.

Medical Staff Concurrence: Date: June 29, 2015

/s/

CHRISTOPHER MARINO, M.D.

Chief of Staff

/s/

C. DIANE KNIGHT M.D.

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