36C25718R0247-033.pdf

DEPARTMENT OF VETERANS AFFAIRS Policy Memorandum 11-13-67 South Texas Veterans Health Care System San Antonio, Texas 78229-4404 August 26, 2013

PATIENTS’ RIGHTS AND RESPONSIBILITIES

1. PURPOSE: To define the rights and responsibilities of all patients receiving treatment at the South Texas Veterans Health Care System (STVHCS) and to establish a procedure for conveying this information to them in a consistent and timely manner.

2. POLICY:

a. Patients will be treated with respect and nondiscrimination:

(1) They will be treated with dignity, compassion and respect as individuals. Consistent with Federal law, VA policy, and accreditation standards of The Joint Commission, they will not be subject to discrimination for any reason, including for reasons of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression.

(2) They will receive care in a safe environment free from excess noise, and with sufficient light to ensure comfort and safety.

(3) They have a right to have access to the outdoors.

(4) STVHCS will seek to honor their cultural and personal values, beliefs, and preferences.

(5) STVHCS that they identify any cultural, religious, or spiritual beliefs or practices that influence their care.

(6) They or someone they choose has the right to keep and spend their money. They have the right to receive an accounting of any funds that VA is holding for them.

(7) STVHCS will respect their personal freedoms in the care and treatment we provide them.

This includes trying to accommodate your normal sleep and wake cycles, food likes and dislikes, and other personal preferences.

(8) In the Community Living Center, they have the right to be free from chemical and physical restraints. In the inpatient acute care setting, and only in rare cases, the use of chemical and physical restraints may be used if all other efforts to keep them or others free from harm have not worked.

(9) In the Community Living Center, they may keep personal items and are expected to wear their own clothes. As an inpatient, they may wear their own clothes depending on their medical condition.

(10) They have the right to keep and use personal items as long as they are safe and legal.

(11) They have the right to social interaction and regular exercise. They will have the opportunity for religious worship and spiritual support. They may decide whether or not to participate in these activities. They may decide whether or not to perform tasks in or for the

STVHCS.

POLICY MEMORANDUM 11-13-67

(12) They have the right to communicate freely and privately. They will have access to public telephones and VA will assist you in sending and receiving mail. They may participate in civic rights, such as voting and free speech.

(13) When a loved one is involved in support and care of a VA patient or CLC resident, VA considers a patient or CLC resident’s family to include anyone related to the patient or CLC resident in any way (for example, biologically or legally) and anyone whom the patient or CLC resident considers to be family. If they are an inpatient, any person they choose can be with them to support them during their stay. Medical staff may restrict visitors for inpatients if medical or safety concerns require it. They will be told promptly about any visitor restriction and the reason for it.

(14) In order to provide a safe treatment environment for all patients or CLC residents and staff, they and their visitors are expected to avoid unsafe acts that place others at risk for accidents or injuries. They are to immediately report any condition they believe to be unsafe.

b. Patient information disclosure and confidentiality

(1) Their privacy will be protected.

(2) They will be given information about the health benefits that they can receive. The information will be provided in a way they can understand. They will also receive information on the costs of their care (for example, co-payments), if any, before they are treated. They are responsible for paying their portion of the costs associated with their care.

(3) Their health record will be kept confidential. Information about the patient will not be released without their authorization unless permitted by law (an example of this is State public health reporting). Patients have the right to have access to or request a copy of his/her own health records.

(4) All patients are to respect the privacy of other patients and CLC residents and are not to reveal their health information that may be overheard or otherwise become aware of.

c. Participation in treatment decisions.

(1) They have a right to express their preferences concerning future medical care in an advance directive, including designating a health care agent to make health care decisions on their behalf when they can no longer do so.

(2) They, and any person(s) they choose, will be involved in all decisions about their care. They will be given information they can understand about the benefits and risks of treatment in their preferred language.. They will be given other options. They can agree or refuse any treatment.

They will be told what is likely to happen to them if they refuse a treatment. Refusing a treatment will not affect their rights to future care but they take responsibility for the impact this decision may have on their health.

(3) They should tell their provider about their current condition, medicines (including over-the-counter and herbals) and medical history. Also they should share any other information that affects their health. They should ask questions when they don’t understand something about their care. This will help in providing them the best care possible.

(4) They will be given, in writing, the name and title of the provider in charge of their care..

They have the right to be involved in choosing their provider. They also have the right to know the names and titles of those who provide their care. This includes students and other trainees. Providers will properly introduce themselves when they take part in a patient’s care.

(5) They will be educated about their role and responsibilities as a patient or CLC resident. This includes their participation in decision-making and care at the end of life.

(6) If they believe they cannot follow the treatment plan, they have a responsibility to tell their provider or treatment team.

(7) They will be informed of all outcomes of their care, including any possible injuries associated with their care. They will be informed about how to request compensation and other remedies for any serious injuries.

(8) They have the right to have their pain assessed and to receive treatment to manage their pain.

They and their treatment team will develop a pain management plan together. They are expected to help the treatment team by telling them if they have pain and if the treatment is working.

(9) As an inpatient or CLC resident, they will be provided any transportation necessary for their treatment plan.

(10) They have the right to choose whether or not they will participate in any research project.

Any research will be clearly identified. Potential risks of the research will be identified and there will not be pressure to participate.

(11) They will be included in resolving any ethical issues about their care. If they have ethical issues or concerns, they may speak with the Integrated Ethics Consultation Service, Integrated Ethics Council for help.

(12) Patients have the right to be free from neglect; exploitation (financial or other); verbal, mental, physical, and sexual abuse or harassment; physical punishment; retaliation and humiliation.

If a patient believes that they or their family member has been neglected, abused or exploited by VA staff, report this promptly to the treatment team or patient advocate. They will receive help immediately

d. Concerns or Complaints

(1) Patients are encouraged and expected to seek help from their treatment team or a patient advocate if they have problems or complaints. Any privacy complaints will be addressed by the STVHCS Privacy Officer. They will be given understandable information about the complaint process in their preferred language. They may complain verbally or in writing, without fear of retaliation.

(2) If they believe the organization has failed to address or satisfy their concerns about health care quality and safety, they may contact the Joint Commission’s Office of Quality Monitoring at 1- 800-994-6610. If they believe that the organization has failed to address their concerns about suspected criminal activities, fraud, waster, abuse, or mismanagement, they may contact the VA Office of the Inspector General at 1-800-488-8244 or email http://www.va.gov/oig/ http://www.va.gov/oig/

e. Additional Rights and Responsibilities of Community Living Center (CLC) Residents - Because the CLC serves as their home for short or long-stay services, they have the following additional rights and responsibilities as a CLC resident:

(1) Staff will knock on their bedroom door prior to entry.

(2) They have the right to receive care from the same staff member everyday to the extent that consistent assignment is possible.

(3) They may have visitors at any time of the day or night provided visitors are respectful of them, their need for privacy and the privacy of others. They may refuse visitors at any time.

(4) They have a right to conjugal visits and they have a right to privacy during those visits.

(5) Their care will be delivered in a setting that resembles home. Therefore, they will be invited to have their meals in a designated dining room area and they will have access to those activities that contribute to meaningful use of time.

(6) In preparation for being discharged to their own home, they or their care giver may be invited to participate in activities that prepare them to go home such as self administration of medications and treatments.

(7) They and their care givers have a right to attend treatment planning meetings and participate in household or resident council.

3. ACTION:

a. Upon admission to inpatient care, patients will be offered their own copy of the Patient Information Handbook. This handbook contains a listing of patient rights and responsibilities.

b. Posters outlining patient rights will be displayed in the admitting area lobby, other hospital lobby areas, and in selected areas placed throughout the system in order to be conspicuous.

c. Outpatients will be offered a copy of the Patient Information Handbook.

d. The Director and Medical Administration Service, will ensure that all patients are informed of their rights.

e. The Treating Physician will determine whether a patient is able to understand the Patient Rights and ensure that the treatment aspects of the patient’s rights are fully protected.

f. The Chief, Human Resource Management Service, will ensure that all new employees are informed of patients’ rights as a part of their orientation process.

g. All STVHCS employees are responsible for ensuring that patients are treated in a courteous, dignified and compassionate manner. All employees, as necessary, will assist patients in understanding their rights.

4. REFERENCES: Title 38, Code of Federal Regulations, Part 17, Section 17.33, revised as of July 1, 2002; The Joint Commission Comprehensive Accreditation Manual for Hospitals, Current Edition.

5. RESPONSIBILITY: Chief of Staff (11)

6. RESCISSION: STVHCS Policy Memorandum 11-2009-67 dated December 15, 2009

7. RECERTIFICATION: August 2018

(Original signature on file)

MARIE L. WELDON, FACHE

Director Attachment (2)

DISTRIBUTION: A

Guidelines for Requests to Change Attending Provider or Treating Specialty in the Inpatient Setting

1. As a partner in the health care process, patients have the right to be involved in choosing their provider. Per the South Texas Veterans Health Care System (STVHCS) Medical Staff Bylaws, Rules and Regulations, Section R.7.5, upon admission to inpatient care at this Medical Center, each patient shall be assigned to the clinical service or section deemed most appropriate for the care and treatment of the condition for which hospitalization is required. These guidelines provide a formal process for addressing patient requests to change attending providers or treating specialties in the inpatient setting of STVHCS.

2. Requests by a patient or their surrogate to discontinue receiving care under a specific resident(s) will be managed by the attending physician or treatment team through direct communication. Psychosocial support services such as Social Work Service, Psychology Service, and the Chaplain Service may be consulted to assist in maintaining the therapeutic relationship through assessment and interventions to address the social, spiritual, and cultural factors that influence patient perceptions and involvement in care. Inability to resolve issues at the level of the attending physician or treating specialty will result in a referral to the Patient Advocate and a formalized approach.

3. When a patient or their surrogate expresses concern about continuing care under the assigned attending provider or requests a change in attending provider, the Patient Advocate will be notified to meet with the patient and/or their surrogate to investigate and/or validate any existing complaint, determine options for resolution of the specific complaint and opportunities to improve future service to patients, and facilitate documentation and review of the request to change the inpatient attending provider(s) or treating specialty.

4. The STVHCS will make every attempt to honor a veteran’s request for a change of provider. Our health care system cannot honor requests for specific providers by name, or requests for providers of specific race, gender (in the inpatient setting), nationality, level of experience or training (resident physician versus staff physician).

5. Upon validation of the patient’s request to change provider(s) or treating specialty, the Request to Change Attending Provider or Treating Specialty form will be completed.

6. The Service Chief of the treating specialty, or their designated representative, will be notified immediately to assist in the transfer of care.

7. It is the responsibility of the Service Chief to notify the attending of record, if s/he is not already aware of the request. The honoring of the request in no way implies improper care. This portion of the process is based solely on the patient’s/surrogate’s right to be involved in choosing their provider. A requested change of provider or service should not be confused with a request for a second opinion.

8. The Chief of Staff must be notified and kept informed of the entire process. If resolution cannot be reached at the level of the Chief of Service, the Chief of Staff will make the final determination.

9. The Medical Center will make every attempt to honor the patient’s request for a change in provider by locating an alternate attending from within the System; however, circumstances may arise where an alternate attending of record cannot be found, in which case Administration will work with the patient/surrogate to find an agreeable solution. It will be the patient’s or surrogate’s responsibility to find alternate care outside the VHA service. At any time during the process, the Ethics Consult Service can be consulted to address specific ethical concerns and or to assist with mediation (see PM 00-11-25 Integrated Ethics Council).

Attachment A, page 1 of 2

REQUEST TO CHANGE ATTENDING PROVIDER(S) OR TREATING SPECIALTY

Please Print

Patient’s Name: ___________________________________________________________

Social Security #: __________________________________________________________

Current Provider(s)/Team: __________________________________________________

Reason for Request: ________________________________________________________

Patient or Patient Surrogate Signature: __________________________ Date: ________

Patient or Patient Surrogate has been visited by the Patient Advocate: Yes No

Patient Advocate Name: _____________________________________________________

Patient Advocate Signature: _____________________________ Date: _______________

Reviewed by (Chief of Service/Representative) Date

PLAN OF ACTION: ________________________________________________________

Attachment A, page 2 of 2

Information on Assignment and Change in Assignment of Primary Care Providers at the

South Texas Veterans Health Care System

1. At the South Texas Veterans Health Care System (STVHCS) patients are assigned to a primary care provider (PCP). Primary Care (PC) is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. PC provides long-term patient-provider relationships, coordinates care across a spectrum of health services, educates, and offers disease prevention programs. It is the policy of the Veterans Health Administration (VHA Directive 2012-011) that the full scope of PC is provided to all eligible veterans seeking on-going health care. Exceptions may be made for some veterans requesting limited care, such as subspecialty care for service-connected conditions, or for those scheduled only for compensation and pension exams.

2. Each veteran receiving PC must be assigned a single PCP. Those who spend a significant part of the year living in two regions of the country and who have complex needs requiring close supervision may have PCP’s assigned at more than one VHA medical facility. The PCP functions as part of an interdisciplinary PC team, which includes, at minimum, a medical doctor, nurse practitioner or physician’s assistant, as well as nurses and administrative support personnel.

3. Primary care programs place a premium on sustaining the personal relationships between patients and their providers. This therapeutic alliance improves the likelihood that patients will participate in preventive health screenings, take active and educated roles in decisions affecting their health, and ultimately become more independent in managing their own health. Psychosocial support services such as Social Work Service, Psychology Service, and the Chaplain Service may be consulted to assist in maintaining the therapeutic relationship through assessment and interventions to address the social, spiritual, and cultural factors that influence patient perceptions and involvement in care.

4. As a partner in the health care process, patients have the right to be involved in choosing their provider. The STVHCS will make every attempt to honor a veteran’s request for a PCP of a specific gender (male or female). Otherwise, the selection of a new PCP is based on a PCP rotation system.

Our health care system cannot honor requests for specific providers by name, or requests for providers of specific race, or nationality.

5. Patients may request a new PCP by completing a “Request to Change Primary Care Provider” form. The honoring of the request in no way implies improper care. This portion of the process is based solely on the patient’s/surrogate’s right to be involved in choosing their provider. If a request for a new PCP is not approved the clinic director or chief medical officer will notify the patient in writing or by telephone with a reason for disapproval.

6. Inability to resolve an issue at the level of the clinic leadership will be referred to the STVHCS Primary Care Service Line Leadership. If an issue cannot be resolved at that level then there will be a referral to the Patient Advocate. At any time during the process, the Ethics Consult Service can be consulted to address specific ethical concerns and/or to assist with mediation (see PM 00-11-25 IntegratedEthics Council).

Vicki Hannigan, M.D. Associate Chief of Staff, Primary Care Roger Roehl, MHA Administrative Director PC Service Line

Attachment B, page 1 of 2

REQUEST TO CHANGE PRIMARY CARE PROVIDER

Please Print

The selection of a new primary care provider will be based on a rotating team selection process and not on patient preference for a particular provider. Exceptions will be made for patients requesting a provider of a particular gender due to personal concerns.

Patient’s Name: ___________________________________________________________

Social Security #: __________________________________________________________

Current Team/Provider: ____________________________________________________

Reason for Request: ________________________________________________________

Patient or Patient Surrogate Signature: __________________________ Date: ________

Reviewed by (Clinic Director or Chief Medical Officer) Date

New Team/Provider: ________________________________________________________

Scheduler Signature: _______________________________________ Date: ____________

SCHEDULING DEPARTMENT WILL NOTIFY PATIENTS BY MAIL

OF NAME OF NEW PRIMARY CARE PROVIDER AND RESCHEDULED

APPOINTMENT DATE AND TIME

Attachment B, page 2 of 2