36C25819R0003-011.pdf

Phoenix VA Health Care System Phoenix, Arizona

Policy Memorandum No. 00lA-01 May 9, 2018

PATIENTS' RIGHTS AND RESPONS¡B¡LITIES

1. PURPOSE: To outline the policy and procedures in accordance with the requirements from The Joint Commission (TJC) and directives from Veteran Health Administration (VHA) concerning rights and responsibilities for individuals who receive care at the Phoenix VA Health Care System (PVAHCS) and the Community Based Outpatient Clinics (CBOCs).

2. POLICY: lt is PVAHCS policy to ensure that individuals who receive care at PVAHCS are provided quality healthcare in a respectful and courteous manner and receive the benefits and rights to which they are entitled.

3. DEFINITIONS:

a. Gomplaint. A complaint is a gap between service expectations and actual experience. A complaint may be expressed verbally or in writing to any employee as well as to officials outside of the facility, such as congressional officers or Veteran service officers.

b. Glinical Appeal. A clinical appeal is a higher-level reconsideration request to override a medical decision made at the facility level. VHA Networks administer the clinical appeals process in accordance with current VHA regulations. Clinical appeals may be filed, in writing, from the patient or their representative through the facility or directly through the Network.

c. Privacv Gomplaints. A privacy complaint is any violation of a systemic breach of privacy policy or of protected privacy related information by an unauthorized access or disclosure of protected information. Privacy complaints must be referred to the Privacy Officer and processed in accordance with VA privacy regulations and tracked using the Privacy Violation Tracking System (PVTS).

d. Discrimination Gomplaints. lf an individual believes that an employee treated the individual in an improper fashion because of race, color, national origin, age, sex, handicap or reprisal discrimination, the individual may file a discrimination complaint through the Federally-conducted external program with the facility's Equal Opportunity Manager, in accordance with VHA regulations.

e. Medical Center Patient Advocate. A Medical Center Patient Advocate is an employee who is specifically designated at each VHA facility to manage the complaint process, including complaint resolution, data capture and analysis of issues/complaints in order to make system improvements. Facility or Medical Center Patient Advocates assist front line staff in resolving issues that occur at the point of service and address complaints that were not able to be resolved at the point of service. Facility or Medical Center Patient Advocates work directly with Service Chiefs and Service management to facilitate resolution to problems beyond the scope of front-line staff, and participate in

Policy Memorandum No. 0014-01 May 9, 2018 resolution of system problems by presenting the patient's perspective of the problem and desired resolution.

f. Service-level Point of Contact (POC). A Service-level POC is an employee designated at the service level, or point of service, who assists front-line staff in resolving issues after first attempts at resolution have not been successful. A Service-level Advocate resolves patient issues, working in collaboration with the Facility or medical center Patient Advocate to identify opportunities for improvement. Service-level Advocates may be granted access to enter data into the Patient ComplainUCompliment Tracking Package.

g External Advocates. External advocates are external stakeholders who seek to represent patients in VA facilities and may include Veterans Service Organizations (VSO) and representatives of state protection and advocacy system. A patient's family and friends are not considered external advocates.

h. Service Recovery. Service Recovery is a systematic approach to proactively solicit Veteran feedback and simultaneously respond to complaints to build confidence and loyalty, while utilizing Veteran feedback to make systems improvements. Service Recovery entails taking a negative experience and turning it into a positive memorable experience. The VHA Patient Advocacy program operates within the structure of Veteran Customer Service and Service Recovery. Further information about Veteran Customer Service is found in Directive 1003 and Handbook 1003.1 . Service Recovery information is found in VHA Handbook 1003.2, Service Recovery in VHA.

i. lnquirv Routins and Information Svstem (lRlS). lRlS allows Veterans to submit questions, complaints, compliments and suggestions through the VA website.

The Veteran self-directs inquiries that are routed to the appropriate VA Central Office Program Offices, Network or facility where care was provided (https://iris.va.oov/scripts/iris.cfq/php.exe/enduser/home.php ). The preferred method of electronic communication for VHA with its constituents is through the use of lRlS.

Responding to electronic inquiries is addressed in VHA Handbook 1003.3 and through lRlS Guidebooks located at http://vaww.va.oov/irisinfo/ .

j. Patient Advocate Trackinq Svstem (PATS). PATS is an application that tracks patient complaints and compliments at each medical center.

k. Familv: A group of two or more persons united by blood, or adoptive, marital, domestic partnership or other legal ties. The family may also be a person or persons not legally related to the individual (such as significant other, friend or caregiver) whom the individual considers to be family.

L lndividuals Receivins Care (lRC): Those individuals who are receiving care in PVAHCS, including the Community Living Center (CLC).

Phoenix VA Health Gare System

Policy Memorandum No. 0014-01 May 9, 2018

4. PROCEDURES: The PVAHCS will follow the Patients Rights and Responsibilities.

a. Complaints

1) lndividuals who receive care at the PVAHCS are encouraged and expected to seek help from their treatment team and/or Patient Advocate if they have problems or complaints.

2) Individuals who receive care at the PVAHCS will be given understandable information about the complaint process available to them.

3) lndividuals who receive care at the PVAHCS may complain verbally or in writing, without fear of retaliation or barriers to service.

4) Written copies of complaints entered in the PATS are available upon request through the Release of lnformation (ROl) Office.

5) All written complaints are managed by the Directo/s Office in collaboration with the Patient Advocate office and a written response is provided within 30 days. lf a response is not completed within 30 days, written acknowledgement will be sent of the delay.

6). PVAHCS will follow the grievance procedures in VHA Directive 1003.4

5. RESPONSIBILITIES: Patient Advocate Program and Service-level Patient Advocates (SPA) willfacilitate all verbal complaints, compliments, and concerns raised by any person, as well as individuals who receive care at the PVAHCS. The Patient Advocate Program and Office of the Director suspense group will facilitate all written complaints, compliments, and concerns. The Release of lnformation Office will provide a written copy of the complaint or compliment that was documented into PATS.

a. The Medical Center Director is responsible for:

1) Ensuring the facility has a Patient Advocacy Program in place.

2) Ensuring the Supervisor, Patient Advocate is included in leadership meetings, as appropriate.

3) Ensuring that patient complaint data and the quality improvement initiatives resulting from them are communicated at least quarterly to the appropriate reporting Committee.

4) Deciding which model (decentralized or centralized) to follow based on most effective manner to resolve complaints.

Policy Memorandum No. 00lA-01 May 9, 2018

5) Promoting an environment that fosters the timely and responsive resolution of complaints.

6) Ensuring Clinical Appeals requirements are met in accordance with current VHA requirements.

7) Ensuring mechanisms are in place to proactively solicit Veteran feedback

8) Ensuring Patient Advocates and other identified staff who serve as points of contact for service recovery work collaboratively to develop an organized, proactive approach to customer service.

9) Ensuring that patient complaint data is utilized to identify trends indicating a need for change in the system process(es) and ensuring that those changes occur.

b. The Patient Advocate Supervisor is responsible for ensuring that patient complaint data is collected, trended, analyzed, and included along with other quality improvement data in the appropriate PVAHCS committees and forums.

c. The Patient Advocate is responsible for:

1) Resolving complaints that cannot be resolved at the point of service level and/or across d isciplines.

2) Presenting patient issues at various facility meetings and committees.

3) lnterpreting patient rights and responsibilities.

4) Managing the use of PATS.

5) Providing trends of complaints and satisfaction data at the facility level

6) Ensuring a process is in place for distribution of the information to appropriate leaders, committees, services and staff.

(7) ldentifying opportunities for system improvements based on quarterly complaint trending.

(8) Ensuring any significant single patient complaint is brought to the attention of appropriate staff to trigger assessment of whether there needs to be a facility system analysis of the problem.

(9) Supporting service-level Patient Advocate programs, if applicable.

(10) Ensuring entry of all clinical appeals and final decisions into the Patient Advocate Tracking Package as indicated by VHA policy.

Policy Memorandum No. 001A-01 May 9, 2018

(11) Understanding PVAHCS and VHA-wide directives, laws, and other governances which apply to patient rights and responsibilities, and the appeals process afforded Veteran patients as outlined in the VHA Handbook 1003.4.

(12) Ensuring mental health patients, or their surrogate decision makers, are aware of their right to seek representation from external advocacy groups established and authorized under Title 42, Chapter 114, Subchapter 1, Part A of United States Code (U.S.C.).

(13) Fulfilling the requirements, pertaining to the Patient Advocacy program as outlined in VHA Handbook 1108.2,lnspection of Controlled Substance.

(14) Reporting and documenting potentially threatening behavior to appropriate authorities in accordance with VHA regulations.

d. Service-level Point of Contact (POC). Service-level POCs are responsible for:

1) Assisting front line staff in resolving issues after first attempts at resolution have not been successful and identifies opportunities for improvement.

2) Entering data into the Patient Advocate Tracking System, as needed.

e. Associate Director is responsible for ensuring mechanisms are in place to

1) Trend, report, and distribute quarterly reports based on data from PATS

2) ldentify opportunities for system improvements based on quarterly complaint trending.

3) Ensure any significant single patient complaint is brought to the attention of appropriate staff to trigger assessment of whether there needs to be a facility system analysis of the problem and follow-up.

4) lntegrate data from PATS with PVAHCS, VISN, and National Quality Management (QM) reporting mechanisms.

f. Staff, within the scope of their position, are responsible for pro-actively soliciting Veteran feedback, and for:

1) lnforming patients who have unresolved complaints/concerns regarding the complaint process of options that are available to them.

Policy Memorandum No. 00lA-01 May 9, 2018

2) Reporting complaints resolved to the Service-level Advocate or in the absence of a Service Level Advocate, to the PVAHCS Patient Advocate for tracking purposes.

3) Reporting potentially threatening behavior to appropriate authorities in accordance with VHA regulations.

RESPONSIBLE BOARD: Qual ity Executive Board

REFERENCES

a. VHA Handboo k 1050.01 VHA National Patient Safetv lmorovement Handbook dated March 4,2011.

b. Title 38 Code of Federal Regulations 17.33a.

c. The Joint Commission Manual, Current Edition, Rights and Responsibilities of the Patient.

d. Patient Rights and Responsibilities; VA Form 10-88 January 15,2013.

e. Commission of Accreditation of Rehabilitation Facilities (CARF), Section 1.K.4, Rights of Person Served.

f \/lJA ñiranfirro 1003.04 vHA Arlrrnr-anrr dated Fahrr tant 7 2î'19, RESCISSION: Medical Center Policy Memorandum No. 001A-01 dated December 2011.

9. ATTACHMENT: Appendix A, 38 CFR 517.33 Patients'rights.

10.FOLLOW UP RESPONSIBILITY: Patient Advocate Supervisor

I I.EXPIRATION DATE: May 2021

/,2 ø n'L

RIMAANN O. NELSON

Medical Center Di rector

Policy Memorandum No. 0014-01 November 1,2017

APPENDIX A

Riohts and Responsibilities of VA Patients and Residents of Gommunitv Livino Centers