D.11 Attachment - Patient Rights VAPIHCS.pdf

DEPARTMENT OF VETERANS AFFAIRS FACILITY POLICY MEMORANDUM

VA PACIFIC ISLANDS HEALTH CARE SYSTEM NO, 136-13-009

HONOLULU, HAWAII 96819-1622 March 27, 2013

PATIENT RIGHTS AND RESPONSIBILITIES

1. PURPOSE:

To establish policy and procedures for the VA Pacific Islands Health Care System (VAPIHCS) regarding the rights and responsibilities of all patients receiving care in our health care system in accordance with Department of Veterans Affairs (VA).

2. POLICY:

a. It is the policy of the VAPIHCS to ensure that patients are provided quality health care in a respectful and courteous manner, with specific rights to be uniformly afforded to all patients undergoing treatment in a VA facility, as applicable to their patient care setting (inpatient or outpatient). Patients are provided with care, treatment and services in a way that respects and fosters their dignity, autonomy, positive self-regard, civil rights and patient involvement. They deserve care, treatment and services in a way that safeguards their personal dignity and respects their cultural, psychosocial and spiritual values. Consistent with Federal law, VA policy, and accreditation standards of The Joint Commission, patients and their family members 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. We will involve the family in their care, treatment and service decisions with the patient's approval.

VAPIHCS follows ethical behavior in its care, treatment, services and business practices.

3. EFFECTIVE DATE: Aug 9, 1999

4. DEFINITION:

a. Family — Family is defined as 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 patient such as significant other, friend, or caregiver, whom the individual considers to be family.

6 PROCEDURES:

a. It is the policy of VAPIHCS to ensure that patients are provided with care, treatment and services in a way that respects and fosters their dignity, autonomy, positive self-regard, civil rights and patient involvement. They deserve care, treatment and services in a way that safeguards their personal dignity and respects their cultural, psychosocial and spiritual values. We will involve the family in their care, treatment and service decisions with the patient's approval. VAPIHCS follows ethical behavior in its care, treatment, services and business practices.

b. The following lists of patient rights are assured for each patient and when appropriate, family member(s) or significant other(s) designated by the patient, unless they are medically contraindicated. As necessary and when applicable, patients shall be personally informed of their rights and responsibilities by facility personnel in a language the patient understands:

HONOLULU, HAWAII 96819-1522 March 27, 2013

(1) To have the integrity of decisions based on identified care, treatment, service needs and to have any conflicts of interest addressed by the facility.

Information about the relationship between the use of care, treatment and services and financial incentives are available to all patients when requested.

(2) To respect their rights and to receive treatment, care and services within the facility's capability, mission and in compliance with law and regulation.

(3) To receive information about their rights and responsibilities and to receive a written copy of the same.

(4) To receive considerate, respectful care at all times, with respect of his or her personal dignity, cultural, psychosocial, spiritual and personal values, beliefs and preferences.

(5) To pastoral and other spiritual services.

(6) To be involved in making decisions about their care, treatment and services provided.

(7) To be involved in resolving dilemmas about care, treatment and services. To contact VAPIHCS Patient Advocate(s) for assistance in resolving any dilemmas or concerns. Patient Advocate phone number is 808-433-0126.

(8) To have a surrogate decision maker approve care, treatment and service decisions when he or she cannot make these decisions, as allowed by law or chooses to delegate decision making to another. This may be a family member, if authorized to make care decisions for the patient,

(9) To have family, as appropriate and as allowed by law, with permission of the patient or surrogate decision maker, involved in his or her care, treatment and service decisions.

(10)To receive information and explanation necessary to give informed consent for any proposed treatments or procedures in accordance with law and regulation. Informed consent process includes a discussion about potential benefits, risks, and side effects of the patient's proposed care, treatment, or services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation.

(11) To receive information during informed consent process about any circumstances under which information about the patient must be disclosed or reported.

(12)To provide written consent for recording or filming for purposes other than identification, diagnosis, or treatment. Patients who may consent to filming or recording also have the right to request cessation of recording or filming and the right to rescind consent for use up until a reasonable time before the recording or film is used.

(13)To receive adequate information, including the name, about the person(s) responsible for the delivery of their care, treatment and services.

(14)To refuse care, treatment and services in accordance with law and regulations.

When the patient is not legally responsible, the surrogate decision maker, as allowed by law, has the right to refuse care, treatment and services on the patient's behalf.

HONOLULU, HAWAII 96819-1522 March 27, 2013

(15)To have their wishes addressed and respected relating to end-of-life decisions.

(16)To formulate an advance directive and designate a surrogate to make health care decisions on his/her behalf within the limits of the law and the hospital's capabilities. The existence or lack of an advance directive does not determine an individual's access to care, treatment and services. Assistance will be provided to patients who do not have an advance directive, but wish to formulate one. The patient or surrogate has the option to review and revise the advance directive at any time. Advance directives and organ donation wishes will be honored within the limits of the law and the facility's capabilities.

(17)To be informed, along with their families when appropriate, about the outcomes of care, treatment and services including unanticipated outcomes. He or she will be informed about how to request compensation for injuries.

(18)To have effective communication and to receive information in a manner that he or she understands. This includes communication between VAP1HCS and the patient, as well as communication between the patient and others outside the facility. Written information will be provided that is appropriate to the age, understanding, and as appropriate to the population served and the language of the patient. Interpreters will be provided to individuals who are hearing impaired or who speak a foreign language and who need assistance with communications. Interpreters are coordinated through designated Social Workers in Primary Care and Mental Health Clinics or the EEO Officer.

(19)To confidentiality of information, personal privacy, and to be treated in safe and secure surroundings.

(20)To be treated in an environment that preserves dignity, the right to privacy and contributes to a positive self image.

(21)To be free from mental, physical, sexual, verbal abuse, neglect and exploitation.

(22)10 appropriate assessment, treatment and management of pain.

(23)To access protective and advocacy services. Social Work Service will assess the patient's needs for special services and assist with the initiation of such services, when appropriate.

(24)To the protection and respect of their rights during research, investigation and clinical trials involving human subjects. VAPIHCS provides patients who are potential subjects with adequate information to participate, or refuse to participate, in research. To continue to access care, treatment, or services unrelated to the research at anytime. To refuse participation in research, investigation, or clinical trials or discontinue participation at any time without jeopardizing his or her access to care, treatment, or services unrelated to the research.

(25)To keep and spend his or her own money and receive an accounting of VA held funds.

(26)To wear his/her own clothes and keep personal items, based on medical condition and hospital regulations.

(27)To social interaction and regular exercise. Patients may decide whether or not to participate in social, spiritual, community activities or to perform tasks while in the

VAP1HCS.

HONOLULU, HAWAII 96819-1622 March 27, 2013

(28)To communicate freely and privately. May also have or refuse visitors.

(29)To have a family member, friend, or other individual of the patient's choice present with the patient for emotional support during the course of stay, unless that individual's presence infringes on others' rights or safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient's surrogate decision maker or legally authorized representative.

(30)To receive information about the costs of care, if any, before he or she is treated.

(31)To have his or her medical record kept confidential. Information will not be released without consent, unless authorized by law.

5. RESPONSIBILITIES:

a. While a guest at this facility, patients and their families are expected to adhere to the following list of patient responsibilities:

(1) Respecting other patients and staff and to follow the facility's rules.

(2) Paying their portion of the costs associated with their care, if any,

(3) Following the treatment plan they develop with their treatment team. If they refuse a treatment, they are responsible for the possible results to their health.

(4) To notify their treatment team if they believe they cannot follow the treatment plan.

(6) For telling their provider about current conditions, medicines (including over-the-counter and herbals), medical history and any other information that affects their health.

(6) For asking questions when they don't understand about their care.

(7) Telling the treatment team if they have pain and if the treatment is working.

(8) Seeking help from their treatment team and/or a patient advocate if they have problems or complaints.

(9) Informing medical center personnel of any changes in their advance directive.

b. It is the responsibility of every employee to ensure that all patients and beneficiaries at VAPIHCS are treated with courtesy, dignity and respect and their rights are observed and honored at all times,

(1) The VAPIHCS Director has the overall responsibility for ensuring patients are provided health care with the dignity they have earned and are afforded under Federal and State laws, VA regulations and in accordance with those Patient Rights issued by this clinic. The Chief of Staff has been delegated the responsibility for the health care provided for VAPIHCS patients and to assure the VAPIHCS Director that such health care is being provided in compliance with the provisions of Patient Rights and Responsibilities and other VA, Federal and State regulations.

HONOLULU, HAWAII 96819-1522 March 27, 2013

(2) Associate Chiefs of Staff and Service Chiefs are responsible for ensuring that this policy is discussed with their assigned staff members, and staff members are knowledgeable about how to assist patients wishing to voice a complain and that they can identify the Patient Advocate Liaison for their service, modules, and Community Based Clinics.

(3) Chief, Human Resource Management Service (or designee), is responsible for ensuring that every newlyhir,.ed employee receives a copy of this policy. ,

(4) Chief, Health Administration Service (or designee), is responsible for ensuring that a copy of the Information Booklet on Patient Rights and Responsibilities is available for patients (or their representatives) treated at VAPIHCS. Also, he/she is responsible for providing copies to responsible service organizations, representatives, or others requesting such copies. Additionally, he/she is responsible for ensuring that both he/she, the Patient Advocate(s) and Product Line managers are fully familiar with and are capable of answering specific questions or concerns expressed by patients, representatives or others regarding Patient Rights and Responsibilities.

c. Upon admission to the Community Living Center (CLC), patients, or their designated representatives, will be provided with the VA Brochures 1B 10-284, P96280 Family Members' Rights and Responsibilities; CLC Resident Handbook which includes Patient and Nursing Home Resident Rights and Responsibilities; and VA PIHCS Advance Directives Brochure. Posters of the Patient and Nursing Home Resident Rights and Responsibilities are posted at the CLC and in the main lobby of outpatient clinical areas.

6 REFERENCES:

a. VHA Handbook 1004.1- Informed Consent for Clinical Treatments and Procedures

b. VHA Handbook 1004.2 -Advance Care Planning And Management Of Advance

Directives VHA Directive 1004 National Center for Health Care in Ethics.

c. The Joint Commission Accreditation Manuals for Ambulatory Care and Long Term Care, current editions.

d. FPM NO 00-13-056 Patient Advocacy Program

e. FPM NO 11-03-017 Advance Directives

1. FPM NO 11-12-050 Disclosure of Adverse Events to Patients

g. FPM NO 136-09-020 Informed Consent for Treatment and Procedures

7. RESCISSIONS: 136-10-009, FPM Patient Rights and Responsibilities

8. REVIEW DATES:

March 2014, March 2015, March 2016, and March 2017

9. REISSUE DATE:

March 2018 i le-tv

FACILITY POLICY MEMORANDUM

NO, 136-13-009

March 27, 2013

DEPARTMENT OF VETERANS AFFAIRS

VA PACIFIC ISLANDS HEALTH CARE SYSTEM

HONOLULU, HAWAII 96819-1522

10. FOLLOW-UP RESPONSIBILITY:

Chief, Quality Management Services acqueli 4R. White, MS, RN, CNAA, CS Chief, Quality Management Service

William F,ADubbs, M.D.

Acting girector

Distribution: E