D.17 JDD VAMC Memorandum 00-52 Patient Rights and Responsibilities.pdf

JOHN D. DINGELL VA MEDICAL CENTER 00-52

DETROIT, MI 48201 August 8, 2016

If policies become expired, this medical center considers policies in effect until rescinded or updated by the policy owner.

Policies and procedures cannot possibly address all situations, please make sure that you exercise good judgment and common sense. Remember, patient needs always come first.

The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

PATIENT RIGHTS AND RESPONSIBILITIES

1. PURPOSE

To establish procedures for informing patients and eliciting from them an understanding and acknowledgment of their rights and responsibilities. This applies to all patients receiving health care in this medical center.

2. POLICY

To provide high quality health care in an atmosphere in which the needs and concerns of the patient are met and individual interests protected. This is based on regard for dignity of the patient as an individual, and care, which is considerate and respectful. By informing patients of their rights and responsibilities, it is believed that they will be able to participate more fully in treatment decisions, which enhance outcome of treatment and quality of care.

The medical center respects the patient's right to make decisions about his or her care, treatment and services, and to involve the patient's family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker. ‘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 individual (such as significant other, friend or caregiver) whom the individual considers to be family. A family member may be the surrogate decision-maker, as defined in VHA Handbook 1004.02, if authorized to make care decisions for the individual, should he or she lose decision-making capacity or choose to delegate decision making to another. The medical center allows a family member, friend or other individual to be present with the patient for emotional support during the course of stay. The medical center allows for the presence of a support individual of the patient's choice, unless the 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.

3. DEFINITION

Patient Rights: Patient rights are outlined in National Patient Rights and Responsibilities tri-fold brochures and posters, IB 10-160, which are displayed in primary care, urgent care and admitting areas, on each ward, and information desks. The patient’s rights include but may not be limited to:

a. The Right to the Medical Center’s Response to His/Her Request/Need for Care: Eligible individuals shall be given impartial access to treatment or service within the medical center’s

2.

Medical Center Numbered Memorandum 00-52 capacity to provide its stated mission and according to applicable law and regulation. This access will be given without regard to race, age, religious beliefs, sex, national origin, cultural, economic and educational background, or source of payment.

b. The Right to the Medical Center’s Reasonable Response to His/Her Request/Need for:

(1) Patient Preference: This medical center will not honor a patient’s preference that discriminates or impinges upon the rights of another patient, employee, or volunteer.

(2) Transfer: When the medical center cannot meet the request or need for care, the patient may be transferred to another facility when medically permissible. Transfer should be made only after the patient has received complete information and explanation concerning the need for, and alternative to, such a transfer. The patient has the right to either consent or refuse the transfer. The facility that the patient is to be transferred to must accept the patient for transfer.

(3) Safety: The patient has the right to expect reasonable safety insofar as medical center practice and environment are concerned.

(4) Communication: The patient has the right to access individuals outside the medical center by means of visitors or by verbal, telephone and written communication. When the patient does not speak or understand the predominant language of the community or has vision, speech, hearing or cognitive impairments he/she will be communicated with in a manner that meets his/her needs, including having access to an interpreter.

(5) Continuity of Care: The patient has the right to expect reasonable continuity of care.

The patient or his/her designee has the right to be informed by his/her physician of continuing healthcare requirements following discharge.

c. The Right to Considerate and Respectful Care: The patient has a right to considerate, respectful care that respects his/her personal value and belief system. The patient’s care includes consideration of the patient as an individual with personal, religious and cultural values and belief systems that impact upon his/her attitude toward his/her illness and response to care provided. The patient has a right to expect freedom from mental, physical, sexual, verbal abuse, neglect, humiliation and exploitation.

(1) Spiritual Needs: The patient has the right to religious and other spiritual services and to be allowed to express his/her spiritual beliefs and cultural practices that do not harm others or interfere with the planned course of medical therapy for the patient.

(2) Care of the Dying Patient: Patients who are suffering an incurable and irreversible condition where death is pending will be treated with dignity and comforted through the provision of aggressive pain management based upon a pain assessment process;

identification and treatment of symptoms that will respond to treatment as desired by the patient and designated representative; and the assessment of the patient’s and his/her family’s psychological needs as well as the ability to cope with the grieving process.

3.

d. The Right to Make Decisions in Collaboration with His/Her Physician: The process by which care and treatment decisions are made will respect and incorporate the patient’s preferences and is based on a partnership between the patient and the physician or other health care professionals to facilitate informed decision making by the patient or designated representative.

(1) Right to Accept or Refuse Care: The patient or designated representative has the right to accept or refuse medical care to the extent permitted by law, and to be informed of the medical consequences of such refusal.

(2) Clinical Appeals Process: The patient or designated representative will have access to fair and impartial review of disputes regarding clinical determinations or services that are not resolved at the facility level. Clinical determinations or services include disputes involving referrals/transfers, discharge planning, clinical care, and other factors that influence the clinical outcomes of care.

(3) Right to Formulate Advanced Directive/Appoint Surrogate for Healthcare Decisions:

The patient has a right to formulate an advanced directive and to appoint a surrogate to make health care decisions on his/her behalf, as permitted by law. At the time of admission, the existence of an advanced directive, which may be in the form of a living will, durable power of attorney for health or a similar document portraying the patient’s preferences, is ascertained. The patient is provided information, which may assist him/her in the development of an advanced directive at the time of admission.

e. The Right to Information Necessary to Make An Informed Decision Regarding His/Her

Care: The patient has the right to obtain from his/her physician a clear, concise explanation of his/her condition and any proposed treatment(s), the potential benefit(s) and the potential drawback(s) of the proposed plan of treatment to include procedures, problems related to recuperation and likelihood of success. Information will also be provided regarding any significant alternative treatment(s) or procedure(s).

(1) Identity: The patient has the right to know, in writing, the identity and professional status of individuals providing service to him/her and to know which practitioner is primarily responsible for his/her care. This includes the patient’s right to know of the existence of any professional relationship among individuals who are treating him/her as well as the relationship to any other health care or educational institutions involved in his/her care.

(2) Consent: The patient has the right to receive from his/her physician information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include but not necessarily be limited to the specific procedures and/or treatment, the medically significant risks involved, and probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information. The patient also has the right to know the name of the person responsible

4.

for the procedures and/or treatment. The patient has the right to give or withhold informed consent.

(3) Disclosure: The patient has the right to have clearly explained the outcome of any treatments or procedures, and when appropriate the family, by the responsible licensed independent practitioner or his/her designee, whenever those outcomes differ significantly from the anticipated outcome and lead to injury or death.

(4) Refusal of Treatment: The patient has the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of his/her action.

(5) Consultation: The patient has the right to request consultation from any other physician he/she desires.

(6) Dilemma in Care Decision: If, during the course of treatment, a conflict occurs between family members or between the patient and family, etc., consultation with the treating multidisciplinary team to include but not limited to the attending physician, patient care coordinator, clinical nurse manager, social worker, case manager, and/or patient advocate may be requested. Referral to the facility's Integrated Ethics Committee, religious or spiritual advisor, or when appropriate the Patient Care Review Board, may also be requested. A member of the consulted team will be assigned responsibility of entering documentation into the medical record.

Issues that may arise necessitating such a request may include patient rights and responsibilities; informed consent; advance directives; research, investigation or clinical trials; treatment decision disagreements; withholding resuscitation and forgoing or withdrawing life-sustaining treatment; denial of admission; and pain management.

(7) Pain Management: All patients have the right to appropriate assessment and management of pain as well as a right to pain relief. Patients will be informed that relief of pain is an important part of their care. Patients will be asked as part of their regular assessment about the presence, quality, and intensity of pain. Health care providers will work with the patient to establish a goal for pain relief and develop and implement a plan to achieve that goal.

(8) Organ Donation: Any patient of sound mind may donate all or any part of his/her body. If the deceased patient would not have wished or does not wish such a donation, the medical center shall not request nor accept such.

(9) Use of Experimental or Investigational Drugs: The patient has the right to enough information to allow him/her to make an informed decision on whether or not to accept the use of experimental and/or investigational drugs that are planned for his/her treatment. Based on that information, the patient has the right to accept or refuse the use of such drugs or treatment. The patient also has the right to know that his/her decision to accept or refuse the use of such drugs/treatment in his/her care will not affect the interest that physicians have in his/her outcome.

5.

f. The Right to Information about the Medical Center’s Patient Rights Policies and

Complaint Mechanism: The patient or a responsible family member has the right to be informed of complaint procedures. The patient has the right, without discrimination, to voice concerns regarding care received, to have those concerns reviewed and resolved when possible. Patient complaints are to be documented into the VistA Patient Representative Tracking Program for Complaints and Compliments. Documentation does not become part of the medical record and is not considered to fall under the confidentiality regulations for quality management documents.

Therefore, upon request, patients are entitled to receive a copy of any formal complaint or compliment. The patient shall be informed of his appellate rights in the event the Patient Care Review Board recommends a health care agreement.

g. The Right of the Patient or Designee to Participate in Ethical Issues: The patient has the right to access protective and advocacy services and expect that the medical center will recognize its obligation to respect the voice of the patient or his/her designated representative when ethical issues arise during care. The patient or his/her designated representative also has the right to be a part of any discussion of the ethical issues in his/her case.

h. The Right to be Informed of Any Human Experiment of Research Affecting Him/Her:

The patient or his/her designated representative has the right to know of any experimental research, experimental drugs, or educational activities that are involved in his/her treatment. The patient has the right to refuse or participate in any such activity or research.

i. The Right to Personal Privacy and Confidentiality within Legal Limits as Follows:

(1) To be interviewed and examined in surroundings that provides reasonable visual and auditory privacy. This includes the right to have a person of the same sex as the patient present during certain parts of a physical examination, treatment or procedure performed by a health care professional of the opposite sex; the right not to remain disrobed any longer than is required to accomplish the purpose of the examination, treatment or procedure.

(2) To wear appropriate personal clothing and religious or other symbolic items as long as they do not interfere with procedure or treatment.

(3) To participate in civic rights.

(4) To keep and spend their own money. The patient will have the right to receive an accounting of VA held funds.

(5) To refuse to talk with or see anyone not officially connected with the medical center, including visitors or persons officially connected with the medical center but not directly involved in the patient’s treatment.

(6) To expect any discussion or consultation involving his/her case will be conducted discretely and that individuals not directly involved in his/her care will not be present

6.

without his/her permission.

(7) To be asked and to give or withhold consent to produce or use recordings, films or other images of the patient for purposes other than his/her care.

(8) To request transfer to another room if another patient or visitor in the room is unreasonably disturbing him/her.

(9) To be placed in protective privacy when considered necessary for personal safety.

(10) To expect that all communications and records pertaining to his/her care are treated as confidential and to expect that his/her medical records will be read only by individuals directly involved in his/her treatment or in the monitoring of the quality of care. Further, the patient has the right to expect that no other individual will have the right to his/her records except upon his/her written authorization or that of a designated representative.

(11) To expect freedom from chemical, physical restraint, or seclusion except in situations in which there is a substantial risk of imminent harm by the patient to him or herself.

j. Incompetent Patient: The right of the patient’s guardian, next-of-kin or legal designee to exercise these rights if the patient is unable to do so. If the patient has been determined incompetent or is found by his/her physician to be medically incapable of understanding the proposed treatment or procedure, is unable to communicate his/her wishes regarding treatment or is an unemancipated minor, then the patient’s guardian, next-of-kin or legally designated representative has the right to exercise these patient rights.

k. Patient’s Right to Request Itemized Explanation of Total Bill for Services Rendered:

Regardless of the source of payment for his/her care, the patient has the right to receive information about the costs of his/her care, if any, before he/she is treated and to request and receive an itemized and detailed explanation of his/her total bill, as feasible, for services rendered at the hospital. The patient has the right to a timely notice prior to termination of his/her eligibility for reimbursement by any third party payer for the cost of his/her care.

l. Patient’s Right to Feedback and Support: Patients have the right to have access to results of locally and nationally conducted surveys. These results will be displayed in a public area of the medical center.

4. RESPONSIBILITIES

a. Business Practice (admission clerk/MAA) is responsible for providing the National Patient Rights and Responsibilities tri-fold brochure, IB 10-160, to all patients presenting for admission and obtaining patient signature on the Patients’ Rights Information Form (Appendix A).

b. Nursing Section is responsible for answering questions regarding patient rights and https://dvagov.sharepoint.com/sites/VHADetroit/Policies/00-52%20Appendix%20A.docx

7.

responsibilities and documenting it on Nursing Admission Database as well as securing an interpreter when requested.

c. The physician is responsible for documenting patient rights information in the chart for patients incapable of understanding, refusing to sign or have family member sign name.

d. The patient is responsible for providing accurate and complete information to the best of his/her knowledge, for reporting whether he/she clearly comprehends a contemplated course of action and following the recommended treatment plan. The patient is responsible for his/her actions if he/she refuses treatment or does not follow the practitioner’s instructions. The patient is responsible for following hospital rules and regulations affecting patient care and conduct.

The patient is responsible for respecting the rights and property of other patients and staff. The patient will respect the medical center’s smoking policy.

5. PROCEDURES

a. Inpatient: The admission clerk/MAA will explain to the patient their rights and responsibilities and document this on the Patients’ Rights Information Form (Appendix A). The ward admitting nurse or physician will answer any questions the patient may ask regarding their rights and responsibilities. Patients under a holding order will be informed by the attending physician of commitment procedures and their right to a court hearing within 10 days.

b. Patient Refusal/Incapable of Understanding: If the patient refuses to participate or appears incapable of understanding an explanation of his/her rights and responsibilities, this will be documented in the nursing admission note and brought to the attention of the attending physician. It will be the physician’s responsibility to ensure that the patient is approached at a later time or his/her next-of-kin or guardian is given an explanation of patient rights and responsibilities.

c. Long Term Patients: Community Living Center residents or their next-of-kin/guardian, as appropriate, will be provided with the Patient’s Rights and Responsibilities booklet which covers patient rights and all rules and regulations pertaining to patient conduct and responsibilities. This information will be reviewed with the patient annually.

6. REFERENCES

National Patient Rights and Responsibilities tri-fold brochures and posters, IB 10-160 VA Regulations, Part 17, Paragraphs 17.34-17.34a The Joint Commission, current edition. Rights and Responsibilities.

Code of Patient Concern, VA Form 10-7991 VHA Directive 2006-041, Veterans Health Care Standards VHA Handbook 1003.4, Patient Advocacy Program dated September 2, 2005 VHA Handbook 1050.1, VHA National Patient Safety Improvement Handbook Policy Memorandum 10N11-11, VISN 11 Clinical Appeals Process Medical Center Numbered Memorandum 00-30, Organ Donation Request, dated May 8, 8.

Medical Center Numbered Memorandum 11-18, Withholding and Withdrawing Life- Sustaining Treatment, dated February 1, 2013 Medical Center Numbered Memorandum 11I-57, Pain Management, dated October 29, 2015.

Medical Center Numbered Memorandum 11-9, Informed Consent, dated July 8, 2013 Medical Center Numbered Memorandum 11-11, The Use of Physical Restrains and/or Seclusion for Behavioral Health Settings, dated August 8, 2012

7. FOLLOW – UP RESPONSIBILITY

Chief of Business Practice is responsible for the content of this Medical Center numbered memorandum (00-52)

8. RESCISSION

Medical Center Numbered Memorandum 00-52, Patient Rights and Responsibilities, dated September 9, 2015.

9. EXPIRATION DATE

August 8, 2021 //s// Pamela Reeves, M.D.

Medical Center Director

Distribution: Facility Wide