D.24 - NMVAHCS - MCP 003-34 - Patient Rights and Responsibilities.pdf

New Mexico VA Health Care System Memorandum 003-34 Albuquerque, New Mexico December 2, 2019

PATIENT RIGHTS AND RESPONSIBILITIES

1. Policy: It is the policy of the New Mexico Veterans Affairs Health Care System (NMVAHCS) to provide high quality patient/resident centered care and to remain responsive to patient concerns, complaints and questions. The NMVAHCS affirms the patient/resident’s right to be involved in their care and to receive appropriate, timely, and respectful care.

Patients/residents have a right to receive treatment and care in a manner that safeguards their personal dignity and allows for the expression of cultural, psychosocial, and spiritual values regardless of race, religion, gender, age, condition, or type of illness. Service to all patients/residents and the public will be provided in an ethical manner within the medical center’s capacity, its stated mission, and applicable laws and regulations.

2. Responsibility:

a. The Leadership of the NMVAHCS is responsible for maintaining a collaborative structure based on the organization’s philosophy to support patient rights and ethical behavior and business practices.

b. All Service Chiefs/Care Line Managers are responsible for ensuring that healthcare practitioners and support staff understand, respect, and uphold the rights and responsibility of patients. Service Chiefs/Care Line Managers are also responsible for ensuring that healthcare practitioners and support staff have the knowledge to answer questions about patient rights and responsibilities on the process of obtaining formal or informal advocacy services.

c. Service Chiefs involved in contracted services are responsible for providing the vendor with Informational Bulletin (IB) 10-160, “Patient Rights and Responsibilities“.

d. It is the responsibility of all NMVAHCS employees to:

(1) Understand, respect, and uphold the rights and responsibilities of patients/residents.

(See Rights and Responsibilities of VA Patients and Residents of Community Living Centers and Rights and Responsibilities of Family Members of VA Patients and Residents of the Community Living Centers.

(2) Immediately report suspected violations of patient rights to their supervisor.

(3) Resolve patient complaints at the point of care/service delivery or make the appropriate referral to the Service Level Patient Advocate when resolution is not possible.

e. Service Level Patient Advocates are responsible for resolving patient or family member issues within their service. Referrals are to be made to the facility Patient Advocates when all means for resolution have been exhausted or the issues are complex and/or involve multiple services/care lines.

f. Facility Patient Advocates are responsible to:

(1) Assist patients and family members with resolution of complex issues not previously resolved by other means.

(2) Assist patients when a dispute over the choice or level of clinical care provided by the treating physician is raised by informing them of the Clinical Appeal (second opinion) process.

g. Chaplains will be responsible for assisting the patient with spiritual counseling and the expression of spiritual practices. Chaplains are also responsible for spiritual support of the dying patient and his/her family member(s).

https://www.va.gov/health/rights/patientrights.asp https://www.va.gov/health/rights/patientrights.asp http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2187 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2187

Memorandum 003-34 Subj: Patient Rights and Responsibilities December 2, 2019 2.

h. Privacy Officers will provide oversight and guidance related to privacy and confidentiality provisions to protect patient information. Any privacy concerns or issues should be routed to the facility Privacy Officers for review and assistance.

i. Social Workers are responsible for providing counseling concerning Advance Directives and for assisting with the psychosocial needs of all patients, including the special needs of dying patients.

j. Nursing staff assumes the pivotal role in carrying out the patient’s treatment in such a manner that the rights of the patient are protected and the patient’s dignity is respected.

Nursing staff is responsible for enforcement of the patient’s right to privacy in room assignments, visitation, and communication; for ensuring treatment and surroundings give reasonable visual and auditory privacy, and for implementation of nursing specific treatment modalities.

k. The patient’s physician assumes a major role in implementing the patient’s rights related to the treatment decision making process, treatment in the least restrictive manner, use of restraints, refusal of treatment, pain management, care of the dying patient, and Advance Directives. The physician is also responsible for assuring documentation in the medical record that reflects the participation of the patient in treatment decisions. When the patient refuses treatment, the medical record should contain documentation that the patient was informed of the medical consequences.

l. The physician, or other staff member, may seek an ethics consultation by referral of a case to the Ethics Consultation Service, as needed.

m. Health Administration Service staff have the responsibility to ensure a process that protects the privacy of the patient’s health information and to provide information to the patient, and/or the patient’s legal representative from the medical record.

3. Procedure:

a. Environmental Management Service will provide a framed patient Bill of Rights and

Responsibilities to be posted in every clinical service area.

b. The Chief, Human Resources Management Service will make this policy available to all

NMVAHCS employees.

c. The facility level Patient Advocates will ensure current Patient Rights and Responsibilities posters are posted and accessible to patients and visitors in all inpatient/outpatient treatment areas and at the Community Based Outpatient Clinics (CBOCs) and Contract Community Outpatient Clinics (CCOCs). NOTE: VHA informed consent policy states that all patients have the right to refuse any medical treatment or procedure offered to them. However, respect for patient preferences does not mean that all patient demands must be honored. The right to refuse medical care does not necessarily include the right to dictate care be delivered in a particular manner or by a specific provider. Reasonable patient requests to have medical trainees excluded from their care should be honored.

Requests that involve providing inappropriate or substandard care or that requires a change in the delivery system of care that would allocate staff time or resources unfairly thus interfering with the care of other patients, may be refused. Ethical issues or concerns involving the role of trainees in patient care should be referred to the Ethics Consultation Service. Patients always have the right to be informed about the level of training, e.g., Memorandum 003-34 Subj: Patient Rights and Responsibilities December 2, 2019 3.

students, interns, residents of trainees involved in their care and VA policy on graduated responsibility and resident supervision. However, if a patient requests that an entire category of providers be excluded from his or her care simply because he is prejudiced against individuals in a particular ethnic or cultural group, this request should generally not be honored.

4. References:

a. Code of Federal Regulations, Title 38, Part 17, Section 17.38, Medical Benefits Package.

b. VHA Directive 1100.16, Accreditation of Medical Facility and Ambulatory Programs.

c. The Joint Commission Comprehensive Accreditation Manuals, (Hospitals, Behavioral Health Care, Home Based Care, Laboratory, and Long Term Care).

d. NMVAHCS Medical Center Memorandum 11-80, Integrated Ethics.

e. NMVAHCS Medical Center Memorandum 003-37, Patient Advocate Program

Management of Patient Compliments and Complaints.

f. NMVAHCS Medical Center Memorandum 11-21, Informed Consent for Clinical

Treatments and Procedures.

5. Rescission: Medical Center Memorandum 003-34, Patient Rights and Responsibilities dated November 30, 2016.

6. Expiration Date: December 2, 2022.

/s/ Andrew M. Welch, MHA, FACHE Director

Signed MCM in D/FMO Files

Distribution “M” https://www.ecfr.gov/cgi-bin/text-idx?SID=eb4b3a8fd988e9bc70e3070691c916be&mc=true&node=se38.1.17_138&rgn=div8 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=5396