D.3 Patient Rights and Responsibilities 02.pdf

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

VISN 19

PATIENT RIGHTS AND RESPONSIBILITIES

I. PURPOSE: Protect and define the rights and responsibilities of the individual patient at all locations of the Eastern Oklahoma VA Health Care System (EOVAHCS), Home Based Primary Care (HBPC) and Community-Based Outpatient Clinics (CBOC’s).

II. POLICY: The staff will support and protect the fundamental human, civil, constitutional and statutory rights of the individual patient, as well as encourage the patient to be responsible for behavior and cooperation. The basic rights of human beings for independence of expression, decision, action and concern for personal dignity and human relationship will be preserved.

III. PATIENT RIGHTS AND RESPONSIBILITIES:

VHA has developed a statement of Patient Rights and Responsibilities which is attached as Appendix A. Eastern Oklahoma VA Health Care System has amplified selected statements of the Patient Rights and Responsibilities as noted parenthetically in Appendix A.

IV. STAFF RESPONSIBILITIES:

a. Medical center staff has responsibility to address the rights of patients concerning treatment, care, and/or services within our capability and mission and in compliance with law and regulation. Staff will utilize the Service Recovery process for the resolution of patient complaints

b. Patient Advocates are responsible to oversee the patient complaint process (see EOVAHCS MCM 00-35, Veteran Customer Service Program).

V. PROCEDURES:

a. The Medical Support Assistant (MSA) or Administrative Officer of the Day (AOD) will distribute the Patient Rights and Responsibilities booklet and advance directive information to each patient or representative upon admission to the medical center. The MSA or AOD documents in the electronic record that the patient was given the Muskogee VA Medical Center Information Booklet on Patient Rights and Responsibilities and information regarding advance directives. Patient Rights and Responsibilities are posted throughout the medical center in waiting areas and hallways.

EASTERN OKLAHOMA VA HEALTH CARE SYSTEM MUSKOGEE, OKLAHOMA

MEDICAL CENTER MEMORANDUM 00-17 FEBRUARY 10, 2019

D.3 PATIENT RIGHTS AND RESPONSIBILITIES

36C25923R0040

EOVAHCS Patient Rights and Responsibilities 02/10/19 Medical Center Memorandum 00-17

b. Any restrictions on the patient’s rights for therapeutic reasons will be made by the appropriate health or mental health professional and will be documented in the medical record. The restriction will be re-evaluated at least once every 72 hours by the practitioner, the inter-disciplinary team, patient and/or family and must have the concurrence of the Service Chief or Chief of Staff. All restricting orders will be discussed with the patient and/or family and documented in the patient record.

c. Patient Advocates will document patient and their family’s compliments, concerns and complaints in the Patient Advocate Tracking System regardless of origin, e.g., patient, family, Congressional offices, VA Central Office, Office of Inspector General, etc.

VI. REFERENCES:

a. M-2, Part 1, Chapter 37, Patient Representative Program;

b. Muskogee VAMC Patient Rights and Responsibilities booklet;

c. Joint Commission Comprehensive Accreditation Manual for Hospitals

VII. FOLLOW UP RESPONSIBILITY: Quality, Safety & Value Service is responsible for the content of this MCM.

VIII. RESCISSION: Medical Center Memorandum 00-17, Patient Rights and Responsibilities, dated June 25, 2015.

/s/

MARK E. MORGAN, MHA, FACHE

Medical Center Director

Attachment: Appendix A-Patient Rights and Responsibilities

Dist. C

EOVAHCS Patient Rights and Responsibilities Appendix A-1

PATIENT RIGHTS AND RESPONSIBILITIES

The Veterans Health Administration (VHA) is pleased you have selected us to provide your health care. We want to improve your health and well-being. We will make your visit or stay as pleasant for you as possible. As part of our service to you, to other veterans, and to the nation, we are committed to improving health care quality. We also train future health care professionals, conduct research, and support our country in times of national emergency. In all of these activities, our employees will respect and support your rights as a patient. Your basic rights and responsibilities are outlined in this document. Please talk with a VA treatment team member or a patient advocate if you have any questions or would like more information about your rights.

I. Respect and Nondiscrimination

• You will be treated with dignity, compassion and respect as an individual. Your privacy will be protected. You will receive care in a safe environment. We will seek to honor your personal and religious values. It is the policy of Eastern Oklahoma VA

Health Care System to treat all patients and not to discriminate with regard to race, color, religion, national origin, age, sex, sexual orientation, gender identity or expression, or disability. (Note: You have a right to have your cultural, psychosocial, values, beliefs, and preferences respected and your pastoral and other spiritual services accommodated. You have the right to treatment, care and services within this facility’s capability and mission and in compliance with laws and regulations. You will be provided an environment of care, which supports a positive self-image.)

• You or someone you choose has the right to keep and spend your own money. You have the right to receive an accounting of any VA held funds.

• Treatment will respect your personal freedoms. In rare cases the use of medication and physical restraints may be used if all other efforts to keep you or others free from harm have not worked.

• As an inpatient or nursing home resident, you may wear your own clothes. You may keep personal items. This will depend on your medical condition. (Note: The hospital provides for the safety and security of you and your personal property. Sufficient storage space, to meet your personal needs, will be provided.)

• As an inpatient or nursing home resident, you have the right to social interaction and regular exercise. You will have the opportunity for religious worship and spiritual support. You may decide whether or not to participate in these activities. You may decide whether or not to perform tasks in or for the Medical Center.

• As an inpatient or nursing home resident, you have the right to communicate freely and privately. You may have or refuse visitors. You will have access to public telephones. You may participate in civic rights, such as voting or free speech. (Note: You will have access to mail services as appropriate. The staff will partner with you to protect your personal privacy and provide protection of your health information.)

• As a nursing home resident, you can organize or take part in resident groups in the facility.

Your family also can meet with the families of other residents.

EOVAHCS Patient Rights and Responsibilities Appendix A-2

• In order to provide a safe treatment environment for all patients or residents and staff, you are expected to respect other patients, residents, and staff and to follow the facility’s rules.

Avoid unsafe acts that place others at risk for accidents or injuries. Please immediately report any condition you believe to be unsafe. (Note: You will be responsible to follow the rules and regulations of this facility.)

II. Information Disclosure & Confidentiality

• You will be given information about the health benefits that you can receive. The information will be provided in a way you can understand. (Note: Your needs in regard to vision, speech, hearing, cognitive impairment, and language will be addressed. A list of interpreters, fluent in selected languages, has been developed by the hospital to assist with any language barriers and to facilitate effective communication.)

• You will receive information about the costs of your care, if any, before you are treated. You are responsible for paying for your portion of the costs associated with your care.

• Your medical record will be kept confidential. Information about you will not be released without your consent unless authorized by law (an example of this is State public health reporting). You have the right to information in your medical record and may request a copy for your records. This will be provided except in rare situations when your VA physician feels the information will be harmful to you. In that case you have the right to have this discussed with you by your VA provider.

• You will be informed of all outcomes of care, including potential injuries caused by your medical care. You will be informed about how to request compensation for injuries. (Note:

You have the right to request an amendment to your health information as permitted under applicable law.)

III. Participation in Treatment Decisions

• You, and any persons you choose, will be involved in all decisions about your care. You will be given information you can understand about the benefits and risks of treatment. You will be given other options. You can agree to or refuse treatment. You will be told what is likely to happen to you if you refuse treatment. Refusing treatment will not affect your rights to future care but you take responsibility to understand the possible results to your health.

(Note: You will receive written information, which is appropriate to your age and understanding. Your surrogate decision maker, as allowed by law, has the right to agree with, or refuse treatment or services on your behalf. If you have a legal surrogate, the treatment team will partner with your surrogate to carry out your treatment wishes. We will provide written information to the surrogate as needed.)

• Tell your provider about your current condition, medicines (including over-the-counter and herbals) and medical history. Also, share any other information that affects your health. You should ask questions when you don’t understand something about your care. Being involved is very important for you to get the best possible results.

• You will be given, in writing, the name and title of the provider of your care. As a partner in the health care process, you have the right to be involved in choosing your provider. You also have the right to know the names and titles of those who provide you care. This includes

EOVAHCS Patient Rights and Responsibilities Appendix A-3 students, residents and trainees. Providers will properly introduce themselves when they take part in your care. (Note: The name of your Primary Care Provider will be given to you during your first visit. The name of your inpatient provider(s) will be given to you within 24 hours of admission. You have a right to have a surrogate decision maker. You also have the right to have your own provider notified of your admission to the hospital, if you so choose.)

• You will be educated about your role and responsibilities as a patient or resident. This includes your participation in decision-making and care at the end of life. (Note: A surrogate decision maker, as allowed by law, is identified when a patient cannot make decisions about his or her care, treatment, and services. You may designate a surrogate to make treatment decisions for you at any time during your hospitalization. You may also change surrogates at any time during your hospitalization. You and your family will have your needs addressed regarding comfort, dignity, and psychosocial, emotional, and spiritual needs as appropriate about death and grief.)

• If you believe you cannot follow the treatment plan, you have a responsibility to notify your provider or the treatment team.

• You have the right to have your pain assessed and to receive treatment to manage your pain.

You and your treatment team will develop a pain management plan together. You are expected to help the treatment team by telling them if you have pain and if the treatment is working.

• As an inpatient or nursing home resident, you will be provided any transportation necessary for your treatment plan.

• You have the right to choose whether or not you will participate in any research project. Any research will be clearly identified. Potential risks and benefits of the research will be explained to you and there will be no pressure on you to participate. (Note: Refusing to participate or withdrawing from participation in research studies will not compromise your access to care, treatment, and/or services.)

• You will be included in resolving any ethical issues about your care. You may consult with the Medical Center’s Ethics Consultation service and/or other staff knowledgeable about health care ethics.

• If you or the Medical Center believes that you have been neglected, abused or exploited, you will receive help. (Note: The hospital maintains a list of names, addresses, and telephone number of patient advocacy groups, such as state authority or a protection and advocacy network, should you need these services.)

IV. Complaints

• Seek help from your treatment team and/or a patient advocate if you have complaints. You will be given understandable information about the complaint process. You may complain verbally or in writing, without fear of retaliation. You are expected to maintain civil language and conduct in interactions with staff and licensed independent practitioners. You may recommend changes freely without coercion, discrimination, reprisal, or unreasonable interruption of care.