Section D.19 - Memorandum 006-001 Patient Rights.pdf

Department of Veterans Affairs Memorandum 006-001 Central Texas Veterans Health Care System (CTVHCS) July 22, 2016 Austin-Temple-Waco Community-Based Outpatient Clinics (CBOCs)

PATIENT RIGHTS

1. CHANGES: Section 5.a.(5); A patient who is competent to make decisions, may keep funds on hand after signing disclosure, or someone of that patient’s choosing.

2. RESCISSION: Memorandum 012-002 dated December 31, 2013.

3. NEXT REVIEW DATE: July 2019.

4. AFFECTED SERVICES: All services.

5. POLICY: CTVHCS will provide personalized, patient-driven, compassionate, state-of-the-art care. Our goal is to make the Veterans’ experience as positive and pleasant as possible. As part of our service to 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 the rights of patients or residents of a community living center (CLC). Basic rights and responsibilities are outlined in this document.

a. Nondiscrimination and Respect

(1) Patients will be treated with dignity, compassion, and respect as an individual.

Consistent with Federal law, VA policy, and accreditation standards of The Joint Commission, patients 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, gender, sexual orientation, or gender identity or expression.

(2) Patients will receive care in a safe environment free from excess noise, and with sufficient light to ensure comfort and safety.

(3) Patients have a right to have access to the outdoors.

(4) We will seek to honor patients’ cultural and personal values, beliefs, and preferences. We ask that patients inform staff of any cultural, religious, or spiritual beliefs/practices that may influence medical care provided by CTVHCS.

(5) A patient who is competent to make decisions may keep funds on hand after signing disclosure, or someone of that patient’s choosing. Patients have the right to receive an accounting of any funds that VA is holding for them.

(6) We will respect a patient’s personal freedoms in the care and treatment that is provided. This includes trying to accommodate a patient’s normal sleep and wake cycles, food likes and dislikes, and other personal preferences.

CTVHCS Memorandum 006-001

(7) In the Community Living Center, residents have the right to be free from chemical and physical restraints. In the inpatient acute care setting, and only in rare cases, the use of chemical and physical restraints may be used if all other efforts to keep patients or others free from harm have not worked.

(8) In the Community Living Center, residents may keep personal items and are expected to wear their own clothes. On inpatient units, patients may wear their own clothes depending on their medical condition.

(9) Patients have the right to keep and use personal items as long as they are safe and legal.

(10) Patients have the right to social interaction and regular exercise. Patients will have the opportunity for religious worship and spiritual support and may decide whether to participate in these activities. Patients may decide whether or not to perform tasks in or for the Medical Center or in the Community Living Center.

(11) Patients have the right to communicate freely and privately. Patients will have access to public telephones and CTVHCS will assist patients in sending and receiving mail. Patients may participate in civic rights, such as voting and free speech.

(12) CTVHCS recognizes that visits by family members, close friends, and clergy are important parts of the healing process. “Family” is defined as a group of two or more persons united by blood or by 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 a significant other, friend, or caregiver) whom the individual considers to be family. Loved ones are welcome to be involved in support and care of inpatients and CLC residents. Medical staff may restrict visitors if medical or safety concerns require it. Patients will be told promptly about any visitor restriction and the reason for it.

(13) In order to provide a safe treatment environment for all patients, CLC residents and staff, patients and their visitors are expected to avoid unsafe acts that place others at risk for accidents or injuries. Patients are requested to immediately report any condition they believe to be unsafe.

b. Information Disclosure and Confidentiality

(1) Patients’ privacy will be protected.

(2) Patients will be given information about the health benefits they can receive.

The information will be provided in a way patients can understand.

(3) Patients will receive information about the costs of their care (for example, co-payments), if any, before they are treated. Patients are responsible for paying their portion of any costs associated with their care.

(4) Patients’ health records will be kept confidential. Information about patients will not be released without their authorization unless permitted by law (an example of this is State public health reporting). Patients have the right to have access to or request a copy of their own health records.

(5) Patients must respect the privacy of other patients and CLC residents and not reveal any known health information about them.

(c) Participation in Treatment Decisions

(1) Patients have a right to express their preferences concerning future medical care in an advance directive, including designating a health care agent to make health care decisions on their behalf if they are no longer able to do so.

(2) Patients, and any person(s) they choose, will be involved in all decisions about their care. Patients will be given information about the benefits and risks of treatment options in their preferred language. Patients can agree to or refuse any treatment.

Should a patient refuse recommended treatment, the likely outcome of treatment refusal will be discussed with him or her. Refusing treatment will not affect a patient’s right for future health care; however, the Veteran is responsible for any adverse health outcome caused by refusing care.

(3) Patients should tell their provider about their current condition, medicines (including over-the-counter and herbals), and medical history as well as any other information that affects their health. Patients should ask questions when they do not understand something about their care. Veterans’ involvement in their health care helps us provide the best care possible for them.

(4) Patients will be given, in writing, the name and title of the provider in charge of their care. Patients have the right to be involved in choosing their provider. Patients also have the right to know the names and titles of those who provide their care, including students and other trainees. Providers will properly introduce themselves to patients when they take part in their care.

(5) Patients will be educated about their roles and responsibilities as a patient or CLC resident. This includes their participation in decision making and care at the end of life.

(6) If patients believe they cannot follow the treatment plan, patients have a responsibility to tell their provider or treatment team.

(7) Patients will be informed of all outcomes of their care, including any possible injuries associated with their care. Patients will be informed about how to request compensation and other remedies for any serious injuries.

(8) Patients have the right to have their pain assessed and to receive treatment to manage their pain. Patients and their treatment team will develop a pain management plan together. Patients are expected to help the treatment team by telling them if they have pain and if the treatment is working.

(9) As an inpatient or CLC resident, a patient will be provided any transportation necessary for their treatment plan.

(10) Patients have the right to choose whether or not they will participate in any research project. Any research will be clearly identified. Potential risks of the research will be identified and there will be no pressure on patients to participate.

(11) Patients will be included in resolving any ethical issues about their care. If patients have ethical issues or concerns, they may speak with the Medical Center’s Ethics Consultation team for help.

(d) Concerns or Complaints

(1) Patients are encouraged and expected to seek help from their treatment team or a Patient Advocate if they have problems or complaints. Any privacy complaints will be addressed by the facility Privacy Officer. Patients will be given understandable information about the complaint process in their preferred language. Patients may complain verbally or in writing, without fear of retaliation.

(2) If patients believe that they or their family member have been neglected, abused or exploited by VA staff, this needs to be reported promptly to the treatment team or Patient Advocate. Patients will receive help immediately.

(3) If patients believe the organization has failed to address or satisfy their concerns about health care quality and safety, patients may contact the Joint Commission’s Office of Quality Monitoring at 1-800-994-6610. If patients believe that the organization has failed to address their concerns about suspected criminal activities, fraud, waste, abuse, or mismanagement, patients may contact the VA Office of the Inspector General at 1-800-488-8244 or e-mail vaoighotline@VA.gov.

(e) Additional Rights and Responsibilities of Community Living Center (CLC) Residents. Because the CLC serves as their home for short or long-stay services, CLC residents have the following additional rights and responsibilities:

(1) Staff will knock on their bedroom door prior to entry.

mailto:vaoighotline@VA.gov

(2) Residents have the right to receive care from the same staff member every day to the extent that consistent assignment is possible.

(3) Residents may have visitors at any time of the day or night provided visitors are respectful of other residents, their need for privacy and the privacy of others. During after 10 a.m., visitors should utilize the phones located outside of the entrances to identify themselves for access into the units.Residents may refuse visitors at any time.

(4) Residents have a right to conjugal visits and a right to privacy during those visits.

(5) Residents’ care will be delivered in a setting that resembles home. Meals will be provided in a designated dining area. Residents will have access to activities that contribute to a meaningful use of their time.

(6) In preparation for being discharged to their own home, residents and/or their care giver may be invited to participate in activities that prepare them to go home, such as self-administration of medications and treatments.

(7) Residents and their caregivers have a right to attend treatment planning meetings and participate in Resident Council.

6. RESPONSIBILITY:

a. The Director is ultimately responsible for ensuring that the rights of all patients are protected and respected. Commensurately, all Directors, Service Chiefs, and Site Managers, are responsible for ensuring that their respective personnel receive and understand this policy and perform accordingly.

b. All personnel will help ensure that the provisions of this policy are met, the patient's rights are protected and respected, and observations of violations are appropriately reported.

c. Medical Administration Service personnel ensure that each patient receives a written copy of Patient Rights and Responsibilities.

d. Patient Advocates see patients/family members in a timely manner, analyze complaints, and take appropriate corrective action in a timely manner.

e. Social Work Service will inform patients of their rights and responsibilities as part of the admission screening process.

7. PROCEDURE:

a. Upon being admitted, either to inpatient or outpatient programs, each patient will be given a copy of the Patient Rights and Responsibilities in leaflet form or in a Patient/Resident Handbook.

b. In an effort to resolve conflicts or dilemmas, attempts should first be made for open dialogue between the patient and healthcare provider(s). In all cases, the Director has ultimate authority. A Patient Advocate is available to listen to unresolved situations, as are members of the CTVHCS Integrated Ethics Council and management staff, typically in ascending order of authority. Patients are kept informed of the progress toward a solution to their problem. Presentation of a complaint does not compromise any patient's future access to care, nor the quality thereof.

c. The attachment lists other CTVHCS policies that address patient rights.

8. REFERENCES: Current Joint Commission Standards.

/s/ Russell E. Lloyd Acting Director

Attachment

ATTACHMENT

POLICIES RELATED TO PATIENT RIGHTS

011-011 Informed Consent 136-016 Release of Information from Medical Records 011-040 Guidelines for Do Not Resuscitate Orders (DNR)/Do Not Intubate (DNI) Orders 119-001 Inpatient Medication Distribution 119-002 Outpatient Drug Policy 120-001 Meal Service 136-003 Referral of Patients Seeking Legal Services and Contact with Local Law Enforcement Officials and Process Servers 14-004 Medical and Patient Library Services 18-001 Extended Care Respite Care Program 139-008 Interdisciplinary Approach to Treatment 122-012 Advance Health Care Planning/Advance Directives 00-030 Code of Ethical Behavior 00-038 Integrated Ethics Program