Standards for Privacy/Patient Rights and Responsibilities 
 
 
 
 

I.                SCOPE:

This policy applies to Saint Francis Hospital - Bartlett and its off-campus departments (“Facility”).

II.             PURPOSE:

To ensure that all patients are afforded their fundamental human, civil, constitutional, and statutory rights in accordance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation for Hospitals, and the Joint Commission (TJC). 

III.          POLICY:  

A.                  A copy of the Patients' Rights is included in the Patient Information Booklet located in each patient room. In addition, a copy of Patient Rights and Responsibilities is given to each person by Admissions Personnel upon registration. 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.

B.                  This policy has been adopted by Saint Francis Hospital-Bartlett in accordance with all Joint Commission, federal and state regulatory requirements. All hospital employees, medical staff and contracted agency staff performing patient care activities shall observe these patient rights. The hospitals’ visitation policy is carried out in a non-discriminatory manner. The Statement of Patient Rights shall include but not be limited to the patient’s (or patient’s representative – as allowed by law) right to:

1.                  Become informed of his/her rights as a patient in advance of, or when discontinuing, the provision of care. The patient may appoint a representative to receive this information should he/she so desire.

2.                  Receive a Hospital Issued Notice of Non-Coverage (HINN) and right to appeal premature discharge. 

3.                  Exercise these rights without regard to age, race, ethnicity, religion, educational background, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

4.                  Considerate, dignified and respectful care, provided in a safe environment, free from neglect, exploitation and verbal, mental, physical and sexual abuse.

5.                  Be treated in a dignified and respectful manner, supportive of his/her cultural, psychosocial, spiritual and personal values, beliefs and preferences. To assure these preferences are identified and communicated to staff, a discussion of these issues shall be included during the initial nursing assessment.

6.                  Be informed about his/her visitation rights. Visitation rights shall include the right to receive visitors chosen by the patient, including but not limited to, the patient’s spouse, domestic partner (including a same-sex domestic partner), another family member or friend. The patient may withdraw or deny such consent at any time. Where appropriate, this right may be exercised by the patient’s support person, on the patient’s behalf by your Support Person.

7.                  Explanation of any visitation limitations based on clinical necessity or reasonable restrictions, such as infection control precautions, patient treatment procedures underway, interference with the care of other patients, legal restriction of contact between patient and another individual, disruptive , threatening, or violent behavior, or the patient’s need for rest or privacy, etc.

8.                  Access to protective and advocacy services or to have these services accessed on the patient’s behalf. A social worker is available to patients and their families/significant others.

9.                  Visits from the Pastoral Care Department staff, as well as professional and lay ministers from the community, to meet the patient’s spiritual needs.

10.              Remain free from restraint and seclusion of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff.

11.              Knowledge of the identity of the physicians and other hospital members providing care, as well as their purpose and who has primary responsibility for coordinating his/her care.

12.               Receive information from his/her physician about his/her illness, health status, diagnosis, course of treatment, outcomes of care (including unanticipated outcomes) and his/her prospects for recovery in terms that he/she or the patient’s representative can understand.

13.              Receive information about any proposed treatment or procedure he/she may need in order to participate in the development of the plan of care. This includes, at a minimum, the right to participate in the development and implantation of his/her inpatient or outpatient treatment/care plan, discharge plan and pain management plan.

14.              Give informed consent or to refuse the course of treatment and to participate in planning for care after discharge. This must not be construed as a mechanism to demand the provision of treatment or services deemed medically necessary or inappropriate. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in the treatment, alternate courses of treatment or non-treatment and the risks involved in each and the name of the person who will carry out the procedure of treatment.

15.              Choose a personal attending physician. The hospital supports informed decision-making by the patient and/or designated representative regarding course of treatment.

16.              Refuse medication. No medication will be administered to a patient without appropriate consent, except for situations in which a physician deems it necessary to prevent a patient from harming themselves or others. If a competent adult refuses treatment or medication, the physician is notified of the refusal. This is documented in the medical record along with informing the patient of consequences of refusal.

17.              Obtain information on disclosure of protected health information, in accordance with federal state and local law.

18.              Full consideration of privacy concerning his/her medical care program. Case discussion, consultation, examination and treatment are confidential and shall be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual involved in his/her healthcare.

19.              Confidential treatment of all communications is records pertaining to his/her care and his /her stay in the hospital. His/her written permission shall be obtained before his/her medical record can be made available to anyone not directly concerned with his/her care, and before the hospital produces or uses recordings, films or other images of the patient for purposes other than his or her care.

20.              Formulate advance directives regarding his/her healthcare, and to have hospital staff and practitioners who provide care in the hospital comply with these directives (to the extent provided by state laws and regulations). The hospital respects and encourages patient self-determination and educates patients about Advance Directives such as the Living Will and Durable Power of Attorney. Patients are provided with information on Advance Directives during the admission process. They also are questioned about the presence of Advance Directives and asked to provide the hospital with a copy to be placed in the medical record. When the hospital cannot meet a patient's request or need for care because the patient desires or requires a service that is not offered or available at the hospital, a transfer to another facility/hospital may be arranged. A patient is not transferred until he/she has been given information and an explanation concerning alternatives to the transfer or the need for transfer.

21.              Have a family member or representative of his/her choice and his/her personal physician notified promptly of his/her admission to the hospital.

22.              Receive information in a manner that he/she understands. Communication with the patient shall be effective and provided in a manner that facilitates understanding by the patient. Written information provided shall be appropriate to the age, understanding and as appropriate, the language of the patient. As appropriate communications specific to the vision, speech, hearing cognitive and language-impaired patient shall be appropriate to the impairment.

23.              Leave the hospital even against the advice of his/her physician.

24.              Be advised of the hospital complaint/grievance process, should he/she wish to communicate a concern regarding the quality of the care he/she receives or if he/she feels the determined discharge date is premature. Notification of the grievance process includes: whom to contact to file a grievance, and that he/she shall be provided with a written notice of the grievance determination that contains the name of the hospital contact person, the steps taken on his/her behalf to investigate the grievance, the results of the grievance and the grievance completion date.

25.              Be provided the name, address and phone number of the state agency for lodging a grievance, if the patient so desires, regardless of whether the patient has first utilized the hospital’s grievance process.

26.              Full support and respect of all patient rights should the patient choose to participate in research, investigation and/or clinical trials. This includes the patient’s right to a full informed consent process as it relates to the research, investigation and /or clinical trial. All information provided to subjects shall be contained in the medical record or research file, along with the consent form(s).

27.              Involvement in decisions related to care, treatment and services received at the end of life.

28.              Be informed of his/her physician or a delegate of his/her physician of the continuing healthcare requirements following his/her discharge from the hospital.

29.              Examine and receive an explanation of his/her bill regardless of source of payment.

30.               Know which hospital rules and policies apply to his/her conduct.

31.              Have all patient’s rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.

32.              Be accompanied by a service animal if the patient has a qualifying disability, per guidelines set forth in the hospital’s Service Animal policy and the Americans with Disabilities Act (ADA).

C.                 PATIENT PRIVACY AND CONFIDENTIALITY:

1.                  Patients' privacy is respected by interviewing, examining, and treating patients in areas that have reasonable visual and auditory privacy (i.e., bedside curtains are pulled during examinations/treatments).

2.                  All healthcare providers will discuss the need for sensitive physical examination or treatment with the patient. This discussion will be used to determine patient’s desire for a chaperone or another same sex gender to perform the examination. A chaperone may be another healthcare provider of the same sex as the patient, a family member or friend based on the patient’s preference. Sensitive physical examinations and treatment are typically those that involve the reproductive and sexual organs, those that may be perceived as potentially threatening to the patient’s sense of privacy or modesty, or those that may induce feelings of vulnerability or embarrassment.

3.                  Healthcare providers should be aware that a patient’s cultural and religious beliefs might necessitate a chaperone or same gender provider.

4.                  Patients may request a transfer to another room if they are disturbed by noises in nearby rooms. Moving of the patient to another room is at the discretion of the Charge Nurse, who keeps in mind the patient's care needs and availability of another room.

5.                  Patient information is to be kept confidential.  

 

6.                  Patients have the right to request “do not publish” status in the Patient Directory, whereby the hospital’s response to callers asking for patient status would be, “we don’t have a patient by that name in our directory.”

 

D.                 PATIENT REVIEW OF MEDICAL RECORD:

 

1.                  The patient or patient’s legal representative (e.g. parent of minor, legal guardian, or health care proxy), with the patient’s permission, may review the patient's medical record; this review must be conducted in the presence of a hospital representative. Please notify the patient’s attending physician that the patient has requested to review his or her record. In the event that the patient has been admitted to the behavioral health unit at any time during this hospitalization, prior to the review, authorized staff on the unit shall contact the attending physician to ensure access to the health record would not be detrimental to the patient or other individuals. In all areas of the hospital, the patient or the patient’s legal representative must sign a medical release prior to review of the record. Please document this information in the record. 

 

E.                  PATIENT COMPLAINTS:

 

1.                  The patient and/or family/significant other has the right to voice complaints without compromising to future access to care. The hospital recognizes the importance of addressing the concerns and/or complaints of patients  /families/significant others regarding treatment/services rendered. Patients are informed in the Patient's Rights of mechanism to voice a concern.

 

F.                  ETHICAL ISSUES:

 

1.                  The Ethics Committee assists in implementing the values of Saint Francis Hospital in practical, patient centered ways. See Ethical dilemmas policy in the Patient Care Services manual.

 

a.                   Functions of the Ethics Committee include:

 

(1)               Acting as a forum for discussion of bioethical issues.

(2)               Providing a format for the education of medical and hospital staff, patients and their families/significant others, as it relates to bioethical issues.

(3)                Acting as a resource and consultative body for bioethical issues as they apply to specific dilemmas involving patient care.  

 

2.                  The hospital respects the patient's Advance Directives and the attempts to provide a framework for the decision-making process that respects the patient's or his/her designated representatives' right to be included

            in treatment decisions.

 

3.                  The Patient Information Booklet includes information on accessing the Ethics Committee.

G.                 PATIENT RESPONSIBILITIES:

1.                  The care a patient receives depends partially on the patient. Therefore, in addition to these rights, a patient has certain responsibilities as well. These responsibilities shall be presented to the patient in the spirit of mutual trust and respect.

2.                  The patient shall be responsible for reporting perceived risks in his/her care and unexpected changes in his/her condition to the responsible practitioner.

3.                  The patient and family shall be responsible for asking questions about the patient’s condition, treatments, procedures, clinical laboratory and other diagnostic test results.

4.                  The patient and family shall be responsible for asking questions when they do not understand what they have been told about the patient’s care or what they are expected to do.

5.                  The patient and family shall be responsible for immediately reporting any concerns or errors they may observe.

6.                  The patient shall be responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician's orders.

7.                  The patient shall be responsible for keeping appointments and for notifying the hospital or physician when he/she is unable to do so.

8.                  The patient shall be responsible for his/her actions should he/she refuse treatment or not follow his/her physician's orders.

9.                  The patient shall be responsible for assuring that the financial obligations of his/her hospital care are fulfilled as promptly as possible.

10.              The patient shall be responsible for following hospital policies and procedures.

11.              The patient shall be responsible for being considerate of the rights of other patients and hospital staff.

12.              The patient shall be responsible for being respectful of his/her personal property and that of other persons in the hospital.

 

IV.              RESPONSIBLE PARTIES

The Directors/ Managers  is responsible for ensuring that all individuals adhere to the requirements of this policy, that these procedures are implemented and followed at Facility and that instances of non-compliance with this policy are reported to the Chief Nursing Officer.

A.                 Auditing and Monitoring per Directors/Managers, Ethics Committee and reviewed by the Quality Department.

B.                 Enforcement

All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such performance management may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law.

V.                 REFERENCES:

-www.jointcommission.org/speak_up_know_your _rights/ 

- CMS CoP §482.13(a) (A-0116) and TJC CAMH LD.01.03.01 and RI Chapter

- Patient Care Services Policy (8720-0012)