1. Joint Commission Standards on Patient Rights and Responsibilities Leadership Kathy Howard March 23, 2011

2. Chapter Overview Identification of basic, overarching patient rights The right to effective communication The right to participate in care decisions The right to informed consent The right to know care providers The right to participate in end-of-life decisions Individual rights of patients Patient responsibilities

3. Outline Patient Rights Resources MAH Hot Topics –Visitation/Support Person –Pt Information Understandable –Pt/Provider Partnership –Consent for Filming/Recording –Name/role of providers given to pt –Advance Directives –Protection from Abuse and Neglect –Complaints/Grievances

4. Patient Rights Resources Brochure of Rights and Responsibilities –On web –Posted in ED, Admitting and Outpt Areas –Available in holders throughout DOB/hospital –Admission Packet Policy on portal (hospital and W2) Specific policies on portal

5. MAH Hot Topics 1. Visitation/support individual (CMS update) –policy updated to reflect obligation to respect pt preference No limits based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression unless it poses a risk/infringement to another’s rights 2. Information understood by patient –All communication tailored to pt’s age, language, cognitive ability and special needs (vision, speech, other impairments)

6. MAH Hot Topics (cont’d) 3.Patient/provider partnership –Respect pt right to accept/refuse care –Med/Surg Consent; End of Life Care; Code Status surrogate decision maker’s responsibility for making decision on behalf of patient –Healthcare Proxy –Durable Power of Attorney for Healthcare –Guardian –Right to be informed (consent, disclosure, etc)

7. 4. Consent for Filming/Recording –Consent prior to any recorded medium except if used in the course of care MAH Hot Topics (cont’d)

8. 5.Patient is kept informed about who is providing and responsible for his/her care. Provider introduces self and relationship to pt 6.Advanced Directives If on file, must be avail on current chart Working on process improvement 7.Protection from Abuse/Neglect Policies/resources (community/internal) MAH Hot Topics (cont’d)

9. 8. Complaints/Grievances –Resolution Process (turnaround expectations) –x 5100 –Deescalate when it happens: anticipate and intervene –Pt/Family right to express grievance/compliant without fear of reprisal MAH Hot Topics (cont’d)