Priscilla A. Pierce, BSN, RN, C, CPHQ
The Hippocratic Oath (circa 4th century BC) set forth a list of standards intended to guide the practice of medicine. Key to the oath is the assertion that the physician must practice within the scope of his or her expertise, preserving life, abiding by a code of ethical and moral behavior when interacting with patients, and maintaining confidentiality at all costs. The core principles of this oath established the moral foundation on which our modern health care delivery system rests. The care and services provided by all health care facilities should be driven by an internal code of ethics which provides the guiding principles that encompass the values and responsibilities of the organization to its patients and customers. It has become standard practice in many regions for patients to be given a copy of a “Patient Bill of Rights” at the time of admission (ATTACHED EXAMPLE #1).
Clearly communicating with the patient at time of their initial contact with the facility regarding steps that have been taken to ensure that their rights will be protected helps foster the development of positive expectations. It is critical that all staff members are educated on the need to provide care to the patients in a caring, compassionate and empathetic manner. Development of a relationship with patients that fosters confidence that they are receiving quality care will support positive patient outcomes and decrease the risk of litigation for the facility.
Establishment of an effective physician-patient relationship requires that the physician strives to do the following:
Patients, also, have obligations to healthcare providers. These include:
The physician’s skills at maintaining an interpersonal, but professional, relationship with the patient may be as valuable and important as his or her technical abilities. The development of a healthy therapeutic relationship with the patient will open the door for the patient to communicate healthcare information which may be critical to arriving at an accurate diagnosis or the selection of an appropriate treatment regimen.
Healthcare providers have an irrefutable obligation to protect a patient’s healthcare information. As the complexity of today’s healthcare delivery system increases due to new technology, so do issues pertaining to patient confidentiality. Until recent times, most or all of a patient’s healthcare needs were met by one primary care physician. With the ever-increasing number of medical specialties and specialized treatment centers, a person’s medical information may now be housed in multiple locations. What was once a single, handwritten record is evolving into a document that is comprised of a combination of handwritten notes, dictated reports, and lab and radiology results originating from different locations. This increases the possibilities for a patient’s medical information to be viewed by others.
In such a complex system, stringent measures must be put into place in order to assure that patient privacy is protected. Policies and procedures must be developed and enforced, along with provision of ongoing staff education pertaining to patient privacy issues. Safeguards must be put into place at multiple levels in order for the organization to meet the obligation to protect the patient’s privacy. These include:
· Limiting access to the patient’s medical record on a “need to know” basis only
· Storing patient medical records away from high traffic, high visibility areas
· Discussing patient information in privacy, away from other patients or visitors
· Providing staff with regular education on issues pertaining to patient confidentiality
· Using patient initials, rather than full names, on dry erase boards which are often used in such areas as the emergency room or surgery
· Obtaining permission from the patient before releasing any medical information
· Verifying the identity of the individual or organization requesting access to, or a copy of, a patient’s healthcare information
· Building multiple security measures into computer systems:
§ assigning passwords which are changed on a regular basis in order to limit unauthorized access to patient records
§ positioning computer screens so that they cannot be viewed by other patients or visitors
§ setting up an automatic “logoff” in the computer system which is triggered by a specific inactivity threshold (i.e. “PC not used for 30”)
§ encrypting files containing patient information in order to ensure that the data are secured and controlled
§ developing an ongoing security awareness and training program for staff
§ requiring verification that any third party sources for data transmission or reporting have the appropriate security measures built into their system
§ establishing a contingency plan in order to address system failures, as well as, emergencies, disasters, theft, or other occurrences that involve the information system
§ periodically performing a risk assessment in order to evaluate the effectiveness of the system
§ enforcing all of the above-mentioned policies and taking disciplinary action when there has been unauthorized access or release of confidential information
· Completing a thorough investigation of any patient complaint regarding unauthorized access or release of information
· Coding patient-specific information that may be contained in reports, committee minutes, reports, or correspondence
It is crucial for all staff members of the facility to have a thorough understanding of the organization’s policies and procedures governing the protection of any information collected or generated during the course of treating patients. This would include financial and research-related activities, as well as, those associated with arrangements the facility may have with educational institutions which utilize the facility for training purposes. At the time a patient first presents at a facility for any sort of medical care or treatment, he/she should be provided with information regarding the facility’s privacy practices.
Should a patient authorize release of their medical information to an individual or entity outside of the hospital, they must sign a release of information consent form. This document should become a permanent part of the patient’s medical record. (ATTACHED EXAMPLE #2) At a minimum, the form should contain:
Honoring the patient’s right to participate in healthcare decision-making is a critical issue today, particularly given the numerous treatment options now available. In order to be able to give true informed consent a patient must have been provided with information on the risks, benefits, and alternatives to a procedure or treatment. The physician need not overwhelm the patient with technical jargon in order to provide the information pertaining to the proposed treatment. Rather, it may be more helpful to the patient if nontechnical terminology is used, along with a basic explanation of the requisite risks, benefits, and alternatives. The process of informed consent should always be documented in the medical record. While a signed consent form is the most common means of documenting this process, the physician may opt to document this information in a progress or procedure note.
A complete informed consent process includes the following components:
At all times, the patient has the right to be aware of the any developments in their care. This includes the right to be made aware of an adverse event or unanticipated outcome that has occurred during their course of treatment. This is a most sensitive issue and is fraught with many legal implications. However, it is hard to ignore the critical importance of open, honest communication on the part of healthcare providers and the patient’s right to same. Organizations should have a policy in place in regards to how they will address such situations should they arise. It is most typical to designate that the patient’s attending physician, accompanied by a member of the hospital administration, will be the one to discuss the incident.
Meeting the Patient’s Communication, Educational and Cultural Needs
Another basic right of the patient is to be provided with effective communication. This includes the need to provide translator services for those patients with a primary language that differs from that of the institution. While family members or friends may be a ready source, caution needs to be used, as they may be unable to accurately translate medical terms and discussions regarding treatment plans. It is often best to use a translator service, or “language bank” for this purpose.
Accommodations must be made for those patients with a sensory impairment. In order to meet the needs of patients who are hearing impaired, the hospital may need to enlist the services of someone able to communicate with the patient using sign language. For those patients with impaired vision or blindness, it may be necessary to provide information translated into Braille.
All education provided to the patient should be provided in a learning style appropriate to the patient’s cognitive, developmental, and emotional capacities. An entry should be made in the medical record, indicating the topic discussed, the patient’s preferred learning modality, the manner in which the was presented (i.e. verbally, written, video), how the patient received the information, and how the effectiveness of the education was evaluated (i.e. return demonstration of process for self-injection).
At discharge, the patient should be provided with written instructions that contain, at a minimum, the following information:
Provision of appropriate, ongoing patient education will support positive patient outcomes. It has, also, been shown to result in higher patient satisfaction and fewer instances of litigious situations. It behooves the physician and benefits the patient if adequate time is spent in this activity. It is possible to utilize technology in the development of standardized educational materials or preprinted forms that include checkboxes for the key elements of the educational process. However, the education itself must be tailored to meet the individual needs of the patient.
Protecting the patient’s dignity is critical at all phases of the healthcare delivery process. This requires attention to such issues as:
· keeping the patient draped and covered as is feasible, when administering care or treatments
· addressing the patient by his or her proper name
· closing the door to the patient’s room when completing an examination or attending to the patient’s personal needs
The healthcare team must, also, be respectful of the patient’s cultural beliefs and customs and make accommodations to meet these needs, as is feasible. Such accommodations could include:
· preparing special meals in order to meet culturally dictated dietary requirements
· flexing visitation regulations to allow for extended family to stay with the patient
· allowing the patient’s religious leader to come and perform a healing or prayer ritual
· respecting the patient’s wishes as pertains to end-of-life issues and burial practices
It is important that hospital staff receive regular education on cultural sensitivity issues pertaining to health care. This can be accomplished through in-service educational offerings, continuing medical education, or staff educational fairs.
Complaints and Grievances
Another basic right of the patient is to file complaints or grievances. Patients should be apprised of this right at the time they are admitted. This can be accomplished by providing a preprinted Patient Rights booklet or brochure. It is critical that staff is educated regarding how to handle a complaint or grievance once received from the patient. Generally, most complaints can be addressed immediately. An example of this would include a complaint about the dinner entrée or meal temperature, which is easily remedied by offering the patient a different meal. Encouraging a service-oriented culture benefits both the patients and the organization. Physiologically, patients who are in a better frame of mind tend to experience better outcomes than those patients who remain angry over unresolved complaints or concerns. On a pragmatic note, happy patients are far less likely to sue over care issues or unacceptable outcomes.
Many organizations seek to address patient complaints in a proactive manner by having a position designated as the patient advocate. This can lead to high patient satisfaction, as patient complaints and concerns are addressed in a consistent and thorough manner. It helps for the patients to be able to put a face with a position and most see the patient advocate as just that, an individual dedicated to making sure that their stay is as pleasant as is possible.
Many complaints are received after a patient is discharged. These should be handled in as thorough and timely manner as those which are received while the patient is still in the hospital. It is desirable for a follow-up letter, written in response to the complaint, to include as much specific information as is possible in order to assure the patient that the issue has been resolved. This would include whether or not the complaint was validated, steps taken to remedy the situation if a problem was identified, along with a point of contact should the patient need additional clarification.
Results of patient satisfaction scores, as well as, complaints should be tracked and trended in order to identify areas most in need of improvement. Primary consideration should be given to any issue that may impact patient safety. At a minimum, a report containing a summary of all complaints received during a designated period of time should be reviewed by hospital Administration. It is often quite beneficial to task the Quality Council with the responsibility of reviewing reports on patient satisfaction and patient complaints on a regular basis in order to identify any trends, positive or negative. The Council can then make decisions as to what areas to target for improvement and enlist the involvement of appropriate departments and individuals in this endeavor.
End of Life Issues
The patient’s right to participate in treatment decisions, also, includes decisions regarding cessation of treatment in the face of medical futility. Discussions regarding the right to refuse further treatment or the withdrawal of life support are often times quite difficult for the patient and family, as well as, members of the treatment team. Given the emotional and psychosocial issues that may be encountered, it is often wise to involve social workers or therapists in such discussions. Once the decision is made to cease aggressive treatment or to abstain from such interventions as cardiopulmonary resuscitation, it is critical that all members of the healthcare team are advised so that the patient’s wishes are honored. Given the technical advances available today, the issues surrounding decisions to cease life sustaining/supporting are occurring with greater frequency. This has heightened the need for further emphasis and education on the emerging field of medical ethics.
It is obvious that there are a myriad of issues surrounding the issue of patient rights. Joint Commission has put considerable efforts into the “Speak Up” program which, as the title denotes, encourages patients to be actively involved in their healthcare. If such a philosophy is adopted by healthcare facilities, it will benefit the patients, as well as, the healthcare providers.
Amori, Geri. “Communication with Patients and Other Consumers: The Ultimate Loss Control Tool” in Risk Management Handbook for Health Care Organizations. San Francisco, California: Jossey-Bass Inc., Publishers, 2004.
Brown, Janet. The Healthcare Quality Handbook. Pasadena, California: J.B. Quality Solutions, 2002.
Donabedian, A. “The Quality of Care: How Can it be Assessed?” in Quality in Health Care: Theory, Application, and Evolution, Gaithersburg, Maryland.: Aspen Publishers, 1995, pp 32-36.
Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, Illinois: Joint Commission Resources, Inc., 2005.
Joint Commission on Accreditation of Healthcare Organizations. Medical Staff Performance Improvement. Oakbrook Terrace, Illinois: Joint Commission Resources , Inc., 2001.
Kadzielski, M. “Physician and Allied Health Professional Credentialing” in Risk Management Handbook for Health Care Organizations. San Francisco, California: Jossey-Bass, Inc., 2004, pp 195 - 200.
Kavaler, Florence and Allen D. Spiegel. “Patient/Consumer Communications to Reduce Risk” in Risk Management in Health Care Institutions. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2003.
Seisser, Mary. “Patient Rights for Empowered Consumers and Risk Managers” in Risk Management Handbook for Health Care Organizations. San Francisco, California: Jossey-Bass Inc., Publishers, 2004.
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