Accreditation Standards forPatient and Family Rights

Rafidah Haryati Che IsmailPenyelaras Akreditasi Hospital Gua Musang

Ethical ConsiderationsPatient and Family Rights

Why ?Healthcare Facilities have to show evidence that they recognize that the patient is a unique individual with his/her needs, values and spiritual beliefs/religion

Service providers need

to establish confidence, trust and clear communication with patients

to understand and protect each patients cultural, psychosocial and spiritual beliefs/religion.

Why ?Outcomes of patient care are safer and much improved when patients and where appropriate, their families or others who make decisions on their behalf, participate in care decisions and process in a way that meets cultural, and spiritual beliefs/religious expectations.

STANDARD6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

STANDARD6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

Criteria for Compliance: The Facilitys management and clinical staff work collaboratively to protect and promote patient and family rights including:

b) considerate, respectful, privacy and confidential medical care;

Evidence: Privacy of consultation rooms Privacy in wards Patient feedback Security of medical records Policies on release of medical information to others

STANDARD6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

Criteria for Compliance: The Facilitys management and clinical staff work collaboratively to protect and promote patient and family rights including:c) informed of the identity of the physician and other care givers;d) reasonable information about investigations, diagnosis, treatment and prognosis, including after discharge care and continuity of care and the right to second opinion;Evidence: Name tags, name stamps on documents Appropriate documented evidence that such information has been communicated to the patient / relatives patient information brochures in multiple languages laymans language for easy understanding

STANDARD

Criteria for Compliance: The Facilitys management and clinical staff work collaboratively to protect and promote patient and family rights including:e) the right to participate in making informed decisions concerning care including the right to refuse proposed treatment, experimental care and the right to leave the hospital against medical advice;

Evidence: Documented evidence of patient/family discussions on the above Evidence to show patients / families are informed of the risks, benefits and alternatives of treatment, example of acceptance from referred centers, referral letters / reports.6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

STANDARD6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

Criteria for Compliance: The Facilitys management and clinical staff work collaboratively to protect and promote patient and family rights including:

f) Informed of applicable/relevant hospital rules and policies;

Evidence: Patient orientation checklists.

STANDARD6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

Criteria for Compliance: The Facilitys management and clinical staff work collaboratively to protect and promote patient and family rights including:

g) administration of pain management where appropriate;

Evidence: System and evidence of appropriate pain management. pain score tools Patient understands what procedure has been done, what pain to expect, and when to ask for assistance.

STANDARD6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

Criteria for Compliance: The Facilitys management and clinical staff work collaboratively to protect and promote patient and family rights including:

h) receive and examine an itemized statement of all charges;

Evidence: Evidence of such communication.

STANDARD6.1.1 THE FACILITY IS RESPONSIBLE FOR PROVIDING PROCESSES THAT SUPPORT PATIENTS AND FAMILIES RIGHTS DURING CARE.

Criteria for Compliance: The Facilitys management and clinical staff work collaboratively to protect and promote patient and family rights including:

i) inform patients and families of their responsibilities.

Evidence: Clients Charter, displayed Patient Information leaflets.

STANDARD6.1.1.2 The management understands patient and family rights as identified in relevant laws and regulations and in relation to the community served.

6.1.1.3 Policies and procedures guide and support patient and family rights in the Facility.

6.1.1.4 The Facility respects the rights of patients and the rights of the patients family to have the prerogative to determine what information regarding their care would be provided to the family or others and under what circumstances.

Evidence: Hospital Policies

STANDARD6.1.1.5 Staff are educated and knowledgeable about the policies and procedures related to patient rights and can explain their responsibilities in protecting patient rights.

Evidence: Evidence of staff training on policies and procedures related to Patient Rights

STANDARD

Criteria for Compliance: There is a process designed to identify and respect patients personal values and spiritual beliefs/religion and where applicable those of the patients family. Staff use the process and provide care that is respectful of the patients personal values and spiritual beliefs/religion.The Facility responds to routine as well as complex requests related to religious or spiritual support.

6.1.2 Patients personal values and spiritual beliefs/religion.Evidence: Halal food Telephone numbers of contact persons of various religions. Right to refuse blood transfusion due to religious beliefs.

STANDARD6.1.3 Care is respectful of the patients need for privacy especially during clinical interviews, examinations, procedures/treatments. Patient may desire privacy from other staff, other patients or even from family members. Also patients may not wish to be photographed, recorded or participate in interviews, thus staff need to enquire about the patients privacy needs related to care given.

Evidence: Facilities for privacy in ward and clinic Policies and procedures for interviews with the media, ensuring patient rights.Criteria for Compliance: a) Staff identify patients expectations and needs for privacy during care and treatment.b) A patients expressed need for privacy is respected for all clinical interviews, examinations and procedures/treatments.

STANDARD6.1.4 Protection of patients possessions from theft or loss: emergency patients / day surgery patients / inpatients

Criteria for Compliance: a) The Facility has a policy that indicates its level of responsibility for patients possessions.b) Patients receive information about the Facilitys responsibility for safe keeping and protecting personal belongings.c) Patients possessions are safeguarded when the Facility assumes responsibility or when the patient is unable to assume responsibility.

Evidence: Hospital policy for safeguarding patient property. Signage / brochures Procedure in place for managing property. Records as evidence.

STANDARD6.1.5 Protection of patients from physical injury infants and children, the elderly, disabled individuals, patients at risk.

Criteria for Compliance: a) The Facility has a policy addressing protection of patients from injury.b) Infants, children, the elderly, disabled individuals, and others at risk are addressed in the process.c) The individuals without identification are screened.Remote or isolated areas of the Facility are monitored.Evidence: Systems for security of infants Safety audits for facilities Fire evacuation drills Incident reporting involving injury to patients Monitoring of remote areas

STANDARD6.1.6 Protection of high risk patients from abuse, negligent care, withholding of services, or assistance in the event of a fire.

Evidence: Policies for the identification of vulnerable patient groups. Evidence of a process to protect these patients from injury. Management of post op patients Management of One Stop Crisis Center (OSCC)Criteria for Compliance: 6.1.6.1) The Facility identifies vulnerable patient groups.6.1.6.2) Children, disabled individuals, the elderly, and others are protected from abuse, negligence, care withholding of services, or assistance in the event of a fire and overall safety of the patients is ensured.

STANDARD6.1.6 Protection of high risk patients from abuse, negligent care, withholding of services, or assistance in the event of a fire.

Criteria for Compliance: 6.1.6.3) Special attention/priority care is to be given to children, disabled individuals, the elderly, individuals with mental or emotional disabilities and other vulnerable group. 6.1.6.4) Staff understand their responsibilities in the protection processes.

Evidence: Staffing requirements Involvement of NGOs. Evidence of staff awareness / training on the management of vulnerable patients : Care of Elderly and Rehabilitation, Care of Disabled

STANDARD6.1.7 Confidentiality of patient information

Evidence: Hospital policy on confidentiality of patient information. Policy on release of patient information. Timelines for the release of patient reports Staff understanding of the processCriteria for Compliance: 6.1.7.1) Where necessary patients are informed on how their information will be kept and about laws and regulations that require the release or protect the confidentiality of patient information.6.1.7.2) Patients are requested to grant permission for the release of information not covered by laws and regulations.6.1.7.3) The Facility respects patient health information as confidential.6.1.6.4) Staff understand their responsibilities in the protection processes.

STANDARD6.1.8 Patients and Families rights to participate in the care process, decision making, as well as refusing diagnostic procedures and treatment.

Evidence: Hospital policy and procedures supporting patient and family involvement in patient care. Evidence that patient and family is informed about the outcomes of treatment, including unanticipated outcomes.Criteria for Compliance: 6.1.8.1) Policies and procedures are developed to support and promote patient and family in care processes including information on medical condition, confirmed diagnosis, planned care and treatment.6.1.8.2) Patients family is informed about the outcomes of care and treatment, including where appropriate the unanticipated outcomes.

STANDARD6.1.8 Patients and Families rights to participate in the care process, decision making, as well as refusing diagnostic procedures and treatment.

Criteria for Compliance: 6.1.8.3) Patients are informed about their rights and responsibilities related to refusing or discontinuing treatment.

6.1.8.4) Staff are trained on the policies and procedures in their role in supporting patient and family participation in care processes

Evidence: Documented evidence that patients have been informed of rights & responsibilities of discontinuing treatment. Evidence of staff awareness.

STANDARD6.1.9 The Facility respects patients and familys wishes and preferences to withhold resuscitative services.Criteria for Compliance: 6.1.9.1) The Facility has a policy as regard its position on withholding resuscitative services which conforms to communitys spiritual beliefs/religion and any legal or regulatory requirements.6.1.9.2) The Facility guides health professional on the ethical and legal issues in carrying out such patients wishes.6.1.9.3) There is documentation about decisions made for withholding resuscitative services. Evidence: Hospital policy on withholding resuscitation conforming to legal requirements. Guidelines for withholding resuscitation. Documentation of decisions made.

STANDARD6.1.10 The Facility supports the patients right to appropriate assessment and management of symptoms as unrelieved could have adverse physical and psychological effects.

Criteria for Compliance: 6.1.10.1) The Facility supports the patients right to appropriate assessment and management of symptoms6.1.10.2) Staff understand the influences on the patients right to report symptoms and accurately assess and manage the symptoms.

Evidence: Hospital policy Staff awareness of patient rights

STANDARD6.1.11 Patients right to respectful and compassionate care at the end of life including pain management, and issues related to psychological, social, emotional and religious concern.

Evidence: Hospital policy Guidelines for management of death and the dying. Staff awareness of patient rightsCriteria for Compliance: 6.1.11.1) The Facility recognises the needs of dying patients.6.1.11.2) Staff respect the rights of dying patients to have those needs addressed in the care process.

STANDARD6.1.12 Grievance Mechanism

Criteria for Compliance: 6.1.12.1) Patients are aware of their rights to voice their complaint and the process to do so. 6.1.12.2) Complaints are reviewed according to the Facilitys grievance mechanism6.1.12.3) Dilemmas that arose during the care process are reviewed.6.1.12.4) Policies and procedures identify how the patients and families participate in this process. Evidence: Policy, guideline and procedure for grievance mechanism. Patient awareness on system for complaint. Documented evidence of resolution of dissatisfaction. Clinical audit.

STANDARD6.2 Informed Consent 6.2.1 Patient informed Consent is obtained through a process defined by the facility and carried out by trained staff. Criteria for Compliance: 6.2.1.1) There are policies and procedures that clearly define the process for informed consent.6.2.1.2) There are policies and procedures that clearly define the process for informed consent.6.2.1.3) The Facility lists the types of treatments and procedures that require informed consent.6.2.1.4) Designated and trained staff obtain the informed consent from the patient or family member where applicable.6.2.1.5) Patient gives informed consent consistent with policies and procedures. Evidence: Policy and procedure for informed consent. List of procedures requiring informed consent. Designation of staff obtaining the consent.

STANDARD6.2.2 The Facility establishes a process within the consent of existing laws when others can grant consent where any delay caused in obtaining the consent would endanger the life of a patient.

Criteria for Compliance: 6.2.2.1) The Facility has policies and procedures where others can grant informed consent.6.2.2.2) Consent may be dispensed with according to the relevant laws where any delay caused in obtaining the consent would endanger the life of a patient.6.2.2.3) Individuals other than the patient granting consent are noted in the patients record.Evidence: Hospital policy Documented evidence of the above.

STANDARD6.3 Research

Criteria for Compliance:

6.3.1.1) The Facility has a committee or however named alternative arrangement to oversee all research conducted in the Facility involving human subjects.6.3.1.2) A Facility that conducts research, investigations, or clinical trials involving human subjects knows that their first responsibility is to the patients health and well-being.6.3.1.3) The Facility informs patients and families in advance about established processes to review research protocols / patient info sheet: weigh the risks and benefits obtain subjects consent withdraw from participation6.3.1 The Facility has policies, procedures and code of ethics for the selection and participation of the patient in clinical research, investigation or clinical trials.

STANDARD6.3 Research

6.3.1 The Facility has policies, procedures and code of ethics for the selection and participation of the patient in clinical research, investigation or clinical trials.Criteria for Compliance: 6.3.1.4) Information is communicated to patients and families to assist with decisions regarding participation.6.3.1.5) Patients who choose to participate in clinical research, investigations or clinical trials are protected.6.3.1.6) Informed consent is obtained before the patient participates in clinical research, investigation or clinical trials

Evidence: Hospital policy on research Documented evidence of all the above requirements.

STANDARD6.4 Organ DonationCriteria for Compliance: 6.4.1.1) The Facility provides relevant information on the procurement, donation process and transplantation process where necessary.6.4.1.2) There are policies and procedures available to guide the procurement, donation process and the transplantation of organs, consistent with relevant laws and regulations and respect the community values, spiritual beliefs/religion. 6.4.1.3) Staff are trained in the policies and procedures.6.4.1.4) The Facility cooperates with other facilities or agencies responsible for all or a part of the procurement, banking, transportation, or transplantation process.Evidence: Hospital policy on organ donation (MOH National Organ, Tissue and Cell Transplantation Policy, 2007) Guidelines and procedures for organ donation. Staff training records on organ donation Policies for inter phasing with other agencies related to tissue banking.

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