UTMB HANDBOOK OF OPERATING PROCEDURES

Section 9 Clinical Policies Subject 9.3 Patient Rights Policy 9.3.13 Patient Rights

04/05/93 -Originated 11/14/06 -Reviewed w/changes -Reviewed w/o changes Patient Services Dept. -Author

Patient Rights

Policy

Patients have the right to make basic decisions about medical and health care services they receive from physicians or other health care providers. Patients have the right to accept, refuse (to the extent permitted by law) or withdraw any treatment. All health care providers are expected to abide by these decisions. UTMB complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and ensures that patient information is kept private and confidential.

Access to and Transfer of Care; Continuity of Care

Patients have reasonable and impartial access to available, medically-indicated care, treatment and services within the capability and capacity of UTMB regardless of their race, religion, beliefs, cultural values, sex, age or financial status. To the extent of its capabilities and capacity, the hospital will arrange evaluation, service, and/or referral as indicated by the urgency of the case. If requested or if medically appropriate and legally permissible, patients may be transferred to another facility only after being informed about the need for, risks, benefits and alternatives to transfer. The institutions to which patients are to be transferred must accept such transfers prior to patients’ departures. Prior to leaving the hospital, patients’ post-discharge continuing health care requirements are explained to them by their physician/ designee. Patients are also notified (with the exception of TDCJ patients) in advance, of appointment times and physicians, and who to contact with questions before scheduled appointments.

Considerate and Respectful Care

Patients are treated in a considerate and compassionate manner with recognition of personal dignity and respect to personal values and beliefs. It is recognized that the individual psychosocial, cultural and spiritual values, beliefs, and preferences of patients may affect the perception and experience of illness or the care received. Patients may wear appropriate personal clothing and religious or other symbolic items, as long as they do not interrupt patient care, harm others, or interfere with diagnostic procedures or treatment.

Pastoral Care Counseling	In some instances, meeting spiritual needs during a patient’s hospital stay can be as important as caring for the physical needs. Chaplains are available to provide support to patients and their families. Reasonable efforts to accommodate the patient’s preferences regarding personal clergy will be made.
Notification of Rights	At the time of admission to the hospital, a written Patient Rights statement is provided to each patient during the nursing assessment. This statement is an assurance that all health care activities are conducted with an overriding concern for the patient’s rights and dignity as a human being. A copy of the Patient Rights statement is also available, upon request, through the patient services department and is available for viewing on the closed circuit patient access channels. For patients with language barriers or those who are unable to read, these rights are interpreted and/or explained to the extent of UTMB’s capabilities. Patient Rights statements are posted in those public areas which are accessible to patients and their families. In addition to these rights, certain areas also have unit-specific patient rights statements.
Involvement in Care	Adult patients and/or, when appropriate, patients’ families or designated surrogates, participate in determining the care provided by: • consenting to recommended treatments or procedures • formulating advance directives • deciding to withhold resuscitative services • deciding to forgo or withdraw life-sustaining treatment • being an active participant in resolving dilemmas involving care decisions • determining the care provided at the end of life • appointing a surrogate decision maker
Informed Consent	Adult patients and/or, when appropriate, patients’ families or designated surrogates, receive from their physician information necessary to give informed consent prior to the start of any care, treatment or service. Informed consent allows the patient to fully participate in care, treatment or service decisions Except in emergencies, the information

Informed Consent, continued

needed to obtain informed consent includes, but is not limited to the following: • the patient’s diagnosis • the general nature of the specific procedure and/or treatment - its purpose, whether it is experimental, and the name(s) of the person(s) performing the procedure or administering the treatment • the benefits, risks, discomforts, side effects, complications and potential problems related to recuperation associated with the procedure or treatment • the likelihood of success • the patient’s prognosis if the procedure is not performed • and reasonable alternative medical treatments In addition to receiving informed consent for medical care and treatment, patients also have the right to consent to the recording or filming of care, treatment and services.

Identity of Care Providers

Patients have the right to know the identity and professional status of individuals involved in their care, and which physician or other practitioner is primarily responsible for that care. Patients may obtain information as to any relationship UTMB has with other health care and educational institutions insofar as their care is concerned. Patients also may obtain information as to the existence of any professional or business relationship among individuals, by name, who are treating them.

Refusal of Treatment

A competent adult patient or the patient’s properly designated agent under the Medical Power of Attorney, formerly Durable Power of Attorney for Health Care has the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal.

Care at End of Life	Optimal comfort and dignity during the terminal stage of an illness is provided to patients. This type of care includes, but is not limited to, treating primary and secondary symptoms that respond to treatment, as desired by the patient in the Directive to Physicians and/or the person designated in the patient’s Medical Power of Attorney or surrogate decision-maker; appropriately and aggressively managing pain; responding to the psychosocial, spiritual, and cultural concerns of the patient and the family regarding death, dying, and the expression of grief.
Advance Directives	An advance directive is defined as “a written instruction such as living will or medical power of attorney for health care recognized under State law and relating to the provision of such care when the person is incapacitated.” In Texas there are three types of advance directives: Directive to Physicians, Medical Power of Attorney, and Out-of-Hospital Do Not Resuscitate (DNR) Order. Upon admission to the hospital, the Interdisciplinary Admission Assessment form is used to assess whether a patient has an advance directive or wishes to formulate one. If a patient wishes to formulate an advance directive, the necessary documents are available on each unit. Once formulated, the completed document, which is signed by the patient, becomes a part of the patient’s permanent medical record. A patient has the option to review or revise advance directives. The existence or lack of an advance directive does not determine an individual’s access to care, treatment or services.
Surrogate Health Care Decision Maker	In some instances, individuals other than (or in addition to the patient) are involved in making decisions about the patient’s care. To promote fair, compassionate and equitable treatment of all patients regardless of age, a patient’s guardian, next-of-kin, or other legal representative has the right to exercise, to the extent permitted by law, the rights of the patient if and when the patient: • has been adjudicated incompetent in accordance with the law • is found by his or her physician to be medically incapable of understanding the proposed treatment or procedure • is unable to communicate his or her wishes regarding treatment • or is an unemancipated minor The patient may also exclude all family members from participating in care decisions.

Handling Conflicts in Care	In some instances, patient care decisions involve questions, conflicts or other dilemmas for hospital staff and the patient, family or other decision makers. The Ethics Consultation Service is the primary mechanism for addressing conflict in care issues. Members of the clergy are also available to assist in the resolution of these issues. The Principles of Ethical Conduct which addresses ethical issues regarding patient care can be accessed on the Internet.
Outcomes of Care, Including Unanticipated Outcomes	Patients and, when appropriate, their families are informed about the results of treatment, including any significant unexpected patient care outcomes or when the outcomes differ significantly from the anticipated outcomes. In accordance with the UTMB Hospitals and Clinics Healthcare Safety Plan, when a healthcare error leads to injury, the patient and/or family should receive a truthful and compassionate explanation about the error and the medical remedies available to the patient.
Communication	For patients with language barriers, an interpreter service is available to assist in communicating information in a manner which is understandable to each patient. Resources are also available for patients who have communication impairments. These resources include talking books, books in Braille and signature guides for the visually impaired; sign language interpreters, Text Telephones for the Deaf; telephone receiver amplifiers and closed-captioned TV for the hearing impaired; and augmentation communicative devices and electrolarynx for the speech impaired. When it is necessary to restrict communication as a component of patient care, the restrictions are explained to the patient and the patient participates in this decision.
Patient Complaint Process	An organized system exists to receive and address patient complaints, whether the complaints are written or verbal, or are received via telephone or in person. This system is maintained through the patient services’ department. The patient services’ department provides a centralized and effective mechanism for the initiation, review, and when possible, resolution of patient complaints and/or concerns. Patients are notified of the services offered by this department during the admitting process, through information provided on patient care units, closed circuit television and through visitation from department representatives. Individuals who file complaints are notified, once the investigation has been completed, of the outcome of the inquiry.

Patient Complaint Process, continued

Privacy Complaints: Patients who feel their privacy has been breached in violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards may notify the patient services’ department or may contract the Institutional Privacy Office directly. The Institutional Privacy Office is responsible for investigating all complaints associated with allegations of privacy violations and will be notified by the patient services’ department of all patient allegations regarding the breach of privacy. Additionally, patients may file privacy complaints with the Department of Health and Human Services as well.

Privacy and Confidentiality

As a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and subsequent Privacy Standards, patients have the right to expect privacy and confidentiality of their protected health information (PHI). UTMB employees may use and disclose PHI for Treatment, Payment and healthcare Operations (TPO). However, UTMB and its employees must limit PHI use and disclose to the “Minimum Necessary” amount of information required to complete the desired task. UTMB may not use and disclose PHI for non-TPO purposes, unless UTMB has obtained a valid authorization for disclosure of PHI from the patient or unless the disclosure is permitted by law. The HIPAA Privacy Standards also grant patients several additional rights. Patients have the right to: • Request amendments to their medical records • Request restrictions on the use and disclosure of their PHI, including the right to request confidential communications • Request access to the PHI in UTMB’s designated record set • Revoke any prior authorization of the use and disclosure of their PHI • Obtain an Accounting of Disclosures • Obtain a notice of privacy practices • File privacy complaint with UTMB Privacy Officer or the Department of Health and Human Services All communications and other records pertaining to a patient’s care, including the source of payment for treatment, are treated as confidential, except to the extent otherwise required by law. A patient’s medical record is read only by individuals with a

Privacy and Confidentiality, continued	legitimate need to know for use in the normal course of business. This includes those directly involved in the patient’s treatment or in the monitoring of its quality. Instructors and students from approved educational programs may also review records as part of their educational programs. Other individuals may read a patient’s medical record only with the patient’s written authorization or that of the patient’s legally authorized representative. Case discussion, consultation, examination, and treatment are confidential and are conducted professionally. Those individuals not directly involved in the patient’s care must have the patient’s permission to be present during these discussions.
Security	Reasonable security is maintained for patients and their visitors through the UTMB police department.
Pain Management	Pain assessment and management is considered an important part of a patient’s hospital experience and care plan. Procedures and resources are in place to assure that pain for all patients is recognized and addressed appropriately.
Access to Protective Services	When clinically pertinent or upon the request of a patient, written information is provided on how to access client advocacy groups. Information regarding the method for filing a complaint with state survey and certification agencies is also provided upon request.
Consent Involving Research Programs	Patients are advised when the care recommended is associated with a research, investigation or clinical trials program. In addition to the elements necessary to obtain informed consent and in accordance with the Institutional Review Board requirements, the following information must be reviewed with those patients considering participation in research programs. This list includes but is not limited to the following elements. Patients are informed of: • the purpose of the study; • the expected benefits of participating in the study; • the potential risks and discomforts; • alternate services or treatments that might be beneficial; • a complete explanation of the procedures which includes w

Consent Involving Research Programs, continued	is going to happen, what is expected of the patient and the time period of the study; • the approximate number of subjects involved in the study; • any additional expenses to the patient or the patient’s insurance carrier which may occur during the performance of the study. All patients asked to participate in research studies may refuse without compromising their ability to access medically indicated services or treatment. Consent requirement for research studies is further addressed in the Institutional Review Board Manual.
References
Access to and Transfer of Care	Policy 3.2.1, Nondiscrimination Policy 9.1.1, Registration at UTMB Hospitals and Clinics Policy 9.1.3. Admitting and Accommodating Texas Department of Criminal Justice (TDCJ) patients Policy 9.1.6, Inpatient Discharge and Transfer Policy 9.1.12, Memorandum of Transfer Policy 9.1.14, Patient Discharge Planning Policy 9.1.21, Examination and Treatment for Emergency Medical Conditions and Women in Labor
Involvement in Care	Policy 6.3.2, Consent to Photograph, Video/Audio Record and/or Televise patients Policy 9.3.10, Consent for HIV antibody Testing and for Disclosure of Results Policy 9.3.17, Patient Consent - Overview and Basic Requirements Policy 9.3.18, Consent for Treatment of a Minor Policy 9.3.20, Universal Childhood and Adolescent Immunizations Policy 9.3.21, Consent for Sterilization Policy 9.15.5, Patients Initiating Advance Directives Policy 9.15.7, Withholding or Withdrawing Life-Sustaining Treatment from a Patient Without an Advance Directive Policy 9.13.18, Communication of Unanticipated Outcomes

Informed Consent	Policy 6.3.2, Consent to Photograph, Video/Audio Record and/or Televise patients Policy 9.3.10, Consent for HIV antibody Testing and for Disclosure of Results Policy 9.3.17, Patient Consent - Overview and Basic Requirements Policy 9.3.18, Consent for Treatment of a Minor Policy 9.3.20, Universal Childhood and Adolescent Immunizations Policy 9.3.21, Consent for Sterilization
Refusal of Treatment	Policy 9.3.16, Refusal of Consent/Treatment
Advance Directives	Policy 9.15.5, Patients Initiating Advance Directives Policy 9.15.7, Withholding or Withdrawing Life-Sustaining Treatment from a Patient Without an Advance Directive Policy 9.15. 8, Withholding or Withdrawing Life-Sustaining Treatment from a Patient Without an Advance Directive
Surrogate Health Care Decision Maker	Policy 9.3.10, Consent for HIV antibody Testing and for Disclosure of Results Policy 9.3.17, Patient Consent - Overview and Basic Requirements Policy 9.3.18, Consent for Treatment of a Minor Policy 9.3.20, Universal Childhood and Adolescent Immunizations Policy 9.3.21, Consent for Sterilization
Outcomes of Care, including Unanticipated Outcomes	Policy 9.13.8, Communication of Unanticipated Outcomes
Communication	Policy 9.3.1, Resources Available for Patients with Disabilities
Patient Complaint Process	Policy 6.1.5, Privacy Complaints

Privacy and Confidentiality	Policy 6.2.0 General Policy on the Use and Disclosure of PHI Policy 6.2.1 Use and Disclosures of PHI base on Patient Authorization Policy 6.2.2 Use and Disclosure of PHI to Family and Friends for Individual Care and Notification Purposes Policy 6.2.4 Use and Disclosure of PHI for Personal Representatives, Minor and Deceased Individuals Policy 6.2.14 Minimum Necessary Use and Disclosure of PHI Policy 9.2.5, Access to Clinical Information system and Electronic Medical Records Policy 9.2.6, Medical Record Access Policy 9.2.7, Access to Medical Records Located on Patient Care Units Policy 9.2.11, Confidentiality of Patient Information
Security	Policy 9.9.1, Security Associated with Offender/Correctional Patients in non-TDCJ Areas Policy 9.9.2, Security Associated With The TDCJ Hospital Policy 9.9.4, Security Management
Access to Protective Services	Policy 9.3.8, Identification of Abuse, Neglect, and Exploitation of Children, the Elderly and/or Disabled Persons Policy 9.3.9, Reporting Suspected Abuse, Neglect, and Exploitation of Children, the Elderly and/or Disabled Persons