Why KISS to ‘Patient and Family Rights (PFR)’ in JCI? Just stick to ‘The Golden Rule’! Think about it: How DO we like to be treated in hospitals?
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Bestselling author John C. Maxwell in his book ‘Ethics 101: What Every Leader Needs to Know’ shows us how the Golden Rule works everywhere, and how, especially in business, it brings amazing dividends. He mentioned that ethics was not a changeable thing, based on our situation or personality or industry. Instead, he explained that he believes that ALL ethics boils down to one thing: The Golden Rule. Essentially, asking the question, “How would I like to be treated?” is an integrity guideline for ANY situation. Think about it: How DO we like to be treated? We want to be valued, to be appreciated, to be trusted, to be respected, to be understood, and don’t want others to take advantage of us. This is where the ‘Patient and Family Rights’ be present in our healthcare services. JCI takes the advantage to put few standards and measurable elements (MEs) unbiased to follow the Golden Rule.&So, do we need to KISS (Keep It Simple and Smart) JCI-PFR chapter's standards and measurable elements (MEs) or we simply abide by the Golden Rule! Think about it before&proceed further..........
Patient and Family Rights (PFR) is the third chapter of section-II: patient-centered standards in the Joint Commission International (JCI) hospital standards of 5th edition.& The notion of ‘patient rights’ has attracted much attention during the past two decades due to several reasons such as patients’ vulnerability and needs on one hand and increasing international attention towards human rights on the other hand. Patient is the core of all the health care providers’ activities and this issue must be clearly considered in all aspects of the activities, since the disease experience as well as the necessity of adherence to the treatment and following the care increases the patients’ vulnerability and their need for comprehensive support. Moreover, changes in the social conditions have raised the patients’ expectations for their rights. But, neglecting patients’ rights in a health care system can give rise to a challenging situation between health care providers and patients. Despite the checklist of Joint Commission International (JCI) standards approved in 1997 which includes patient right issues, studies have shown that patient and family right still compromised in few healthcare services and most important finding is that developing countries Ministry of health program related on PFR is somehow imperfect compare to patient and family rights (PFR) standards of JCI. JCI standards are unique tools designed to measure patient care quality worldwide. In Patient and Family Rights (PFR) chapter of JCI Accreditation for hospitals, there are nineteen (19) standards and seventy-seven (77) measurable elements (ME).
The hospital leadership is primarily responsible for how a hospital will treat its patients. Thus, leadership needs to know and to understand patient and family rights and their hospital’s responsibilities as identified in laws and regulations. Leadership then provides direction to department/service leaders who ensure that staffs throughout the hospital assume responsibility for protecting these rights. To effectively protect and to advance patient rights, leadership works and seeks to understand their responsibilities in relation to the community served by the hospital. The hospital respects the right of patients, and in some circumstances the right of the patient’s family, to have the prerogative to determine what information regarding their care would be provided to family or others, and under what circumstances. For example, the patient may not wish to have a diagnosis shared with family. Patient and family rights are a fundamental element of all contacts among a hospital, its staff, and patients and families. Thus, policies and procedures are developed and implemented to ensure that all staff members are aware of and respond to patient and family rights issues when they interact with and care for patients throughout the hospital. The hospital uses a collaborative and inclusive process to develop the policies and procedures, and includes patients and families in the process. Generally, the chapter started with 12 standards and 48 measurable elements (MEs) and the standards are:
Standard PFR.1: The hospital is responsible for providing processes that support patients’ and families’ rights during care
Standard PFR.1.1: The hospital seeks to reduce physical, language, cultural, and other barriers to access and delivery of services
Standard PFR.1.2: The hospital provides care that is respectful of the patient’s personal values and beliefs and responds to requests related to spiritual and religious beliefs
Standard PFR.1.3: The patient’s rights to privacy and confidentiality of care and information are respected.
Standard PFR.1.4: The hospital takes measures to protect patients’ possessions from theft or loss.
Standard PFR.1.5: Patients are protected from physical assault, and populations at risk are identified and protected from additional vulnerabilities
Standard PFR.2: The hospital supports patients’ and families’ rights to participate in the care process
Standard PFR.2.1: Patients are informed about all aspects of their medical care and treatment
Standard PFR.2.2: The hospital informs patients and families about their rights and responsibilities to refuse or discontinue treatment, withhold resuscitative services, and forgo or withdraw life-sustaining treatments.
Standard PFR.2.3: The hospital supports the patient’s right to assessment and management of pain and respectful compassionate care at the end of life
Standard PFR.3: The hospital informs patients and families about its process to receive and to act on complaints, conflicts, and differences of opinion about patient care and the patient’s right to participate in these processes
Standard PFR.4: All patients are informed about their rights and responsibilities in a manner and language they can understand
Hospitals frequently serve communities with a diverse population. Patients may be aged, have disabilities, speak multiple languages or dialects, be culturally diverse, or present other barriers that make the process of accessing and receiving care very difficult. The hospital has identified those barriers and has implemented processes to eliminate or to reduce them for patients seeking care. The hospital also takes action to reduce the impact of these barriers on the delivery of services. Besides, each patient brings his or her own set of values and beliefs to the care process. Some values and beliefs are commonly held by all patients and are frequently cultural and religious in origin. Other values and beliefs are those of the patient alone. All patients are encouraged to express their beliefs in ways that respect the beliefs of others. Strongly held values and beliefs can shape the care process and how patients respond to care. Thus, each healthcare practitioner seeks to understand the care and services, he or she provides within the context of the patient’s values and beliefs. When a patient or family wishes to speak with someone related to religious or spiritual needs, the hospital has a process to respond to the request. The process may be carried out through on-site religious staff, local sources, or family-referred sources. The process to res for example, when the hospital or country does not officially “recognize” and/or have sources related to a religion or belief for which there may be a request.
Another concern is patient privacy, particularly during clinical interviews, examinations, procedures/treatments, and transport, is important. Patients may desire privacy from other staff, from other patients, and even from family members. Although there are some common approaches to providing privacy for all patients, individual patients may have different or additional privacy expectations and needs according to the situation, and these expectations and needs may change over time. Thus, as staff members provide care and services to patients, they inquire about the patient’s privacy needs and expectations related to the care or service. This communication between a staff member and his or her patient builds trust and open communication and does not need to be documented. Medical and other health information, when documented and collected, is important for understanding the patient and his or her needs and for providing care and services over time. This information may be in paper or electronic form or a combination of the two. The hospital respects such information as confidential and has implemented policies and procedures that protect such information from loss or misuse. The policies and procedures reflect information that is released as required by laws and regulations. Staff respects patient privacy and confidentiality by not posting confidential information on the patient’s door or at the nursing station and by not holding patient-related discussions in public places. Staffs are aware of laws and regulations governing the confidentiality of information and inform the patient about how the hospital respects their privacy and the confidentiality of information. Patients are also informed about when and under what circumstances information may be released and how their permission will be obtained. The hospital has to develop a policy that indicates if patients have access to their health information and the process to gain access when permitted.
Other important part is that the hospital communicates its responsibility, if any, for the patient’s possessions to patients and families. When the hospital takes responsibility for any or all of the patient’s personal possessions brought into the hospital, there is a process to account for the possessions and to ensure that they will not be lost or stolen. This process considers the possessions of emergency patients, same-day surgery patients, inpatients, those patients unable to make alternative safekeeping arrangements, and those incapable of making decisions regarding their possessions.
Moreover, the hospital is responsible for protecting patients from physical assault by visitors, other patients, and staff. This responsibility is particularly relevant to infants and children, the elderly, and others unable to protect themselves or to signal for help. The hospital seeks to prevent assault through such processes as investigating individuals in the facility without identification, monitoring remote or isolated areas of the facility, and quickly responding to those thought to be in danger of assault. Each hospital identifies its at-risk patient groups (such as children, disabled individuals, the elderly) and establishes processes to protect the rights of individuals in these groups. Vulnerable patient groups and the hospital’s responsibility may be identified in laws and regulations. Staff members understand their responsibilities in these processes. Children, disabled individuals, the elderly, and other identified populations at risk are protected. Comatose patients and individuals with mental or emotional disabilities are also included. Such protection extends beyond physical assault to other areas of safety, such as abuse, negligent care, withholding of services, or providing assistance in the event of a fire.
It is&patients and families rights to participate in the care process by making decisions about care, asking questions about care, requesting a second opinion, and even refusing diagnostic procedures and treatments. When a patient requests a second opinion, it is expected that the hospital will not prohibit, prevent, or obstruct a patient who is seeking a second opinion, but rather, the hospital will facilitate the second opinion by providing the patient with information about his or her condition, such as test results, diagnosis, recommendations for treatment, and the like. The hospital must not withhold this information if a patient requests it for a second opinion. The hospital is not expected to provide and pay for a second opinion when requested by the patient. Policies address the patient’s right to seek a second opinion without fear of compromise to their care within or outside the hospital. The hospital supports and promotes patient and family involvement in all aspects of care. All staff members are trained on the policies and procedures and on their role in supporting patients’ and families’ rights to participate in the care process. For patients and families to participate in care decisions, they need basic information about the medical conditions found during assessment, including any confirmed diagnosis, and on the proposed care and treatment. During the care process patients also have a right to be told of the outcomes of the planned care and treatment. In addition, it is important that they be told of any unanticipated outcomes of the care and treatment, such as unanticipated events during surgery or with prescribed medications or other treatments. Patients and families understand that they have a right to this information and who is responsible for telling them. Patients and families understand the type of decisions that must be made about care and how to participate in those decisions. In addition, patients and families need to understand the hospital’s process to obtain consent and which care processes, tests, procedures, and treatments require their consent. Although some patients may not wish to personally know a confirmed diagnosis or to participate in the decisions regarding their care, they are given the opportunity and can choose to participate through a family member, friend, or a surrogate decision maker. For patients, it should be clear who will provide them with the information about their medical condition, care, treatment, outcomes, unanticipated events, and the like. Patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or to continue care or treatment after it has been initiated. Some of the most difficult decisions related to refusing or withdrawing care are related to decisions about withholding resuscitative services or forgoing or withdrawing life-sustaining treatment. These decisions are difficult not only for patients and families, but for health care professionals and the hospital as well. No single process can anticipate all the situations in which such decisions must be made. For this reason, it is important for the hospital to develop a framework for making these difficult decisions. The framework-
helps the hospital identify its posi
ensures that the hospital’s position conforms to its community’s religious and cultural norms and to any legal or regulatory requirements, in particular when legal requirements for resuscitation are not consistent with the patient’
addresses situations in which these decisions are
guides health professionals through the ethical and legal issues in carrying out such patient wishes
To ensure that the decision-making process related to carrying out the patient’s wishes is applied consistently, the hospital develops policies and procedures through a process that includes many professionals and viewpoints. The policies and procedures identify lines of accountability and responsibility and how the process is documented in the patient’s record. The hospital informs patients and families about their rights to make these decisions, the potential outcomes of these decisions, and the hospital's responsibilities related to such decisions. Patients and families are informed about any care and treatment alternatives.
Managing pain is another patient right to be addressed. Pain is a common part of the patient experience, and unrelieved pain has adverse physical and psychological effects. A patient’s response to pain is frequently within the context of societal norms and cultural and religious traditions. Thus, patients are encouraged and supported in their reporting of pain. Dying patients have unique needs that may also be influenced by cultural and religious traditions. Concern for the patient’s comfort and dignity guides all aspects of care during the final stages of life. To accomplish this, all staff members are made aware of patients’ unique needs at the end of life. These needs include treatment of primary an response to the patient’s and family’s psychological, social, emotional, religious, a and involvement in care decisions. The hospital’s care processes recognize and reflect the right of all patients to assessment and management of pain and the assessment and management of a patient’s unique needs at the end of life.
Patients have a right to voice complaints about their care and to have those complaints reviewed and, when possible, resolved. Also, decisions regarding care sometimes present questions, conflicts, or other dilemmas for the hospital and the patient, family, or other decision makers. These dilemmas may arise from issues of access, treatment, or discharge. They can be particularly difficult to resolve when the issues involve, for example, withholding resuscitative services or forgoing or withdrawing life-sustaining treatment. The hospital has established processes for seeking resolution of such dilemmas and complaints. The hospital identifies in policies and procedures those who need to be involved in the processes and how the patient and family participate.
Admission as an inpatient or registration as an outpatient to a health care hospital can be frightening and confusing for patients, making it difficult for them to act on their rights and to understand their responsibilities in the care process. Thus, the hospital prepares a written statement of patient and family rights and responsibilities that is given to patients when they are admitted as inpatients or registered as outpatients to the hospital and is available each visit or throughout their stay. For example, the statement may be posted in the facility. The statement is appropriate to the patient’s age, understanding, and language. When written communication is not effective or appropriate, the patient and family are informed of their rights and responsibilities in a language and manner they can understand. Please find one written statement of Patient Right and Responsibility of a hospital.
&Access to Care: All patients have the right to:&
Access healthcare services regardless of race, religion, national origin, beliefs, values, language, age or disability
Access emergency services regardless of the ability to pay
Receive assistance to meet vision, speech, hearing, language, physical mobility and cognitive impairment needs, where necessary
Receive care and services without unnecessary delay, and if there is a sign of delay in care, treatment and/or services, the patient, family, caregiver, or legal guardian shall be notified
Change physician and to transfer to another hospital as long as it is medically appropriate and feasible
Seek a second opinion without fear of compromise to their care within or outside healthcare services
Participate in research when medically appropriate
&Patient Care: All patients have the right to:
Be informed about the treatment and services prior to care&
Receive respectful and considerate care at all times and to maintain the patient’s personal dignity&
Participate in the development, implementation, and revision of their plan of care, treatment and services&
Make the decision to withhold or withdraw treatment if there is a terminal condition that includes a “Do Not Resuscitate” order&
Accept or refuse any and all drugs, treatments or procedures and to be informed of medical consequences of such refusal&
Be given an appropriate and effective grievance support mechanism&
Receive education that is appropriate to the patient’s age, cognitive level and patient care needs&
Know about options for organ or tissue donation, when relevant&
Receive timely pain assessment and management&
Be free from restraint or seclusion unless medically necessary
&Research: All patients have the right to:&
Receive information about&medical treatment, which&may be used for purposes of research&
Give consent prior to participation in research&
Refuse to participate in research, with the assurance that care will not be adversely affected by such a refusal
&Payment for Services: All patients have the right to:&
Be informed of the hospitals’ policies regarding payment, and to request, prior to treatment, an estimate of charges for medical care, if applicable&
Receive detailed explanation of their bill in a form that can be understood
&Privacy and Confidentiality: All patients have the right to:&
Have physical privacy during medical examination and treatment&
Refuse to talk with or see anyone not related to his or her care including visitors or persons connected with the hospital but not directly involved in their care&
Have a person of one’s own gender present during certain parts of the physical examination, treatment or procedure&
Have their medical record read only by individuals directly involved in their care or as authorized&
Have all records pertaining to a patient’s medical care treated as confidential&
Have a family member or a family physician to be notified of his/her emergency admission to the hospital&
Amend their medical records or health information, as per healthcare services policies&
Select a family member or legal representative to be present during presentation of medical information
&Access to Information and Communication: All patients have the right to:&
Be informed of the patient and family rights at the earliest possible moment in the course of his/her hospitalization or at time of Outpatient Department admission&
Know the name and specialty status of those caregivers directly providing care and/or service&
Have, upon request, access to additional information about the healthcare practitioner responsible for the care&
Have, upon request, access to all information contained in their medical records, unless access is specifically restricted by the attending physician and in consult with family representative, legal or surrogate guardian for medical reasons or is prohibited by law&
Receive information along with a family member or a surrogate decision maker if preferred by him/her about medical conditions, any confirmed diagnosis, planned care and treatments, process used to give consent if needed and their rights to participate in care decisions in a professional manner and in an understandable language by the concerned healthcare provider in a timely manner
&Safety and Security: All patients have the right to:&
Receive care in a safe, secure and non-threatening environment&
Receive considerate and respectful care in a smoke-free environment
&Quality of Service: All patients have the right to:&
Express a concern or a complaint regarding the quality of care, and/or service received&
Be informed of the hospitals’ mechanism for initiation, review and resolution of a complaint
Patient and Family Responsibilities: In order to receive the best possible care, the patient, the patient’s surrogate or legal guardian or family representative are required to:
Provide, to the best of their knowledge, accurate and complete information about the patient’s condition, medical history including medications, and other matters relating to the patient’s health&
Report unexpected changes in the patient’s condition to the responsible healthcare provider&
Respect and follow healthcare services rules and regulations&
Respect restricted areas&
Follow the treatment plan recommended by the caregiver responsible for the patient’s care including the instruction of nurse or other caregivers&
Assume responsibility for his/her decision and its consequences should treatment be refused or not followed per the caregiver’s plan of care&
Ensure that the financial obligations are fulfilled as promptly as possible&
Respect other patient’s rights&
Refrain from smoking, control noise and limit the number of visitors, according to healthcare services rules and regulations&
Respect the property of healthcare services and of other persons&
Keep follow-up appointments, and when unable to do so for any reason, call to cancel the appointment&
Ask questions if information provided is not understood&
Safeguard personal belongings by identifying valuables to healthcare services personnel&
Do not share medications with others&
Leave the hospital when officially discharged&
Respect the rights of healthcare services personnel, and treat them with due courtesy and respect&
Special topics in PFR: This is chapter, there are three major topics discussed separately about patient and their family rights.
General Consent
Informed Consent
Organ Donation
General Consent: In this topic, there are only one standard and three measurable elements (MEs) and the standard is:
Standard PFR.5: General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the first time as an outpatient, is clear in its scope and limits.
Many hospitals obtain a general consent (rather than rely on implied consent) for treatment when the patient is admitted as an inpatient to the hospital or when the patient is registered for the first time as an outpatient. When a general consent is obtained, patients are given information on the scope of the general consent, such as which tests and treatments are included under the general consent. Patients are also given information about those tests and treatments for which a separate informed consent will be obtained. The general consent notes if it is likely that students and trainees will participate in care processes. The hospital defines how a general consent is documented in the patient’s record. So, there are three major issues need to address:
Patients and families are informed as to the scope of a general consent, when used by the hospital.
The hospital has defined how a general consent, when used, is documented in the patient record.
Patients and families are informed about which tests and treatments require informed consent
Informed Consent: This part contains 4 standards and 17 measurable elements (MEs) and the standards are-
Standard PFR.5.1: Patient informed consent is obtained through a process defined by the hospital and carried out by trained staff in a manner and language the patient can understand.
Standard PFR.5.2: Informed consent is obtained before surgery, anesthesia, procedural sedation, use of blood and blood products, and other high-risk treatments and procedures.
Standard PFR.5.3: Patients and families receive adequate information about the illness, proposed treatment(s), and health care practitioners so that they can make care decisions.
Standard PFR.5.4: The hospital establishes a process, within the context of existing law and culture, for when others can grant consent.
One of the main ways that patients are involved in their care decisions is by granting informed consent. To consent, a patient must be informed of those factors related to the planned care required for an informed decision. Informed consent may be obtained at several points in the care process. For example, informed consent can be obtained when the patient is admitted for inpatient care in the hospital and before certain procedures or treatments for which the risk is high. The consent process is clearly defined by the hospital in policies and procedures. Relevant laws and regulations are incorporated into the policies and procedures. Patients and families are informed as to which tests, procedures, and treatments require consent and how they can give consent (for example, given verbally, by signing a consent form, or through some other means). Education by hospital staff is provided to patients and families as part of the process of obtaining informed consent for treatment (for example, for surgery and anesthesia). Patients and families understand who may, in addition to the patient, give consent. Designated staff members are trained to inform patients and to obtain and to document patient consent. When the planned care includes surgical or invasive procedures, anesthesia, procedural sedation, use of blood and blood products, or other high-risk treatments or procedures, a separate consent is obtained. This consent process provides the information identified and documents the identity of the individual providing the information. Not all treatments and procedures require a specific, separate consent. Each hospital identifies those high-risk, problem-prone, or other procedures and treatments for which consent must be obtained. The hospital lists these procedures and treatments and educates staff to ensure that the process to obtain consent is consistent. The list is developed collaboratively by those physicians and others who provide the treatments or perform the procedures. The list includes procedures and treatments provided on an outpatient basis and inpatient basis. Besides, Staff members clearly explain any proposed treatment(s) or procedures to the patient and the family. The information provided includes
the patient’
the proposed treatment(s);
the name of the person pro
potential be
possible problems and
possible results of non-treatment.
Staff members also inform the patient of the name of the physician or other practitioner who has primary responsibility for the patient’s care or who is authorized to perform procedures or treatment(s). Frequently, patients have questions about their primary care practitioners’ experience, length of time with the hospital, and the like. The hospital needs to have a process to respond when patients request additional information about their primary care practitioners. Informed consent for care sometimes requires that people other than (or in addition to) the patient be involved in decisions about the patient’s care. This is particularly true when the patient does not have the mental or physical capacity to make care decisions, when culture or custom requires that others make care decisions, or when the patient is a child. When the patient cannot make decisions about his or her care, a surrogate decision maker is identified. When someone other than the patient gives consent, that individual is noted in the patient’s record.
Organ Donation: The following two standards are intended to be used in situations in which organ or tissue transplantation will not occur but during those times when patients request information about organ and tissue donation and/or when organ or tissue donation may occur. When organ or tissue donation and transplantation are performed, the standards for organ and tissue transplant programs are found in ‘Care of Patient (COP)’ chapter between standards COP.8 and COP.9.3.
Standard PFR.6: The hospital informs patients and families about how to choose to donate organs and other tissues.
Standard PFR.6.1: The hospital provides oversight for the process of organ and tissue procurement
The hospital is responsible for defining the process of obtaining and recording consent for cell, tissue, and organ donation in relation to international ethical standards and the manner in which organ procurement is organized in their country. The hospital has a responsibility to ensure that adequate controls are in place to prevent patients from feeling pressured to donate. The hospital supports the choice of patients and families to donate organs and other tissues for research or transplantation. Information is provided to patients and families on the donation process and the manner in which organ procurement is organized for the community, region, or nation (such as a national or regional organ procurement agency or network). The shortage of organs for transplant has resulted in questionable practices in the procurement and transplantation of organs. The practice of inducing vulnerable individuals or groups (such as illiterate and impoverished persons, undocumented immigrants, prisoners, and political or economic refugees) to become living donors, organ trafficking (the buying and selling of organs over black market trade), the harvesting of organs without consent from executed prisoners or dead patients, and transplant tourism are inconsistent with ensuring organ donor and recipient safety. Oversight for the process of organ and tissue procurement includes defining the donation process that is consistent with laws and regulations, respecting the community’s religious and cultural values, ensuring ethical practices, and identifying requirements for consent. Hospital staffs are trained on the donation process that supports patient and family choices. Staff are also trained in the contemporary concerns and issues related to organ donation and availability of transplants. The hospital cooperates with other hospitals and agencies in the community responsible for all or a portion of the procurement, banking, transportation, or transplantation process.
Overall Required Written Policies (Including Those Required in English) in PFR: The standards listed in the tables identify a requirement for a written document for PFR. In some cases, that document is in the form of a policy and procedure. In other cases, the document is less formal but addresses the issue identified in the standard. In many cases, a number of standards requirements or MEs can be combined into one policy and procedure. Hospitals may find it useful to group all related policies and procedures. The surveyor(s) may not need to review all these documents in detail. However, to facilitate the review, it is best to gather all of the documents into one book or identify each document by the corresponding standard number(s) if they are part of a larger document. Some of these documents need to be provided to JCI surveyors in English, and these documents are indicated in the “In English?” column in the tables. Other documents do not need to be translated. For non-English documents, the survey team will have one member able to read the documents, or alternatively, the survey team may request that one or more individuals be available to describe the contents of the document and answer questions concerning the document. In PFR, there are required of 11 documents to support the meet of the measurable elements (MEs).
Closed Patient Medical Record Review on PFR: This session is held to validate the hospital’s compliance with the documentation track record started with 4 months for initial surveys and 12 months for triennial surveys.
The survey team leader may request 5 to 10 closed records for review. The records will be requested if the surveyor(s) wants to validate the hospital’s documentation track record (4-month or 12-month) and/or to ensure compliance with documentation or patient care process requirements due to situations or information identified during the tracer activities.
The survey team will also indicate the time period for selecting the records, typically the past 4 or 12 months. Hospital staff should acquaint the survey team with the hospital’s practice and expectation regarding the completion of a patient record following discharge of the patient.
For the Closed Patient Medical Record Review, hospital leaders should provide one staff member with a translator (if needed) for each surveyor involved in the Closed Patient Medical Record Review. To assist the surveyor(s), the selected staff person(s) should be knowledgeable about the medical record and the clinical care processes. Academic medical center hospitals are encouraged to include residents and fellows in the record review.
The surveyor(s) will review the selected records with the assistance of the hospital representative, as needed, to complete the form. One column of the form is completed for each record reviewed. If more than five records are reviewed, the surveyor(s) will use another form.
For each documentation requirement, the surveyor(s) will check “Y” (yes) on the form to indicate that the required element is present, “N” (no) if the element is not present, or “NA” if the element is not applicable to that patient’s record.
The survey team aggregates the completed review forms to score the standards. The findings from the active or open review of patient records are integrated into aggregation and scoring.
For PFR, the required 6 forms listed in the table will be checked by surveyor to validate PFR standards.
The survey team leader retains the forms to support the survey findings.
Not only, JCI even World Health Organization (WHO) identifies the patient right as a set of rights which individuals own in the health care system and health care providers are obliged to follow them. In addition, WHO highlights the basic fact that collaboration of patients, physicians and nurses is required to provide appropriate conditions in order to protect patients’ rights. Patients’ right includes all the duties and responsibilities that a therapeutic center has against the patients. In other words patients’ rights are their legitimate and rational physical, spiritual, emotional and social needs that are proposed as standards and rules and the health care team are required to implement them. In recent decades, along with the outstanding progress in science particularly medicine and development of up to date therapeutic methods as well as technological improvements in medical fields, there have been great developments in medical interventions which has led to many ethical challenges. Involvement of patients in decision making and supporting their rights causes improvement in treatment process, decreased hospitalization period and treatment costs and it can prevent the potential irreversible physical and psychological injuries. Adherence to patients’ rights is the single most important ethical feature of a hospital that requires serious consideration in order to establish a peaceful environment for better recovery of the hospitalized patients. Patients must be informed about all stages of treatment and their rights and responsibilities in each of them. Patients’ right is a fundamental indicator in defining the standards for applying clinical governance services. Hospitals must be a place for understanding and respecting the patients’, their families as well as the physicians’ and other health care workers’ rights. All health care centers must be aware of the ethical aspects of golden rules and respect them. Highest levels of care can only be achieved through appropriate interaction between health care providers and health care receivers with understanding of their responsibilities and respecting each other’s rights.
Finally, always stick to the 'Golden Rule' and think&“How would I like to be treated in this situation?”Looking for more of the latest headlines on LinkedIn?