Joint Commission Standards on
Patient Rights and
Kathy Howard
March 23, 2011
Chapter Overview
Identification of basic, overarching patient rights
The right to effective communication
The right to participate in care decisions
The right to informed consent
The right to know care providers
The right to participate in end-of-life decisions
Individual rights of patients
Patient responsibilities
• Patient Rights Resources
• MAH Hot Topics
– Visitation/Support Person
– Pt Information Understandable
– Pt/Provider Partnership
– Consent for Filming/Recording
– Name/role of providers given to pt
– Advance Directives
– Protection from Abuse and Neglect
– Complaints/Grievances
Patient Rights Resources
• Brochure of Rights and Responsibilities
– On web
– Posted in ED, Admitting and Outpt Areas
– Available in holders throughout DOB/hospital
– Admission Packet
• Policy on portal (hospital and W2)
• Specific policies on portal
MAH Hot Topics
1. Visitation/support individual (CMS update)
– policy updated to reflect obligation to respect pt
• No limits based on age, race, ethnicity, religion, culture,
language, physical or mental disability, socioeconomic status,
sex, sexual orientation and gender identity or expression
unless it poses a risk/infringement to another’s rights
2. Information understood by patient
– All communication tailored to pt’s age, language,
cognitive ability and special needs (vision, speech,
other impairments)
MAH Hot Topics (cont’d)
3. Patient/provider partnership
– Respect
pt right to accept/refuse care
– Med/Surg Consent; End of Life Care; Code Status
surrogate decision maker’s responsibility for
making decision on behalf of patient
– Healthcare Proxy
– Durable Power of Attorney for Healthcare
– Guardian
– Right to be informed (consent, disclosure,
MAH Hot Topics (cont’d)
4. Consent for Filming/Recording
– Consent prior to any recorded medium except
if used in the course of care
MAH Hot Topics (cont’d)
5. Patient is kept informed about who is
providing and responsible for his/her
Provider introduces self and relationship to pt
6. Advanced Directives
If on file, must be avail on current chart
Working on process improvement
7. Protection from Abuse/Neglect
Policies/resources (community/internal)
MAH Hot Topics (cont’d)
8. Complaints/Grievances
– Resolution Process (turnaround expectations)
– x 5100
– Deescalate when it happens: anticipate and
– Pt/Family right to express grievance/compliant
without fear of reprisal

Joint Commission Standards on Patient Rights and