Center for Improvement in Healthcare Quality Newsletter
October 2021

News You Can Use

October Compliance Tip of the Month

October’s tip of the month is focused on the standard/requirements regarding Patient Rights. Specifically, the right of a patient to have a family member or representative and/or their own personal physician notified of hospitalization even when the admission is elective.
The most common finding cited in hospital’s is the lack of documentation in the patients’ medical record that 1) They were informed of the right and/or 2) That their wishes were documented and acted upon. In order to demonstrate compliance with the regulations both items must be provided and documented. The organization is free to define the process and mechanism as it deems appropriate however a process/policy must be adhered to. Both the CMS and CIHQ standards/requirements have been included for reference.

CIHQ

PR-3: Notification of Hospitalization
The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
  1. For every inpatient admission, the organization must ask the patient whether the hospital should notify a family member or representative about the admission. If the patient requests such notice and identifies the family member or representative to be notified, the organization must provide such notice promptly to the designated individual. Notice and the patient’s response thereto shall be documented in the patient’s medical record.
    • When a patient is incapacitated or otherwise unable to communicate the organization must make reasonable efforts to identify and promptly notify a family member or patient’s representative.
    • The organization must document that the patient, unless incapacitated, was asked no later than the time of admission whether he or she wanted a family member/representative notified, the date, time and method of notification when the patient requested such, or whether the patient declined to have notice provided. If the patient was incapacitated at the time of admission, the medical record must indicate what steps were taken to identify and provide notice to a family member/representative.
  2. For every inpatient admission, the organization must ask the patient whether the hospital should notify his/her own physician. If the patient requests notice to and identifies the physician, the organization must provide such notice promptly to the designated physician, regardless of whether the admission was scheduled in advance or emergent. Notice and the patient’s response thereto shall be documented in the patient’s medical record.

CMS

§482.13 Condition of Participation: Patient's Rights
A hospital must protect and promote each patient’s rights.
§482.13(b) Standard: Exercise of Rights
§482.13(b)(4) - The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
Interpretive Guidelines §482.13(b)(4)

Identifying Who Is to Be Notified

For every inpatient admission, the hospital must ask the patient whether the hospital should notify a family member or representative about the admission. If the patient requests such notice and identifies the family member or representative to be notified, the hospital must provide such notice promptly to the designated individual. The explicit designation of a family member or representative by the patient takes precedence over any non-designated relationship.
The hospital must also ask the patient whether the hospital should notify his/her own physician. In the case of scheduled admissions, the patient’s own physician likely is already aware of the admission. However, if the patient requests notice to and identifies the physician, the hospital must provide such notice promptly to the designated physician, regardless of whether the admission was scheduled in advance or emergent.
When a patient is incapacitated or otherwise unable to communicate and to identify a family member or representative to be notified, the hospital must make reasonable efforts to identify and promptly notify a family member or patient’s representative. If an individual who has accompanied the patient to the hospital, or who comes to or contacts the hospital after the patient has been admitted, asserts that he or she is the patient’s spouse, domestic partner (whether or not formally established and including a same-sex domestic partner), parent (including someone who has stood in loco parentis for the patient who is a minor child), or other family member, the hospital is expected to accept this assertion, without demanding supporting documentation, and provide this individual information about the patient’s admission, unless:
  • More than one individual claims to be the patient’s family member or representative. In such cases it would not be inappropriate for the hospital to ask each individual for documentation supporting his/her claim to be the patient’s family member or representative. The hospital should make its determination of who is the patient’s representative based upon the hospital’s determination of who the patient would most want to make decisions on his/her behalf. Examples of documentation a hospital might consider could include, but are not limited to, the following: proof of a legally recognized marriage, domestic partnership, or civil union; proof of a joint household; proof of shared or co-mingled finances; and any other documentation the hospital considers evidence of a special relationship that indicates familiarity with the patient’s preferences concerning medical treatment;
  • Treating the individual as the patient’s family member or representative without requesting supporting documentation would result in the hospital violating State law. State laws, including State regulations, may specify a procedure for determining who may be considered to be the incapacitated patient’s family member or representative, and may specify when documentation is or is not required; or
  • The hospital has reasonable cause to believe that the individual is falsely claiming to be the patient’s spouse, domestic partner, parent or other family member.
Hospitals are expected to adopt policies and procedures that facilitate expeditious and non-discriminatory resolution of disputes about whether an individual should be notified as the patient’s family member or representative, given the critical role of the representative in exercising the patient’s rights. Hospitals may also choose to provide notice to more than one family member.
When a patient is incapacitated and the hospital is able through reasonable efforts to identify the patient’s own physician – e.g., through information obtained from a family member, or from review of prior admissions or outpatient encounters, or through access to the patient’s records in a regional system of electronic patient medical records in which the hospital participates – the hospital must promptly notify the patient’s physician of the admission.

Prompt Notice

The hospital must provide the required notice promptly. “Promptly” means as soon as possible after the physician’s or other qualified practitioner’s order to admit the patient has been given. Notice may be given orally in person, by telephone, by e-mail or other electronic means, or by other methods that achieve prompt notification. It is not acceptable for the hospital to send a letter by regular mail.

Medical Record Documentation

The hospital must document that the patient, unless incapacitated, was asked no later than the time of admission whether he or she wanted a family member/representative notified, the date, time and method of notification when the patient requested such, or whether the patient declined to have notice provided. If the patient was incapacitated at the time of admission, the medical record must indicate what steps were taken to identify and provide notice to a family member/representative and to the patient’s physician.
It is recommended that the organization have a policy that includes the process used to provide patient with their rights as well as a procedure to be used to assure that the documentation in the medical record reflects the provision and action needed to demonstrate compliance.
ARS resources to assist with compliance:
Resource Library – Patient Rights / Restraint & Seclusion
  • 2103 Policy – Patient Rights & Responsibilities
  • 3015 Policy – Patients Right to Notify Others of an Inpatient Admission
  • 1000 Form – Patient Notification of Admission Acknowledgement Form
  • 2112 Tool – Patient Rights & Responsibilities Information Pamphlet
Survey Preparation Library – Medical Record Audit Tools
  • 1048 Tool – Medical Record Audit for Patient Rights
Staff Training:
  • Basic patient Rights – Rev 2.20

September a Month of Reflection

September 11, 2021 marked the 20th anniversary since that bright, sunny Tuesday turned our world upside down. CIHQ remembers and mourns for all the lives lost that day.

Quarter 3 Survey Satisfaction Results

CIHQ wants to extend appreciated to the accredited hospitals that provided feedback via our new satisfaction survey process following an accreditation survey. The main contact/survey coordinators are sent a link to complete a short satisfaction survey following an initial or reaccreditation survey. Be on the lookout for your opportunity to provide us vital feedback in order to assist us in improving you survey experience!
Below are the results of the surveys for Quarter 3 2021: