Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool. Joint Commission Standards will be updated monthly online and appear regularly in print. Go to www.advanceweb.com/nurses; under Resources on the left navigation bar, click on Joint Commission.

The Ethics, Rights and Responsibilities (RI) chapter focuses on improving patient care, treatment, services and outcomes by identifying and valuing the rights of each individual patient and by maintaining ethical business practices. It is divided into three sections:

1. "Organizational Ethics" addressing hospital business practices

2. "Individual Rights" addressing patient rights

3. "Individual Responsibilities" addressing patient and family responsibility

This review focuses on the problematic standards related to Individual Rights. Problematic Standards are paraphrased and the challenging Elements of Performance (EP) are identified. Federal and state privacy and confidentiality regulations impact family involvement in these standards.

Avoiding Common Pitfalls

RI.2.10 The hospital respects the rights of patients.

EP 2 addresses patients' right to have cultural, psychological, spiritual and personal values, beliefs and preferences respected. This standard is protected by the U.S. Constitution as well as the Joint Commission and is part of not only nursing practice, but nursing tradition. It becomes problematic when:

·  Patients are unable to communicate their beliefs, values or preferences at time of admission and follow-up does not occur when patients are capable or a family member is available to identify them.

·  The patient's initial assessment identifies needs based on beliefs, values or preferences, but these are not incorporated in the individual plan of care and interventions to meet these needs are not documented.

RI.2.30 Patients are involved in decisions for their care.

RI.2.40 Informed consent is obtained.

EP 1 addresses patient involvement in care and treatment decisions. Patient interview and medical record documentation must reflect involvement. Daily discussion and reinforcement of care and treatment plans keep patients informed and allow for an opportunity for involvement; updating the plan of care (especially when conditions or treatments change), evidence of informed consent and documenting daily patient/nurse communication satisfy the documentation of that involvement.

RI.2.80 The hospital addresses the wishes of the patient related to end-of-life decisions.

All EPs address policies and practices related to advance directives and the withdrawing or foregoing of life-sustaining treatment and withholding resuscitative services. Most common compliance issues revolve around follow-up. When documentation during access or admission states:

·  the patient requests information related to advance directives, subsequent documentation and patient interview must reflect the patient received the information.

·  the patient has previously generated an advance directive but does not have it with him, a copy of the advance directive must be obtained and placed on the chart.

In the interim, the patient's wishes are made known by a brief description of the content in the medical record.

RI.2.100 The patient's right to and need for effective communication is met.

EP 3 requires that the hospital provide or assist the patient in the provision of interpretation (including translation) services as necessary. The information standard (IM.6.20) requires the medical record contain the patient's language and communication needs. Two points to remember:

·  Language and other communication needs identified on admission assessment must be followed up in the plan of care, problem list and interventions noted.

·  The use of interpreters follows hospital policy based on reliability of accurate translation of information and confidentiality.

RI.2.300 The patient's need related to privacy, confidentiality and security are met.

EP 1 addresses the confidentiality of patient information.

·  Telephone conversations, computer screens, documents with patient information discarded in the trash and elevator consultations are just a few areas of potential breech of confidentiality.

EP 2 addresses patient privacy.

·  Knocking on a door and announcing your presence prior to going behind that closed curtain are the easy answers. However, this must be done in all patient situations, including outpatient treatment areas, procedure areas and specialty units. Protection of patient privacy can be more challenging when constant observation is needed such as in psychiatry.

EP.4 provides for safety and security of patients.

·  Strict adherence to hospital policy for ID badges increases patient safety.

RI. 2.160 Patients have the right to pain management.

EP 1 speaks to resources available for staff and patient education related to pain management.

·  Staff competency in pain management is a topic for discussion.

·  Patient education always includes reporting of pain and pain management when appropriate.

Jean Kalemba, a consultant, was previously director of performance improvement at Mountainside Hospital, Montclair, NJ.