NABH – Chapter 4

PATIENT RIGHTS & EDUCATION (PRE)

Dr Chethana Hosur
M Phil-HHSM, BITS- Pilani, PGD-Medical Laws and Ethics
Consultant- Healthcare Operations, Quality and Audits
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 PRE- Standards-8, OE-53
PATIENTS RIGHTS & EDUCATION
Protection of Rights & Information about
responsibility of care

Supporting individual beliefs & values

Educating patient/ family members to make

informed decisions

Informed Consent
Right to information & education about
healthcare needs
Right to information on expected costs

Complaint Redressal process

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 SUMMARY - PRE
✓The organisation defines, protects and promotes the patient and family's rights and
responsibilities. The staff is aware of these rights and is trained to protect them.
Patients are informed of their rights and educated about their responsibilities at the
time of entering the organisation.

✓The expected costs of treatment and care are explained clearly to the patient
and/or family.

✓Patients are educated about the mechanisms available for addressing grievances.

✓Informed consent is obtained from the patient or family for specified

procedures/care. The key components of information shall include risks, benefits
and alternatives.

✓Patients and families have a right to get information and education about their
healthcare needs in a language and manner that is understood by them.

✓The organisation develops effective patient-centred communication.

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 Key Policies Required
S. No. Name of Policy
1 Patient & Family Education
2 Patients & Family Rights & Responsibilities
3 Patient Confidentiality & Privacy
4 Patient Information - Feedback from Patients
5 Informed Consent
6 Handling Dissatisfied Patients
7 Complaint Management Policy
8 Patients as partners in care
9 Voicing a Complaint

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 Key Departments/ Personnel involved
Departments:
• Top Leadership
• Front office
• All Clinical departments Staff:
• All Administrators
• All Doctors and nurses
working in ICU’s and patient
care areas.

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 Key Forms/ Formats Required
S. No. Forms

1. Patient Feedback form S. No. Brochures/ Displays

1. Patients Rights & Responsibilities
2. Complaint/ Grievance Redressal
Form 2. Grievance Redressal mechanism
3. Informed Consent Forms- not 3. Patient education booklets/
blanket videos/ leaflets on specific
a. Transfusion of Blood & Blood (common) disease process,
products complications and prevention
b. Anesthesia strategies.

c. Surgery – Generic & Procedure

specific
S. No. Manual
d. Initiation of Research Protocol
1 PRE Manual
e. Other invasive/ high risk
procedures/ treatment
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PRE.1 The organization protects and promotes
patient and family rights and informs them about
their responsibilities during care.
 PRE.1 The organization protects and promotes patient and family
rights and informs them about their responsibilities during care.

Commitment a. Patient and family rights and responsibilities are documented,

displayed and they are made aware of the same. *

Achievement b.Patient and family rights and responsibilities are actively

promoted. *

CORE c.The organisation protects patient and family rights.

CORE d.The organisation has a mechanism to report a violation of

patient and family rights.

CORE e.Violation of patient and family rights are monitored,

analysed, and corrective/preventive action taken by the top
leadership of the organisation.

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• Patient rights and responsibilities are documented and displayed : Display
of patients rights and responsibilities at key areas of hospital like OPD, Wards,
Patient waiting areas, Billing etc.
• Patient and families are informed of their rights and responsibilities in a
format and language that they can understand : Patient/family members
should be explained and educated about their Rights & Responsibilities at the time
of admission by the billing staff.
• Staff are aware of their responsibility in protecting patient and family
rights : All hospital staff including nurses, doctors , paramedics, GRE, contract
workers, ambulance driver, administrative staff should be trained on Patients Rights
& Education
• Violation of patient and family rights is recorded , reviewed and
corrective/preventive measures taken
 PRE.2. Patient and family rights
support individual beliefs, values
and involve the patient and family
in decision-making processes.

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 PRE.2. Patient and family rights support individual beliefs,
values and involve the patient and family in decision-making
processes.
Commitment a. Patients and family rights include respecting values and beliefs,
any special preferences, cultural needs, and responding to requests
for spiritual needs.

Commitment b. Patient and family rights include respect for personal dignity and
privacy during examination, procedures and treatment.

Commitment c. Patient and family rights include protection from neglect or abuse.

CORE d. Patient and family rights include treating patient information as

confidential.

Commitment e. Patient and family rights include the refusal of treatment.

Commitment f. Patient and family rights include a right to seek an additional

opinion regarding clinical care.

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 Cont…
CORE g. Patient and family rights include informed consent before the
transfusion of blood and blood components, anaesthesia, surgery,
initiation of any research protocol and any other invasive/high-risk
procedures/treatment.

Commitment h. Patient and family rights include a right to complain and

information on how to voice a complaint.

Achievement i. Patient and family rights include information on the expected cost
of the treatment.

Commitment j. Patient and family rights include access to their clinical records.

Commitment k. Patient and family rights include information on the name of the
treating doctor, care plan, progress and information on their health
care needs.

Commitment l. Patient rights include determining what information regarding their

care would be provided to self and family.

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 PATIENT'S RIGHTS

• To be respected for personal dignity and privacy

during examination, procedure & treatment
• Protection from physical abuse and neglect
• To have confidentiality of information
• Obtaining informed consent before carrying out
procedure
• Right to Information on how to Voice a complaint
• Right to information on the expected cost of
treatment
• Right to have access to his/her clinical records
• Right to access medical care facility regardless of
caste, religion, nationality or disability

• Right to refusal to treatment

• Involvement in decision making
 PATIENT'S RESPONSIBILITIES

• To provide correct and detailed history of health

problem to the doctor
• To follow the treatment planned established by the
consultant doctor, nurse and the health care
professional
• To be aware that they are solely responsible for the
consequences in case of discontinuation of treatment
prescribed by the care provider during the hospital
stay
• To understant that in case they leave against medical
advice it will be at their own risk
• To pay all the hospital bills in timely manner
• To co-opertae with the staff for maintaining the
cleanliness and administrative procedures of the
hospital
• To be responsible for the belongings they carry in the
hospital
• To follow the hospital rules and regulations
PRE.3.The patient and/or family members are
educated to make informed decisions and are
involved in the care planning and delivery
process.

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PRE.3.The patient and/or family members are educated to make informed
decisions and are involved in the care planning and delivery process.
CORE a. The Patient and/or family members are explained about the
proposed care, including the risks, alternatives and benefits.

Commitment b. The patient and/or family members are explained about the
expected results.

Commitment c. The patient and/or family members are explained about the
possible complications.

Achievement d. The care plan is prepared and modified in consultation with the
patient and/or family members.

Commitment e. The patient and/or family members are informed about the
results of diagnostic tests and the diagnosis.

Commitment f. The patient and/or family members are explained about any
change in the patient's condition in a timely manner.

Achievement g. The patient and/or family members are provided multi-

disciplinary counselling when appropriate.
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 A DOCUMENTED PROCEDURE FOR OBTAINING PATIENT AND/OR
FAMILY'S CONSENT EXIST FOR INFORMED DECISION MAKING ABOUT
THEIR CARE
• General Consent : General Consent for treatment Is obtained when the patient enters the
organisation.
PRE.4. Informed consent is obtained
from the patient or family about their
care.

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 PRE.4. Informed consent is obtained from the patient or family
about their care.

CORE a. The organisation obtains informed consent from the patient or

family for situations where informed consent is required. *

Commitment b.Informed consent process adheres to statutory norms.

CORE c. Informed consent includes information regarding the

procedure; it's risks, benefits, alternatives and as to who will
perform the procedure in a language that they can understand.

Commitment d.The organisation describes who can give consent when a

patient is incapable of independent decision making and
implements the same. *

CORE e.Informed consent is taken by the person performing the

procedure.

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• Informed Consent : Informed consent includes information regarding the procedure,
it's risk, benifis, alternative and who will perform the procedure in a language that they
can understand.

Informed consent from the patient / family is required whenever patient is undergoing
any of the following procedures

Any surgical procedure NICU Consent Form

Consent form for Procedure and Treatment MICU Consent form
Consent for High risk Consent for Formula Feed
Consent for Anaesthesia MTP Consent
Consent for Blood transfusion Consent-Epidural pain relief labor
HIV Consent Various IVF Consents
Consent for DAMA Restraint Consent
Transfusion of blood or any other blood
Consent for transporting the patient by Ambulance
product
Consent form for Elective Induction of Labor
 INFORMED CONSENT
✓
✓ CONSENT-CONSENSUS OF MIND
✓ Express consent –written in distinct and explicit language-should contain
✓ The nature of the treatment or procedure that will be performed.
✓ Any alternatives to the treatment or procedure if applicable.
✓ The risks involved in the proposed and alternative procedures
✓ The risk/prognosis if the procedure is not carried out.
✓ The relative chances of success or failure of both procedures so that pt has
option to accept or reject treatment

✓ If the doctor proceeds with treatment in absence of consent, patient can sue
✓ For negligence – in failure to obtain consent.
✓ For battery and assault.
 CONSENT
IMPLIED CONSENT
✓ OPD Consultation (restricted to IPPA)
✓ Unconscious patient unable to consent and no family members.
✓ In all emergencies, law implies consent.

VALID CONSENT-Cornerstone of protecting against litigation

✓ Major- 18yrs
✓ Free from fear, fraud, misrepresentation of facts
✓ Not a mechanical act, ritualistic but by application of mind
✓ Blanket consents with clause/ disclaimer non liability- invalid
✓ Procedure specific consents
✓ No more a mere medical record but legal document

INFORMED REFUSAL
PRE.5. Patient and families have a right to
information and education about their
healthcare needs.

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 PRE.5. Patient and families have a right to information and
education about their healthcare needs.

CORE a. Patient and/or family are educated in a language and format

that they can understand.

Commitment b.Patient and/or family are educated about the safe and effective
use of medication and the potential side effects of the medication,
when appropriate.

Commitment c.Patient and/or family are educated about food-drug interaction

Commitment d.Patient and/or family are educated about diet and nutrition.

Commitment e.Patient and/or family are educated about immunisations.

Cont….
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 Cont….

Commitment f.Patient and/or family are educated on various pain management

techniques, when appropriate.

Commitment g. Patient and/or family are educated about their specific disease
process, complications and prevention strategies.

Commitment h. Patient and/or family are educated about preventing healthcare

associated infections.

Achievement i.The patients and/or family members' special educational needs

are identified and addressed.

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 PATIENT AND FAMILIES HAVE A RIGHT TO INFORMATION AND
EDUCATION ABOUT THEIR HEALTH CARE NEEDS

• Patient and family are educated about

the safe and effective use of medication
and the potential side effects of
medication
• Education about their diet and nutrition
• Education about immunization
• Education about their specific disease
process, complication and prevention
strategies
• Education about preventing healthcare
associated infections
 PRE.6. Patients and families have a right to
information on expected costs.

$899 $1,900 $3,900

month month month
 PRE.6. Patients and families have a right to information on
expected costs.

CORE a.The patient and/or family members are made aware of the
pricing policy in different settings (out-patient, emergency, ICU
and inpatient).

Commitment b.The relevant tariff list is available to patients.

Commitment c.The patient and/or family members are explained about the
expected costs.

Commitment d.Patient and/or family are informed about the financial

implications when there is a change in the care plan.

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 PATIENT AND FAMILIES HAVE A RIGHT TO INFROMATION ON
EXPECTED COSTS

• Uniform Billing policy which defines

the charges for various activities
including OPD & IPD
• An updated tarriff list shall be made
available to patient whenever required
• A written estimate of the expenses of
the treatment shall be given to the
patient
• In case there is any change in patient
condition, the financial implications
shall be informed to the patient .
PRE.7.The organisation has a mechanism to capture
patient's feedback and to redress complaints.
 PRE.7.The organisation has a mechanism to capture patient's
feedback and to redress complaints.

Commitment a. The organisation has a mechanism to capture feedback from

patients, which includes patient satisfaction.

Achievement b.The organisation has a mechanism to capture patient experience.

CORE c.The organisation redress patient complaints as per the defined

mechanism. *

Commitment d. Patient and/or family members are made aware of the procedure
for giving feedback and/or lodging complaints.

Commitment e. Feedback and complaints are reviewed and/or analysed within a

defined time frame.

Commitment f. Corrective and/or preventive action(s) are taken based on the

analysis where appropriate.

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THE ORGANISATION HAS A MECHANISM TO CAPTURE PATIENT FEEDBACK
AND REDRESSAL OF COMPLAINT
• Along with collecting patient feedback the organization shall also capture
patient experience - Patient experience is collected in APP under below
parameters
1. Administrative & Discharge Services
2. Consultant Services
3. Medical & Nursing services
4. Food (Dietry Services)
5. Hospital Environment
6. Diagnostic & Ancillary services

• Suggestion Box : Available in OPD & Wards

• Google review
 PRE.8.The
organization has a
system for effective
communication
with patients and/or
families.

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PRE.8.The organization has a system for effective communication
with patients and/or families.

Commitment a.Communication with the patients and/or families is done

effectively. *

Commitment b.The organisation shall identify special situations where

enhanced communication with patients and/or families would be
required. *

Commitment c.Enhanced communication with the patients and/or families is

done effectively. *

Commitment d.The organisation ensures that there is no unacceptable

communication.

Achievement e.The organisation has a system to monitor and review the

implementation of effective communication.

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IMPLEMENTATION ISSUES

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 Implementation Issues
1. Complaint management process
• Receiving the complaint, tracking and investigating it, carrying out the audit
and resolving it.
• Formation of a Risk Assessment Committee
• Adherence to timelines in resolving the issue

2. Maintaining patient confidentiality and privacy

• Disclosure of information without patients consent – exceptional
circumstances like medical emergencies, information needed by “third
parties”
• Disclosure of information with the patients consent

3. Collecting accurate feedback from patients

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 Implementation Issues
4. Informed Consent:
• Obtaining Consent
• Complete Consent Form

5. Handling dissatisfied patients:

• Compassion
• Acknowledge
• Respond to the problem
• Evaluate

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QUALITY INDICATORS

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 QUALITY INDICATORS
A standard patient
satisfaction feedback
Average rating given by patient of form can be used for
Out patient satisfaction index OPD to the hospital obtaining rating from
patients. Number of
feedback collected should be
statistically significant
A standard patient
satisfaction feedback
form can be used for
obtaining rating from
Average rating given by patient of
In-patient satisfaction index patients. Number of feedback
IPD to the hospital
collected should be
statistically significant

Average waiting time shall be

separately calculated for OPD
Total waiting time of all patients for
consultation, Billing,
a particular service / Total number
Average waiting time for services Pharmacy and
of patients whose waiting time has
diagnostics
been taken
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 Time taken for discharge
shall be taken from the time
Sum of time taken for discharging
when the discharged was
Average discharge time patients / Total patients whose
ordered by the doctor till the
discharge time is taken
time when patient was
relieved from room/bed
(Number of medical records Standard process of
Percentage of medical records having incomplete and improper informed consent must be
having incomplete and improper consent / Total number of in place to determine what
consent medical records where consent constitutes incomplete or
was applicable improper consent

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 Training topics related to Patients’ Rights and Education

All staff specially front office,

Rights of a patient and how to protect nurses, duty doctors,
the same consultants and managers of
patient care departments

General
Consultants, duty doctors and
Taking consent from patients consent and informed
nurses
consent

Feedback mechanism and Customer care executives,

Patient feedback and complaints
complaint processes nurses, nursing in-charges

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CASE STUDY DISCUSSION

• A patient was started on oral anticoagulants in hospital for treatment

of a deep venous thrombosis following an ankle fracture. The
intended treatment course was three to six months. However,
neither the patient nor the referring GP were aware of the planned
duration of treatment. The patient continued to take this medication
for several years, being unnecessarily exposed to the increased risk of
bleeding associated with this medication. At some point, the patient
was prescribed a course of antibiotics for a dental infection. Nine
days after he started taking the antibiotic, the patient became unwell
with back pain and hypotension, as a result of a spontaneous
retroperitoneal haemorrhage, and required hospitalization and a
blood transfusion. A blood coagulation test revealed grossly elevated
results; the antibiotic had potentiated the therapeutic anticoagulant
effect.

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Be Determined & Start your journey towards
achieving Quality

BON VOYAGE !!!!!

BON
VOYAGE!!!