|Standard||Intent of Standard||Measurable Element||Text|
|PFR.1||The hospital is responsible for providing processes that support patients’ and families’ rights during care.|
|PFR.1 Elements 1–3||
q1. Hospital leadership works to protect and to advance patient and family rights.|
q 2. Hospital leadership understands patient and family rights as identified in laws and regulations and in relation to the cultural practices of the community or individual patients served.
q 3. 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.
|PFR.2 Elements 1, 5–6||
q1. The hospital supports and promotes patient and family participation in care processes. (Also see AOP.1.8, ME 3 and MMU.6.1, ME 4|
q 5. Patients and families are informed about their right to participate in care decisions to the extent they wish.
q 6. Staff members are trained on the policies and procedures and their role in supporting patient and family participation in care processes.
|Intent of PFR.1.2||When a patient or family wishes to speak with someone related to religious or spiritual needs or observe a spiritual or religious custom, 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.|
|Intent of PFR.1.3||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.|
|Intent of PFR.1.4||The hospital communicates its responsibility, if any, for the patient’s possessions to patients and families.|
|Intent of PFR.2||Patients and families 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. 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 the proposed care and treatment … Patients and families understand the type of decisions that must be made about care and how to participate in those decisions. 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… 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.|
|PFR 2.1||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|
|Intent of PFR.2.1||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… 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.|
|PFR 2.1 Element 3||q 3. The hospital informs patients and families about their rights to refuse or to discontinue treatment and the hospital’s responsibilities related to such decisions.|
|Intent of PFR.2.2||These needs include treatment of primary and secondary symptoms; pain management; response to the patient’s and family’s psychological, social, emotional, religious, and cultural concerns; and involvement in care decisions.|
|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.|
|Intent of PFR.3||Also, decisions regarding care sometimes present questions, conflicts, or other dilemmas for the hospital and the patient, family, or other decision makers. … The hospital has established processes for seeking resolution of such dilemmas and complaints. (Also see APR.11) The hospital identifies in policies and procedures those who need to be involved in the processes and how the patient and family participate. (Also see SQE.11)|
|PFR.3 Element 4||q 4. Patients and families participate in the resolution process.|
|Intent of PFR.4||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… 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.|
|PFR.5 Elements 1, 3||
q 1. Patients and families are informed as to the scope of a general consent, when used by the hospital.|
q 3. Whether or not a general consent is obtained, all patients and families are informed about which tests and treatments require informed consent. (Also see PFR.5.1)
|Intent of PFR.5.1||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. (Also see PFR.5, ME 3 and GLD.18)|
|PFR.5.1 Element 6||q 6. The identity of the individual providing the information to the patient and family is documented in the patient’s medical record.|
|PFR.5.3||Patients and families receive adequate information about the patient’s condition, proposed treatment(s) or procedure(s), and health care practitioners so that they can grant consent and make care decisions.|
|Intent of PFR.5.3||When informed consent is not required, staff members clearly explain the proposed treatment(s) or procedure(s) to the patient and family. The information provided includes elements a) through h) as relevant to the patient’s condition and planned treatment.|
|PFR.6||The hospital informs patients and families about how to choose to donate organs and other tissues.|
|Intent of PFR.6 and PFR.6.1||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) …. Hospital staff are trained on the donation process that supports patient and family choices.|
|PFR.6 Elements 1–3||
q 1. The hospital supports patient and family choices to donate organs and other tissues.|
q 2. The hospital provides information to patients and families on the donation process.
q 3. The hospital provides information to the patient and family on the manner in which organ procurement is organized.