Millennium and the Joint Commission Rights and Responsibilities of the Individual
Accreditation Requirements
April 23, 2010
Introduction
The purpose of this white paper is to provide information as to the positioning of
Millennium in support of enabling the ability of clients to comply with the Rights and
Responsibilities accreditation requirements of the Joint Commission. The source for the
accreditation requirements is the 2010 Comprehensive Accreditation Manual for
Hospitals (CAMH) published by the Joint Commission.
General Focus of the Requirements
The general focus of the accreditation requirements for Rights and Responsibilities
within the CAMH can be summarized as follows:
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Assuring that the provider generally follows ethical behavior in its business
practices and in the care it provides to patients
Assuring that the provider makes clinical decisions based on the needs of patients
and not based upon other considerations – most significantly financial or
economic
Assuring that the provider respects the rights of patients, and that patients are
informed of their rights
Assuring that patients are treated with respect and dignity, and may be free from
mental or physical abuse or neglect
Assuring that patients are educated about their care, about possible outcomes,
about alternatives to treatment, about pain management, understand who may be
involved in their care and able to be involved in decisions about their care
Ensuring that informed patient consent is obtained concerning treatment
Ensuring that patient wishes regarding end of life decisions are documented,
available and supported by the provider
Assuring patients are communicated to in an effective manner appropriate to their
age, gender, language and level of comprehension
Ensuring that patients understand their own responsibilities related to their care
and to their financial responsibilities for their care
Assuring that patient/family complaints are addressed satisfactorily
Ensuring that patient confidentiality, privacy and security are upheld
Millennium’s Role in Enabling Compliance
Most of the requirements found within the Rights and Responsibilities section of the Joint
Commission accreditation requirements are supported by policy and procedure as to the
actual compliance requirements outlined above. However, there are some key system
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roles that Millennium can play in support of these activities. At a summary level, these
can include:
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Enabling the ability of providers to protect patient privacy and confidentiality
Documenting consent relative to how a patient’s information may be used or
disclosed
Supporting security requirements for the protection of patient information
Assisting in the management of patient rights related requests such as for the
exercise of rights of access to their record, proposing amendments, making
requests and asking for restrictions as to how their information may be used or
disclosed
Assisting in the informing of the patient as to their financial responsibilities for
services provided
Supporting the documenting and availability of patient advance directives and
consent status relative to informed consent to treat
Documenting the presence of surrogate decision makers
Documenting assessments of the patient’s ability to comprehend information
shared with them
Documenting the activities involved with patient education as to treatment,
alternatives to treatment, outcomes, after care instructions and other information
as to the care provided to the patient
Indication of the need for translation services
Documenting assessments for pain management
The solutions key to supporting these requirements include
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Access Management (Registration, Scheduling and Eligibility management) for
support of capturing information through the admitting/registration process as to
the need for translator services, identification of surrogate decision makers,
documentation of consent statuses, capture of living wills and other advanced
directive documents provided by the patient and for eligibility determination for
coverage of the services provided
Documentation Management for documentation of assessments performed
relative to patient comprehension and pain management, documentation of
advanced directives, and of activities performed to educate the patient as to their
treatment, their rights and their responsibilities
Security capabilities including authentication controls, access controls and
auditing capabilities to help establish and assure authorized use of patient
information
Health Information Management (ProFile) capabilities to manage patient rights
related requests towards the patient record held by the provider, and for
management of disclosure activity where patient authorization is required and
where accountings of disclosure activity have to be provided to the patient
At a more granular level, Millennium can assist in enabling compliance with the Rights
and Responsibilities requirements in the following ways (NOTE: Specific Joint
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Commission accreditation standards are listed with specific requirements stated in italics
followed by the abilities of Millennium to enable compliance). The Joint Commission
requirements that are highlighted for comment are those that seem to most directly imply
a system role in compliance.
RI.01.01.01 – The hospital respects patient rights
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The hospital accommodates the patient’s right to religious and other spiritual
services
The system enables the capture of religious preference through registration
conversations, and may be used to capture congregation information as an optional
client defined registration data element as appropriate. The system can support
generation of customized census reports for clergy use if appropriate to the policies of
the organization. Religious preference also may be documented as a part of the
admission assessment process. The system can also record a patient election to opt
out of clerical visits as a part of the opt out functionality described in RI.2.130 below.
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The hospital informs the patient of his or her rights
The primary means of enabling compliance with this requirement are around
documenting the administration of notices to the patient as to their rights including
notices of privacy practices and any patient bill of rights types of documents, and in
providing abilities to manage requests related to the exercise of patient rights towards
their medical record. The system enables capture of consent, witnessing or notice
acknowledgement statuses regarding administration of privacy policies, financial
responsibility, subrogation of patient rights to their health plan and other admission or
registration related collection of such statuses for a health encounter. In some cases,
the system can generate consent forms which may contain information about the
patient’s rights or similar policy statements. The system can support electronic patient
signature of consent forms through registration functions automated by self service
kiosks or as adjuncts to a normal registration process within Access Management.
The electronic form is associated to the patient’s encounter for subsequent reference,
and is viewable as an administrative document where such documents are otherwise
enabled for viewing within Millennium. The system does not associate the consent
form with a particular consent type at this time. Alternatively, the system also
supports document scanning of any signed paper based forms for association to the
patient’s record at the person or the encounter level. The system makes the privacy
related consent status available to the care team for reference through patient
demographic information panels and inquiries.
The system enables the recording of the acknowledgment of the administration of a
Notice of Privacy Practices as well as a patient’s consent for their personal health
information to be used or disclosed as permitted by HIPAA under purposes related to
Treatment, Payment or Healthcare Operations as defined within the Privacy Rule.
The system can administer these consent statuses particular to a version of the
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Privacy Policy or notice provided to the patient by the provider. The consent status
information may be recorded through registration or through a direct maintenance
task designed for consent status management. The consent status may be displayed in
registration inquiries and in demographic panels within Powerchart.
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The hospital respects the patient’s right to privacy
The system can provide support to compliance with this requirement by helping the
provider document and implement patient requested restrictions on communications
with the patient and about other patient needs relative to things like receiving visitors,
having their information included in directories such as at the information desk and
on other matters concerning deliveries, phone calls, and the like. Through the
registration process, the system supports capture of a visitor status code to deal with
restrictions or opt out conditions relative to visitors or callers. This information is
accessible to the patient care team through patient lists, through the patient
demographic tab in Powerchart and on the patient access list (PAL), and if an opt-out
status from directories; a patient’s information can be suppressed from locater
functions used by the information desk or public switchboard of a provider. The
system can support also support capture of alternate addresses and contact
information for communicating with the patient, but this is not widely used for actual
routing of communication such as for printing clinical reports for mailing to the
patient. Lastly, if a patient asks for a restriction of privacy related consent, the
consent status can be recorded relative to the restriction, and made available for
reference where the consent status is otherwise displayed – most significantly in the
release of information management (ROI) function within ProFile to allow for an
HIM professional responsible for fielding requests for disclosures from the patient
record to be aware that there may be restrictions that apply to the release of
information to the patient’s family or others.
The system provides for appropriate information security/access controls including
role based task and data security as appropriate; support for minimum necessary
policies in information display and output through flexible configuration or use of
only the appropriate amounts of information for the purpose at hand online or in
output; support for audit of accesses to patient electronic records and requirements for
specific authentication and authorization of users with access rights to the system.
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The hospital allows the patient to access, request amendment to and obtain
information on disclosures of his or her health information in accordance with
law or regulation
For enabling a patient’s right of access to their record or to request amendment to
their record, the system enables the recording of patient requests relative to their
rights and the provider’s response through what is called the Privacy Workbench
within the ProFile HIM solution. The system can facilitate release of information
from the electronic or paper record to fulfill an authorization or an inspection request
from the patient, and the system can contribute to an accounting of disclosures for
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what is released through release of information management activity supported by the
system. The system can distinguish by type of disclosure what are reportable
disclosures to the patient, and also understand when a patient authorization is required
for a disclosure to occur.
The system supports the ability to provide a patient an electronic copy of their record
in a Continuity of Care Document (CCD) format. The record can be created at the
end of the care process and placed on removable media for the patient, sent to the
Cerner Health Record or made available through IQHealth which is a portal view into
the EMR for the patient to see their own record. The system can also be defined to
securely allow the patient to view their health information online during the care
process through MyStation.
Under the American Recovery and Reinvestment Act (ARRA) of 2009, the patient’s
right to receive an account of disclosures will be expanded to include all disclosures
related to treatment, payment or healthcare operations as defined by HIPAA that are
made from an electronic health record. Millennium offers a number of methods for
logging disclosure activity including as may be done through Clinical Reporting,
from output functions used by end users of the clinical applications and for access to
clinical information through web based applications such as WebConnect. The output
functions used by end users have logging enabled through Millennium’s core audit
services for logging externally to P2 Sentinel. P2 Sentinel supports provision of
reports of output events that may be used to help prepare the accounting of
disclosures for the patient.
RI.01.01.03 – The hospital respects the patient’s right to receive information in a manner
he or she understands
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The hospital provides information in a manner tailored to the patient’s age,
language and ability to understand
The hospital provides interpreting and translation services as necessary
The hospital communicates with the patient who has vision, speech, hearing or
cognitive impairments in a manner that meets the patient’s needs
The primary assist the system can provide to enable compliance with this requirement
is through the documentation of the native language of the patient, and the possible
need for translation services. This information can be captured through the
registration process. The system can create a work list off of the indication from
registration that an interpreter is required for provision of translation services. It also
may be documented through the assessment process. Secondarily, the system can
assist in documenting the comprehension level of the patient as a part of the
assessment process as captured through the admission assessment using the
appropriate assessment documentation forms. As a byproduct of the capture of
clinical demographic information about the patient, the system provides support for
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capture of the age of the patient, and through the assessment process, information as
to the comprehension level of the patient.
Through triage capabilities for the ED in FirstNet, the system can record the need for
translator services. The content provided to the patient through the depart process
supports comprehension requirements and language requirements for principal
languages such as Spanish, Portuguese, Russian, Vietnamese and others could be
added if needed by the client based their own experience and patient base – and the
appropriate indication of language drives generating the forms in the appropriate
language.
RI.01.02.01 – The hospital respects the patient’s right to participate in decisions about his
or her care
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The hospital respects the patient’s right to refuse care in accordance with the law
or regulations
A responsible clinician can document patient refusal through selection from a list of
choices in nomenclature in a PowerForm within Powerchart. Additional information
about the refusal can be documented in an Interactive View within Clinical Notes or
in comments attached to the nomenclature response.
From a surgical perspective, a procedure can be cancelled and a reason for
cancellation entered that may pertain to a patient refusal to undergo the procedure.
In the ED, refusal of care or leaving against medical advice can be documented
through a PowerForm and printed out, signed and scanned back in if desired, but we
do not offer standard content. A patient leaving against medical advice can be
documented as a discharge disposition – and Cerner is considering adding a discharge
PowerForm as standard content that would include documentation of the
circumstances of departure in these cases, but this would not include signature of the
patient.
For mental health patients, initial refusal to receive care can be captured through the
normal means of clinical documentation. If a patient were judged not to be competent
or non-participatory in therapeutic activities related to their condition, the system
could be used to enable documentation of what is appropriate to include in the
medical record.
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When a patient is unable to make decisions about his or her care, the hospital
involves a surrogate decision maker in making these decisions
The primary support the system can give to compliance with this requirement is
through the aspect of it that requires the provider to enable identification and
documentation of a surrogate decision maker for the patient. As of Millennium 2007,
the system can support definition of a person to person relationship of Agent for
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purpose of capturing information about someone designated to serve as the surrogate
decision maker for the patient. The designation of an Agent relationship type enables
the capture of additional relationship information through registration about the
person designated to be in this role relative to the patient.
This information may also be something captured through the admission assessment
within Documentation Management, and through the documentation of a durable
power of attorney for healthcare similar to how the existence of an advance directive
may be indicated.
In the ED with FirstNet, through triage, the system supports documenting who is
accompanying the patient to the ED, but not much more information is collected at
that time – the system also supports capture of other information such as a need for a
translator - fuller information normally will be collected later as part of a more
complete registration – but the triage form could be extended to collect other contact
information if need be, but not as a part of what typically is the standard triage
process.
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The hospital provides the patient or surrogate decision maker with the
information about the outcomes of care that he must be knowledgeable about to
participate in current and future care decisions
The hospital informs the patient or surrogate decision maker about unanticipated
outcomes of care that relate to sentinel events considered reviewable by the
commission
The system does not play a direct role per se in informing patients and their families
about the outcome of care including unanticipated outcomes. From a clinical
documentation perspective, PowerForms can be used for documenting sentinel events
tied to the patient if a client were to choose to do so. In the case of medication
management related adverse events, a quick documentation form template for is
available for adverse drug events (ADEs) for use by clients. That could in turn be
pulled by PowerVision for reporting of such events.
RI.01.03.01 – The hospital honors the patient’s right to give or withhold informed
consent
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The hospital has a written policy on informed consent
The hospital’s written policy identifies the specific care that require informed
consent in accordance with law and regulation
The hospital’s written policy describes the process used to obtain informed
consent
Informed consent is obtained and documented according to policy
The informed consent process includes a discussion about the patient’s proposed
care
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The informed consent process includes a discussion about potential benefits, risks
and side effects of the patient’s proposed care, the likelihood of the patient
achieving his or her goals and any potential problems that might occur during
recuperation
The informed consent process includes a discussion about reasonable alternatives
to the patient’s proposed care. The discussion encompasses risks, benefits and
side effects related to the alternatives, and the risks related to not receiving the
proposed treatment
The informed consent process includes a discussion about any circumstances
under which information about the patient must be disclosed or reported
There is not a current capability to define consent requirements for procedures or to
be aware of consent requirements at time of scheduling of procedures that may
require informed consent. Consent administration is typically done procedurally, and
the appropriate clinical personnel verify that it has been collected prior to the time of
a procedure or an examination as a part of pre-procedure or pre-surgical checklist
processes. SurgiNet supports the client’s ability to document that informed consent
was obtained per their documented policy/process. SurgiNet offers standard content
for pre-procedure checklist and Universal Protocol requirements which prompts
surgical personnel to verify that informed consent has been obtained.
Consent forms signed offline can be scanned in as electronic documents or
administered and signed electronically and associated to the encounter for which the
procedure is scheduled or provided. Witnessing can also be documented through this
same means. Within RadNet as of Millennium 2007.18, consent forms can be
scanned and associated to an order rather than just to the encounter.
Similarly, there is not a capability to provide for patient education materials in a
systematic automated way based upon the procedure to be performed. Patient
education materials are generally assumed to be made available offline. The ability to
generate such materials is limited to self administered medication instructions and to
post care instructions provided as a part of post operative, post procedure or discharge
instructions that may be documented to be given to the patient as a part of the clinical
documentation recorded in the patient’s electronic record. Clinical staff typically uses
the system to document the fact that patient education activities occurred associated
to options for treatment. This can be done in a variety of ways depending on the
situation – for example, through Interactive View, PowerForm or Clinical Note
entries (for care planning related education or discussions), through technologist
comments (for RadNet and education provided relative to diagnostic imaging) and
through surgical documentation (for discussion of surgical procedures and options).
RI.01.03.03 – The hospital honors the patient’s rights to give or withhold informed
consent to produce or use recordings, films or other images of the patient for purposes
other than care
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Occasionally, hospitals make and use recordings, films or other images of
patients for internal use other than the identification, diagnosis or treatment of
the patient. When this occurs, and the patient is able to give consent, the hospital
obtains and documents informed consent priopr to producing the recordings,
films or other images.
Where recordings, films or other images are made for external use, the hospital
obtains and documents informed consent prior to producing them. This informed
consent includes an explanation of how this material will be used.
The primary means of support for this consent requirement would be similar to the
comments made on RI.01.03.01 above regarding how the patient’s consent is
documented and captured through a physical form that is then scanned in as an
electronic document or a form that is signed electronically, and associated to the
person or the encounter to which it applies. The system does not otherwise provide
automation to manage this type of consent at this time either for purpose of indication
of the consent status for this type of consent or for managing its revocation.
Revocation would depend on succeeding the consent with a documented revocation.
The manner in which this consent is documented separate or as a part of a more
general consent form is subject to the provider’s policy and procedure in this matter.
RI.01.03.05 – The hospital protects the patient and respects his or her rights during
research, investigation and clinical trials
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The hospital documents the following in the research consent form: That the
patient received information to help determine whether or not to participate in the
research, that the patient was informed that by refusing to participate or
discontinue participation that will not jeopardize his or her access to care
unrelated to the research and that the name of the person who provided the
information and the date the form was signed is documented
The research consent form describes the patient’s right to privacy, confidentiality
and safety
The hospital keeps all information given to subjects in the medical record or
research file along with the consent forms
PowerTrials Screener systematically identifies potential clinical trial candidates.
Clinical research personnel use the PowerTrials Screener tool to build protocolspecific inclusion/exclusion pre-screening modules and then determine the patient
population to be screened. The screening functionality has been designed for use
within the researcher’s workflow and/or the clinician’s workflow. A pre-screening
engine embedded within Millennium screens the specified patient population against
the defined inclusion/exclusion criteria and alerts clinicians or researchers to patients
who meet initial trial eligibility requirements. PowerTrials Screener also provides
follow-up workflow support to manage the list of potential clinical trial candidate
patients as they are screened further or determined to be not interested or not
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qualified. Patients can also choose to be opted out of pre-screening for clinical trials.
PowerTrials Manager documents the consent and enrollment process.
For those hospitals that have determined that patients should consent to being
systematically pre-screened for potential eligibility for clinical trials/research (which
goes beyond HIPAA requirements) PowerTrials facilitates this process by allowing
the institution to define a system default (all patients included in pre-screening or all
patients excluded from pre-screening). The system default setting can be changed or
confirmed at the patient level when a clinician or researcher documents a patient’s
interest in being pre-screened as either interested or not interested. The interest
indicator will systematically scope a patient in or out of the population to be prescreened.
RI.01.05.01 – The hospital addresses patient decisions about care received at the end
of life
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Upon admission, the hospital provides the patient with information on the extent
to which the hospital is able, unable or unwilling to honor advance directives
Most commonly, an assessment form can be used (in part or in whole) to document
the presence of an advanced directive. If a PowerForm is used in this way, the
advance directive is accessible to the care team in the Medical Advanced Directive
section of the Gen View. This is the most effective way to document the presence of
the advanced directive in a manner accessible to the care team.
Alternatively, the system can support the capture of advanced directives as scanned
documents from offline forms or as generated as paper based forms which are signed
and scanned and associated to the encounter or the person or as electronic forms as
described above. The presence of an advanced directive on file can also be indicated
through a registration field defined by a provider to be used for that purpose.
In the ED, FirstNet supports use of PowerForms to collect Advance Directives as
other solutions do. Other forms of patient rights notices such as EMTALA rights
pamphlets are usually administered on paper, but may be put into discharge
instructions if appropriate for inclusion in information given to the patient at that
time.
For mental health patients, the system also supports documentation of a psychiatric
advance directive as an individual form for which Cerner provides a recommended
template (the Behavioral Health Advance Directives PowerForm) or as a section of a
more comprehensive form as supported by the PowerForm discussed above.
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The hospital documents whether or not a patient has an advance directive
Staff and licensed independent practitioners who are involved in the patient’s
care are aware of whether or not the patient has an advance directive
For OP settings, hospital’s written advance directive policies specify whether the
hospital will honor advance directives
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See response above for how advance directives may be documented and indicated to
the patient care team. The preferred method of documentation for communicating this
information to the patient care team would be through the use of an assessment.
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The hospital honors the patient’s right to formulate or review/revise advance
directives
Beyond previous, the system would not directly manage revisions to advanced
directives except by enabling display of the current form of advanced directive if
maintained on line, but actual review and revision would be done on a procedural
basis and may then be updated to what is maintained on line through document
scanning or as documented through amendment to the initial information captured
through the assessment process.
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Hospital documents and honors patient wishes regarding organ donation
As to organ donation, the system can facilitate recording of the patient’s intent
through similar means as to the capture of advance directives
RI.02.01.01 – The hospital informs the patient about his or her responsibilities related to
his or her care
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The hospital informs the patient about his or her own responsibilities in
accordance with its policy
See information in Millennium and JC Leadership Accreditation Requirements
whitepaper, item LD.04.02.03 for information on how the system supports sharing of
information with the patient regarding financial responsibilities – additionally, the
system can generate patient education materials such as for self medication
administration and for post discharge or post operative self care instructions if the
provider chooses to maintain such information on line for output. In some cases, this
information can be produced specific to the particular needs of the patient
dynamically based on documented diagnosis and services received by the patient such
as from the FirstNet emergency department solution for post discharge care
instructions. In all cases, the system can be used to record the fact that patient
education activities have been performed by the responsible care providers.
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The medical record of a patient who receives urgent or immediate care contains
all of the following – the time and means of arrival, indication that the patient left
against medical advice when applicable, conclusions reached at the termination
of care including the patient’s final disposition, condition and instructions given
for follow up care and a copy of any information made available to the
practitioner or medical organization providing follow up care
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All of the above information is able to be documented in the patient’s medical record,
and a copy of anything provided to the next provider in line providing post discharge
care can be retained whether generated using the Continuity of Care Document
(CCD) in Cerner’s Multi Media Archive or in Clinical Notes.
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