The first chapter of standards in the Joint
Commission on Accreditation of Healthcare
Organizations' standards for Behavioral
Health Programs is titled, "Ethics,
Rights, and Responsibilities." The
expectation is that the organization addresses
patient rights and ethical issues in its
delivery of care and services to its clients.
Accreditation Requirement(s)
To conform to these standards, the organization
must show evidence of the following:
The organization follows ethical behavior
in its care, treatment, services, and
business practices.
The organization addresses conflicts
of interest.
The integrity of decisions is based
on identified healthcare needs of the
clients.
The organization will demonstrate efforts
at reflecting concern and respect for
the client in its delivery of care, treatment,
and services.
Respect for clients' cultural
and language needs will be addressed when
interacting with clients.
The organization will make efforts
to raise staff awareness of the ethical
issues surrounding the provision of care,
treatment, and services.
The organization will implement policies
governing the issues and methods available
to support ethical decision-making.
The program must ensure that clients
are made aware of the Consumer Bill of
Rights and Responsibilities developed
by the President's Advisory Commission
on Consumer Protection and Quality in
the Health Care Industry. (Copies are
available at www.hcqualitycommission.gov.)
Policies and procedures will only partially
meet the expectations for accreditation
compliance in this chapter. Staff must
be able to communicate their knowledge
of, and commitment to, ethical practices
and support of clients' rights. Staff
orientation and education regarding this
topic and the program's policies should
be ongoing.
Rights and responsibilities statements
should be posted in prominent locations
for clients, staff, and visitors to see.
Ensure that the primary language and
visual impairments are addressed when
creating written copies of clients' rights
(large print, translation into languages
spoken by the majority of clients being
served by the program).
Ascertain whether a client is able
to understand the written list of rights
and responsibilities. Document that the
rights were reviewed verbally with the
client.
If a client speaks a language not usually
encountered by the program, offer alternative
methods for reviewing the list of rights
and responsibilities (AT&T Language
Line, local translation services).
Review Federal and state regulations
that may require additional information
to be shared and/or reviewed with clients
(for example, CMS Conditions of Participation
requirements for a formal Grievance Procedure).
