Staff opinions on patients' rights may stun you

Try a survey to reveal need for education

When the risk manager for Maricopa Health System in Phoenix surveyed medical staff and employees about patient rights, she was dismayed to learn that many staff thought more than half of 20 key patient rights are not adequately honored at the medical center.

Conducting a similar survey at your hospital could provide surprising results and could identify needed efforts in staff education.

The patient rights survey was conducted in December 1994, to find out if the medical staff and employees know what patient rights are and whether they thought the rights were being honored at the medical center, says Risk Manager Jeannette Ward, RN, MA, JD.

Although most responding employees and staff agreed the medical center adequately meets patients' rights to receive information in clear and simple words, to participate in decision making about their care, to be assured of medical record privacy and confidentiality, and to receive complete information about their medical condition, the responses were not as positive for other patients' rights, Ward says.

Some of the areas respondents listed most often as shortcomings at the medical center were meeting the patients' rights to:

* be seen as soon as possible;

* obtain a second opinion;

* view their own medical records;

* be informed about how patients' complaints are handled;

* formulate advance directives;

* appoint a proxy;

* receive an explanation of their bill, regardless of payer source.

Ward promptly initiated a three-part staff education program, in an effort to remedy the situation before an upcoming survey by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

The Maricopa Health System includes a 541-bed hospital and 13 primary care centers in Maricopa County. The staff consist of 2,300 employees, 250 house staff physicians, and about 280 attending physicians, all of whom were asked to complete the survey.

Shortly after the Patient Self-Determination Act went into effect on Dec. 1, 1991, Maricopa conducted a massive education program on patient rights.

In essence, the act requires that Medicare and Medicaid-certified hospitals, nursing facilities, hospices, home health agencies and prepaid health plans, such as HMOs must:

* Provide written information to patients at the time of admission concerning an individual's right under state law to make decisions concerning medical care.

* Maintain written policies and procedures with respect to advance directives.

* Document in the individual's medical record whether or not the individual has executed an advance directive.

* Ensure compliance with requirements of state law respecting advance directives.

* Provide for education for staff and the community on issues concerning advance directives.

Ward says she envisioned the survey as a method for re-evaluating the effectiveness of the health system's ongoing patient rights education program. She believed staff know what patient rights are, but that they needed to be reminded to follow patient-rights policies and procedures already in place in the system.

On the single-page survey form, 20 patient rights were listed in a column along one side of the page, under the heading, "The patient has the right." In the next column, respondents were asked to check whether they agree, disagree, or are undecided about whether each statement is a patient right. In the third column, they were asked to indicate whether they think the right is practiced in the Maricopa system. (See a sample of the blank survey form, p. 11.)

Ward compiled the list of 20 rights from the 1995 Medicare Patients' Bill of Rights1 and from the Joint Commission's 1995 accreditation manual section on patient rights and organizational ethics.2

Another good source for this type of material is the American Hospital Association's Patients' Bill of Rights.3

The survey was sent to three groups: employees, house staff, and attending physicians. Staff received copies of the survey with their paychecks. They were asked to return the form to the risk manager's office by interoffice mail as soon as possible. Surveys arrived in the risk manager's office for about three weeks.

The envelope, please

In all, 541 of the 2,830 surveys (about 16%), were completed and returned -- enough to make the survey findings statistically valid, Ward says. The data were entered into a computer program called Statistical Package for the Social Sciences (SPSS) for analysis.

Ward found the results surprising. "I didn't realize so many of the percentages would be so low," she says.

The lowest ratings came from the 477 employees who responded to the survey. When the employees' responses were averaged with house staff and medical staff percentages, the results for each of the 20 rights under the "is this practiced here" column fell below 90%; that is, fewer than 90% checked "is practiced here." The average response for 11 out of the 20 rights was below 75%.

For instance, although 79.7% of the responding employees said they believe patients have the right to view their own medical records, only 46.1% thought that right was carried out at Maricopa.

Ward decided staff needed to know more about the right to view medical records and a number of other low-scoring rights -- including, for example, the right to a second opinion and the right to have a bill explained regardless of the payer source.

Ward immediately initiated a "super-education program" that included the following components:

* A memo alerting staff to the problem areas.

The risk management staff prepared a "Did You Know?" memo, listing patient rights problem areas and sent it to all hospital staff.

* Presentations at committee meetings.

Ward presented the results of her survey to several inter-institutional committees, such as the performance improvement committee and the medical executive committee.

"We asked the medical staff and managers to let all health system staff members know this isn't how it's supposed to be," she says.

* An educational packet to prepare for a Joint Commission visit.

Ward included patient rights information in the educational packet that she sent to department managers regarding the upcoming Joint Commission survey. The department managers distributed the information to their staffs.

Ward plans to conduct the patient rights survey again in the near future. "That will tell us if the education helped and if not, we'll decide what other courses of action we need to take," she says.

The survey also showed physicians' perceptions and staff perceptions differ concerning patient rights, Ward says. While the physicians maintain they are handling patient rights correctly, staff who observe physicians may discern flaws in their behavior, Ward says. She plans to gear her educational efforts differently to staff and physicians, taking into account what each group already knows about health care issues.

"People perceive things differently and in some instances we may not be able to fix that perception difference," Ward says.

Prepare for a deluge

Ward was surprised not only by the survey responses, but also by the size of the response. The "phenomenal" response meant a sizable amount of data to analyze, she says.

For hospital risk managers who decide to conduct a similar survey, Ward recommends setting up procedures for entering and analyzing data well before beginning the project. At Maricopa, the data entry and analysis were done by two people with many other responsibilities, so this aspect of the survey took close to 31Ž2 months to complete.

Ward says the SPSS analysis program she used is fairly simple and user-friendly. It is likely to be available at health care centers involved in research, and at those with medical school teaching affiliations.

Having patient rights in place in a hospital's policy and procedures manual, and doing the research and educational work to be sure employees understand patient rights are just one half of the equation. Patients, too, must be informed of their rights.

For compliance with Joint Commission standards, health care organizations can no longer rely on a simple posting of patient rights, cautions Patricia Staten, MS, associate director of the department of standards interpretation at the Joint Commission.

Patients must be informed of their rights when they are admitted to the facility, Staten says. The statement of rights can be provided during the admission interview or as part of the patient information packet given to patients when they arrive at the hospital unit. Patients' records must be documented to show that the patients have received their rights, she adds.

Hospitals should have in their policy and procedure manuals methods for assisting patients who have difficulty understanding their rights, Staten says. Those methods may include reading rights aloud or having an audiovisual system set up to convey the information.

Surveyors talk to patients

Joint Commission surveyors carefully examine patient-rights issues during survey site visits. Surveyors spend half their time talking to patients, patients' families, and hospital staff to determine whether various policies and procedures are being applied, Staten says. Surveyors also look at medical records for documentation that patient rights have been distributed.

(See a Joint Commission staff member's comments on typical compliance problems, p. 12.)

Failing to comply with any patient rights requirement would not cause a hospital to be rated as noncompliant or nonaccredited, but it could affect the hospital's overall scoring, Staten says.

[Editor's note: To purchase the SPSS data analysis software, contact: Statistical Package for the Social Sciences, 444 N. Michigan Ave., Chicago, IL 60611-3962. Telephone: (800) 543-2185.]


1. Health Care Financing Administration. "An Important Message From Medicare: Your Rights While You're a Medicare Hospital Patient." In The 1995 Medicare Handbook. Baltimore.

2. Joint Commission on Accreditation of Healthcare Organizations. "Patient Rights and Organizational Ethics." In 1995 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL.

3. American Hospital Association. A Patient's Bill of Rights (management advisory). Adopted in 1973; revised Oct. 21, 1992. *