OO12 The policies and procedures that address:
➢ Patient privacy, security, and confidentiality
➢ Patient ethical issues and/or needs
➢ Promotion of a nondiscriminatory environment for patients and families
Patient Privacy, Security, and Confidentiality
Policy Title |
Location |
Purpose |
Privacy |
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Patient Privacy Rights |
BHSF |
Provides general rules regarding patient privacy rights for all BHSF hospitals (OO12 01 BHSF-100 Patient Privacy Rights) |
Provision of the BHSF Notice of Privacy |
BHSF |
Describes guidelines on the provision of notice of privacy practices to patients at first service delivery (OO12 02 BHSF 101.10 Provision of the BHSF Notice of Privacy Practices; OO12 03 Notice of Privacy Practices Brochure [English]; OO12 04 Notice of Privacy Practices Brochure [Spanish]); OO12 05 Patient Acknowledgement of Notice of Privacy Practices [English]; OO12 06 Patient Acknowledgement of Notice of Privacy Practices [Spanish]) |
Security |
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Security Management Plan |
Homestead Hospital |
Summarizes plan to provide a physical environment free of security hazards for all patients, visitors, employees, volunteers and staff (OO12 07 HH-400-5610-1148 Security Management Plan) |
Patient Safety Plan |
Homestead Hospital |
Provides framework for proactively identifying potential and actual risks to patient safely |
Security Lockdown of the Hospital |
Homestead Hospital |
Explains procedures to follow in totally or partially restricting movement in and out of the hospital due to external or internal incidents that can threaten safety of patients, visitors and staff. (OO12 09 HH-400-5610-1195 Security Lockdown of the Hospital) |
Code Green |
Homestead Hospital |
Describes an organized response to aggressive behavior that is believed to be a potential threat to patients, visitors, employees, staff volunteers or facilities. (OO12 10 HH-400-5610-1030 Code Green – Disruptive patient, visitor or employee) |
Code 9 – Medical Emergencies of Visitors/Non-Patient Employee Inside the Hospital Building |
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Outlines a uniform process for responding to medical emergencies involving visitors and non-patient employees (OO12 11 HH-400-5610-1080 Code 9 – Medical Emergencies of Visitors/Non-Patient Employee Inside the Hospital Building) |
Confidentiality |
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Using, Disclosing and Requesting Patient Information for Baptist |
BHSF |
Describes how to protect the confidentiality of patient health information when used for health treatment purposes (OO12 12 BHSF-301 Using, Disclosing and Requesting Patient Information for Baptist Health Treatment Purposes) |
Use or Disclosure of Medical Record Information |
BHSF |
Summarizes appropriate internal and external use/disclosure of medical record information to protect confidentiality and privacy of protected health information (OO12 13 BHSF-400 Use or Disclosure of Medical Record Information) |
HIPAA Privacy Procedures - Patient’s Request for Restriction on Uses and Disclosures of Health Information |
BHSF |
Describes patient’s rights and process for requesting limitation or restriction on use of health information for treatment, payment or healthcare operations; and limitation on disclosure to someone who is involved in their care or payment of their care (OO12 14 BHSF 352.02 HIPAA Privacy Procedures - Patient’s Request for Restriction on Uses and Disclosures of Health Information) |
Patient Ethical Issues and/or Needs
Policy Title |
Location |
Purpose |
Ethical Issues and Ethics Consultation Requests |
Homestead Hospital |
Outlines the steps when an Ethics consult is requested (OO12 15 HH-100-7940-1320 Ethical Issues and Ethics Consultation Requests ; OO12 16 Homestead Hospital Clinical Ethics Committee Charter) |
Levels of End-of-Life Care including Withholding/Withdrawing of Life Prolonging Procedures and Deactivation of Cardiac Rhythm Management Device for Comfort Measures |
Homestead Hospital |
Delineates the different levels of end-of-life care for adults and their corresponding management including withdrawing/withholding of life prolonging procedures and deactivating cardiac rhythm management devices (OO12 17 HH-400-7983-798 Levels of End-of-Life Care) |
Neonatal – Levels of End-of-Life Care/Allowing Natural Death, including Withholding/Withdrawing of Life Prolonging Procedures |
Homestead Hospital |
Describes different levels of end-of-life care for neonates suffering from terminal and/or irreversible condition(s) and their corresponding management including withdrawing/withholding of life prolonging procedures (OO12 18 HH-400-5830-798-1 Neonatal - Levels of End-of-Life Care) |
Comfort Measures Only (CMO) Standard of Care |
Homestead Hospital |
Outlines the management of patients whose care is focused on providing comfort at life’s end (OO12 19 HH-400-7983-796 Comfort Measures Only [CMO] Standard of Care) |
Brain Death Determination in Adults |
Homestead Hospital |
Explains the neurological death criteria and process to be followed to determine it (OO12 20 HH-400-5830-800 Brain Death Determination in Adults) |
Standard of Care of the Potential Organ Donor Determined to be Brain Dead by Neurological Criteria to Maintain Organ Vitality |
Homestead Hospital |
Illustrates the management of patients determined to be brain dead by neurological criteria to maintain organ viability for donation (OO12 21 HH-400-5830-810 Standard of Care of the Potential Organ Donor Determined to be Brain Dead by Neurological Criteria to Maintain Organ Vitality) |
Donation After Cardiac Death |
Homestead Hospital |
Describes the process of offering the option for organ donation to adult patients and their legal decision makers after the decision for withdrawal of life support and life sustaining therapies has been made (OO12 22 HH-400-5830-799 Donation After Cardiac Death) |
Code of Ethics Policy |
BHSF |
Delineates employee responsibility and access to Code of Ethics which is a key component of the Corporate Compliance Program (OO12 23 BHSF-819 Code of Ethics policy; OO12 24 Code of Ethics brochure) |
Medical Staff Quality Committee Charter |
Organizations and Functions Manual – Medical Staff office |
Describes the process of reviewing quality of medical care by physician peers and council membership (OO12 25 Medical Staff Quality Committee charter, highlighted) |
Nursing Peer Review |
Homestead Hospital |
Outlines the process of reviewing nursing care quality by RN peers and the council membership (OO12 26 HH-100-12 Nursing Peer Review) |
Promotion of a Nondiscriminatory Environment for Patients and Families
Policy Title |
Location |
Purpose |
Patient Rights and Responsibilities |
Homestead Hospital |
Explains organizational support and respect of Patient Rights and Responsibilities and the process of informing patients about it (OO12 27 HH-400-5830-700 Patient Rights and Responsibilities; OO12 28 Patient Rights and Responsibilities brochure [English]; OO12 29 Patient rights and Responsibilities brochure [Spanish]) |
Complaint and Grievance Management |
Homestead Hospital |
Describes procedure for handling patient complaints and grievances (OO12 30 HH-400-6050-703 Complaint and Grievance Management) |
Patients and Visitors with Communication and Special Needs |
Homestead Hospital |
Sets guidelines for accommodating individuals with special needs in accordance with the Americans with Disability Act (OO12 31 HH-400-5660-715 Patients and Visitors with Communication and Special Needs policy) |
Patient Visitation |
Homestead Hospital |
Illustrates incorporation of patient-and family-centered care concept in patient visitation. |
Interpreter Services for Patients and Families |
Homestead Hospital |
Establishes guidelines for provision of interpreter or translation services to patients and/or families when language barriers or disabilities hinder effective communication. (OO12 33 HH-400-5660-791 Interpreter Services for Patients and Families) |
Patient and Guest Services Department – Scope of Service |
Homestead Hospital |
Illustrates the scope of service and the role of the of the Patient and Guest Services department as liaison between the patients and/or guests and the hospital to ensure service excellence |