HSHS Wisconsin Hospitals

Also known as Patient Bill of Rights

At Hospital Sisters Health System (HSHS), we wish for patients to know and understand their rights and responsibilities when receiving care and services at our facilities. We are committed to meeting patient needs and will treat everyone with the respect due each person. Patients are entitled to high quality care that responds to their physical, emotional, social, psychological, and spiritual wellbeing.

Rights Related to Respect and Dignity

• HSHS respects the rights of the patients served.
• Patients may not be denied appropriate hospital care because of their race, creed, color, national origin, ancestry, sex (including gender identity), sexual orientation, marital status, age, newborn status, handicap or source of payment.
• Patients shall be informed about the care they will receive in a way they understand. This includes interpreter services free of charge or assistance, if they have visual, hearing, speech or learning difficulties.
• Patients shall be treated with consideration, respect and recognition of their individual and personal needs, including the need for privacy in treatment.
• Patients, or when appropriate, the patient’s representative (as allowed under State law), shall be informed of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible.
• Patients or their designated representative shall be given, at the time of admission, a copy of the hospital's policies on Patient Rights and Responsibilities.
• Except in emergencies, patients may not be transferred to another facility without being given a full explanation for the transfer; without provision being made for continuing care; and without acceptance by the receiving institution.
• Patients have the right to refuse transfer, even in the case of an emergency.
• Patients shall be presented information in a manner they understand.
• Patients shall receive information about the individuals responsible for their care, treatment, or services, including the names of the physician(s), clinical psychologists or other practitioners.
• Patients shall have the right to an environment that preserves dignity and contributes to a positive self-image.
• Patients shall have the right to receive religious and spiritual services.

Rights Related to Complaints, Grievances, Advocacy and Resolution Process

If we have not met a patient’s needs, we ask that they share their concerns with us, especially regarding treatment, safety or quality of care. A patient or their legally authorized representative has the right to share these concerns at the time of service with their care provider, nursing or department leader or Hospital Supervisor. Our desire is to resolve matters as soon as possible, so that patients receive the best care possible.

Patient procedures related to initiation, review and resolution of complaints, grievances, and advocacy may be filed with the following:

HSHS Wisconsin Hospitals: (HSHS St. Vincent Hospital – Green Bay, HSHS St. Mary’s Hospital Medical Center – Green Bay, HSHS St. Clare Memorial Hospital – Oconto Falls, HSHS St. Nicholas Hospital – Sheboygan)

If you have a concern, please call the hospital that you received care and ask to speak to the department leader where the concern originally arose. Please call the hospital switchboard and ask to be transferred:

HSHS Corporate Office

• Civil Rights, Discrimination, or Privacy Grievances:
  • Corporate Compliance/Privacy Officer & 1557 Coordinator, (217) 492-6590 | 4936 Laverna Road, Springfield, IL 62794

Community Resources

• Abuse, Neglect, or Safety Grievances:
  • Brown County Human Services (920) 448-6000 | 111 North Jefferson St., Green Bay, WI  54301
  • Sheboygan County Human Services (920) 459-6400 | 1011 North 8th Street, Sheboygan, WI  53081
  • Oconto County Human Services (920) 834-7000 | 501 Park Ave., Oconto, WI  54153

State

• Report any concern or grievance:
  • Wisconsin Department of Health Services – Bureau of Health Services of the Division of Quality Assurance (800) 642-6552 | DQA/Bureau of Health Services Complaint Coordinator, PO Box 2969 Madison, WI 53701-2969

Federal

• Privacy or Patient Rights Grievances:
  • U.S. Department of Health & Human Services Office for Civil Rights (800) 368-1019 | 233 North Michigan Avenue Suite 240, Chicago, IL 60601

Healthcare Accrediting Organization

• Report any concerns or grievance:
  • The Joint Commission (800) 994-6610 or fax: (630) 792-5636)
  • Office of Quality and Patient Safety – The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181
  • Online at www.jointcommission.org (“Report a Patient Safety Event” under “Action Center” on the website home page).
• Medicare beneficiaries who are inpatients must be provided a standardized notice, “An Important Message from Medicare” (IMM) within two (2) days of admission and within two (2) calendar days before discharge, which informs Medicare patients of their right to file a complaint regarding quality of care, if they disagree with a coverage decision or if they wish to appeal a premature discharge.
  • Patients will receive written notice of the hospital decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
• Patients shall have the right to access protective and advocacy services. Staff from the Hospital Case Management Department act as patient advocates:
  • Case Management Department at HSHS St. Vincent Hospital – Green Bay; HSHS St. Mary’s Hospital Medical Center – Green Bay; HSHS St. Clare Memorial Hospital – Oconto Falls; or HSHS St. Nicholas Hospital – Sheboygan: (920) 433-8575.
  • Case Management Department at HSHS Sacred Heart Hospital – Eau Claire; HSHS St. Joseph’s Hospital – Chippewa Falls: (715) 717-1613.

Rights Related to Plan of Care

• Patients shall have the opportunity to participate, to the fullest extent possible, in the development and implementation of their inpatient, outpatient, discharge, and pain management treatment/care plan and in decisions regarding continuation or discontinuation of care.
• Patients or their representative (as allowed under State law) shall have the right to make informed decisions regarding their care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.
• Patients or their legally authorized representative shall have the right to receive a copy of and review their current list of medications per the hospital medical record.
• Patients or their legally authorized representative shall have the right to review their medical record related to their care and have it explained to them.

Rights Related to Advance Directive

• Advance Directives are written statements, such as a living will or durable power of attorney for healthcare, recognized under State law, naming a person of the patient’s choice, who shall make healthcare decisions, should the patient become physically or mentally unable to do so, independently. Patients have the right to formulate advance directives and to have hospital staff and providers comply with these directives. The patient’s wishes will be honored to the extent of the law and hospital policy.

Rights Related to Notifying of Admission

Patients shall have the right to have a family member or representative of their choice, and/or their primary care provider, notified promptly of an admission to the hospital.

• Rights Related to Privacy, Confidentiality or Medical Records
• Patients shall have the right to personal privacy.
• Patients shall have the right to access information contained within their medical record, within a reasonable time frame.
• Patient’s medical record, including all computerized medical information, shall be kept confidential.
• DHS 124.05(3)(a)1.d. Patients or any legally authorized person shall have access to the patient's medical record as required by law.
• Patients shall have the right to give or withhold informed consent, related to the hospital using or producing recordings, films, or other images of the patient, served for purposes other than their care.

Rights Related to Safety

• Patients shall have the right to receive care in a safe setting that has an effective abuse prevention plan, which contains elements of abuse prevention, screening, identifying, training, protecting, investigating, reporting and responding.
• Patients shall have the right to be free from all forms of abuse (i.e., physical, mental, neglect, verbal, sexual), corporal punishment, exploitation or harassment.

Rights Related to Consent, Treatment or Research

• Patients, the patient's legally authorized representative, or any person authorized in writing by the patient, shall receive, from the appropriate person within the facility, information about the patient's illness, course of treatment and/or prognosis for recovery, including outcomes that were not expected, in terms the patient or their authorized representative can understand.
• Except in emergencies, the consent of the patient or the patient's legally authorized representative shall be obtained before treatment is administered.
• Patients or the patient's legally authorized representative shall give prior, informed consent for the patient's participation in any form of research or experimental trials.
• Patients are protected and their rights are respected during research, investigation, and clinical trials.
• Patients or the patient’s legally authorized representative shall have the right to be informed about any proposed procedures or treatments.
• Patients or the patient’s legally authorized representative may be asked to sign an Informed Consent before the start of a procedure.
• Patients or the patient’s legally authorized representative shall have the right to ask questions and be listened to.
• Patients or the patient’s legally authorized representative shall have the right to transfer care to another facility, if the hospital is unable to provide the care they need or as they request. Patients shall have the right to know if and why such transfer may be necessary. The hospital cannot transfer the patient unless the receiving hospital accepts them as a patient.

Rights Related to Patient Billing

• Patients or the patient’s legally authorized representative are permitted to examine their hospital bill and receive an explanation of the bill, regardless of source of payment. Every patient or patient’s legally authorized representative shall receive, upon request, information relating to financial assistance that is available through the hospital.

Rights Related to Restraints

• Patients shall have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by hospital staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Rights Related to Psychiatric and Chemical Dependency

• Patients who receive treatment for mental illness, a developmental disability, and/or alcohol or drug abuse shall be recognized as having, in addition, the rights listed under Wisconsin s. 51.61, Stats., and ch. DHS 94.

Rights Related to Visitation

• Patients may designate persons who are permitted to visit the patient during the patient's stay, in accordance with hospital policy, as well as refuse any visitors.
• Patients shall have the right to choose a support person who can determine, who may visit the patient, if the patient is unable to indicate visitors. Support persons and visitors are not entitled to the same rights as the patient’s (legally) authorized representative.
• The hospital reserves the right to limit visitors as medically necessary or for safety reasons. Patients or their support person, where appropriate, are informed of the visitation rights, including any clinical restriction or limitation on such rights, at the time they are notified of their other rights under this section.
• Patients or their support person, where appropriate, are informed of their right, subject to their consent, to receive visitors whom they designate (i.e., a spouse, domestic partner, family member, or friend), and their right to withdraw or deny such consent at any time.
• Patients are not restricted, limited, or otherwise denied visitation privileges on the basis of race, creed, color, national origin, ancestry, sex (including gender identity), sexual orientation, marital status, age, newborn status, handicap or source of payment.
• Patient visitors have the right to enjoy full and equal visitation privileges consistent with patient preferences.

Rights Related to Staff and Patient Rights

• Staff assigned to direct patient care have the responsibility to be informed of and demonstrate their understanding of patients’ rights and responsibilities, through orientation and appropriate in-service training activities.

Responsibilities of Patients

• Patients shall be responsible for showing mutual respect and consideration to providers, staff and hospital property, as well as, other individuals and their property.
• Patients shall be responsible for following the hospital’s policies and procedures, instructions, and rules and regulations to support quality of care and a safe environment.
• Patients shall be responsible for asking questions when they do not understand their care, treatment, or services, or what they are expected to do.
• Patients shall be responsible for following instructions for their plan of care, treatment, or services, and expressing concerns about their ability to follow the proposed plan of care, treatment, or services.
• Patients shall be responsible for accepting certain outcomes of care, treatment, or services, if they do not follow the planned care, treatment, or services.
• Patients shall be responsible for providing to the hospital, the necessary information for processing payment of services.
• Patients shall be responsible for meeting financial commitments and obligations in a timely manner.
• Patients shall be responsible for sharing expectations of, and satisfaction with, the organization.
• Patients are responsible for providing an Advance Directive or Living Will, if they have one.

References

• Wis. Adm. Code, Chapter 50, Section 50.36 (1) Rules and Standards
• Wis. Adm. Code, Chapter DHS 124, Section 124.06 Patient Rights and Responsibilities in Critical Access Hospitals
• 42 CFR § 482.13 Condition of Participation: Patient’s Rights
• Joint Commission – Rights and Responsibilities of the Individual