POLICY AND PROCEDURE Function: Leadership Policy Number: 902.00 Subject: Chain of Command Distribution: Hospital-wide Prepared By: Policy and Procedure Committee; Associate Administrator Effective Date: Last Review, Revision Date: 1/84 6/13 Approved By: Vice President of Nursing Approved By: Executive COO Purpose: The Chain of Command policy has been designed to: Provide professional nursing and hospital staff and physicians with appropriate direction for the prompt handling of urgent/emergent patient care issues. To make available a formal line of communication for staff members who have concerns that a prescribed treatment plan (or the lack thereof) or a medical decision or other medical act might adversely affect the welfare of a patient or that of the hospital. Introduction: St. Francis Hospital is committed to providing safe, quality patient care. Members of the healthcare team are obligated to work toward resolution of identified real and potential problems within the system that may affect patient care. If the member is unable to resolve such issues independently, the team member is obligated to present the issue in a timely manner to successively higher levels of command until a satisfactory resolution is achieved. Chain of Command in healthcare refers to an authoritative structure established to resolve administrative, clinical, or other patient safety issue by allowing healthcare clinicians to present an issue of concern through the lines of authority until a resolution is reached. Scope and Responsibility: The policy applies to all patient care areas where chain of command needs enacted. Compliance with this policy will be the responsibility of the employee identifying an urgent/emergent patient care issue or event; and/or identified hospital issue, requiring heightened communication. Applies to all hospital staff, Administration, the Medical Staff, and all Department Directors. DEFINITIONS: Chain of Command: A chain of command is an aspect of organizational structure that is meant to show a clear line of responsibility from the top position in an organization all the way down to the bottom. A chain of command is established so that everyone knows whom they should report to and what responsibilities are expected at their own level. The lines of authority and responsibility within
Page 2 of 5 the hospital administration and the medical staff governance structure through which to channel communication from the staff employee or the attending physician to the appropriate administrative and/or medical leader to facilitate resolution of a patient care or hospital issue. POLICY: A. The hospital staff and the Medical Staff have the responsibility to cooperate in their mutual efforts to assure delivery of patient care of the highest quality in accordance with the established policies, procedures, and standards of the hospital. B. Hospital Staff will adhere to the following procedure for problem resolution related to urgent/ emergent patient care concerns and problems. Urgent/Emergent patient care concerns/problems include, but are not limited to the following: Life threatening concerns to patients; Potential for complications jeopardizing the safety of patients, family or employees; Refusal to adhere to established policies or procedures; Delayed response; Impairment of a coworker; Acts that might constitute the unauthorized practice of medicine; Falsification of records; or Questions involving such issues as billing practices or charges should go directly to the Risk Manager, Vice President of Finance (CFO)/ Executive COO/Vice President of Nursing (CNO) for resolution. C. For non-emergent/urgent issues involving the need to institute an internal chain of command: Direct supervisor Department Manager/Clinical Coordinator/House supervisor Director of Human Resources as indicated Administrator on call Vice President of Department Executive COO CEO Example of non-emergent/urgent issues: Communication issues that interfere with patient and family care, such as communication barriers: o Complexity of care o Clinical responsibility o Disruptive or escalation behavior PROCEDURE: Urgent/Emergent Patient Care Issues A. After the nurse evaluates the patient and the prescribed treatment regimen and makes the determination that there is a patient management issue, he/she shall confer with
Page 3 of 5 Department Manager/Charge Nurse and/or Nursing Supervisor regarding the concerns. Other hospital staff encountering a patient management issue will report concerns to the primary nurse or charge RN. B. If, after consultation it is determined there is a valid concern, the nurse shall discuss the concerns with the attending physician to obtain clarification of the orders or prescribed treatment. If after discussing with the attending, the nurse remains concerned that the issue at hand may adversely affect the patient or does not comply with established policy and procedure of the hospital, or if the nurse is unable to reach the attending physician, (s)he shall take the following steps: 1. Document the calls to the attending physician on the patient s medical record. Document using the Physician Notify screen in Meditech areas or nursing notes in non-meditech areas. 2. Notify his/her Charge Nurse or Clinical Director or Nursing Supervisor of the situation. Document such notification in the patient s medical record, including date, time and person notified and what was communicated or decided during the exchange. 3. Retain accountability for the patient; continue to monitor the patient s status and perform actions necessary to provide for the patient s well being. C. The Charge Nurse/Clinical Director or Nursing Supervisor will investigate the issue thoroughly and will call the attending physician to resolve the issue or problem. 1. If the issue/problem is not resolved, the charge nurse will collaborate with the primary nurse, the Clinical Director, Nursing Supervisor (in the absence of the Clinical Director) and the physician to address the issue. 2. If no resolution is reached after collaborating with the nurse, Charge Nurse/ Clinical Director and physician, the Clinical Director or Nursing Supervisor (in the absence of the Clinical Director) notifies the Administrator on call, who will call or direct call placed to Medical Director of unit or, Department Chair of service (i,e, - Medicine, Surgery) 3. If the problem or issue is not immediately resolved, the Department Chair, Administrator or Nursing Supervisor notifies the Chief of Staff. 4. The Department Director/Manager notifies the Vice President of Nursing (CNO- Chief Nursing Officer)/Associate Administrator and Risk Manager as soon as possible. (During other than regular business hours, the Hospital Administrator- On-Call will be notified). D. The Administrator-On-Call/CNO/Associate Administrator and/or the Risk Manager assure that the problem/issue is resolved to both Nursing and physician s satisfaction. E. Attending physician: 1. Discusses issue/problem with nurse in charge of patient care. 2. If issue or problem is not resolved, the physician/nurse notifies the charge nurse of the unit. 3. If the issue or problem remains unresolved, the attending physician notifies the Department Director/Manager and/or Vice President of Nursing (CNO-Chief
Page 4 of 5 Nursing Officer) and Hospital Administrator-On-Call as well as the Chief of Service. 4. If problem or issue remains unresolved, the attending physician notifies the Chief Executive Officer and the Chief of Staff. F. In the event of an emergency situation wherein time is of the essence and the initiation of the usual chain of command would delay care, the Charge Nurse/Clinical Director/Nursing Supervisor may notify the attending physician (if a consultant is involved in the care), and/or the Chief of Service in question. If this effort produces no action, the Charge Nurse/Clinical Director/Nursing Supervisor may contact the Chief of Staff and ask him/her to come into the hospital to evaluate the situation. At the same time, the Clinical Director of the Unit, the Nursing Supervisor, the Director/Senior Manager of the Service, the Vice President of Nursing (CNO-Chief Nursing Officer) (after hours, the Administrator On Call), and the Risk Manager, should be notified of the actions taken. G. Training of key personnel in conflict resolution techniques: Talking directly with the staff member or provider at the time of concern in a discrete area away from the patient s bedside. Arrange for support during discussion with the staff member or provider Review of policy or procedure with staff member or provider Just in time education, as appropriate Documentation: H. The nurse who is responsible for initiating the chain of command process will objectively document the patient care assessment factors involved, the conversation with the patient s physician and the nursing unit director/nursing Supervisor, and any other pertinent facts related to the process, along with date and time, in the patient s medical record. I. If the issue is not resolved, the documentation of pertinent factual information related to the patient s care and the chain of command process will be objectively documented in the patient s medical record by the nurse/vice President of Nursing (CNO-Chief Nursing Officer) or Associate Administrator/Risk Manager involved at each level of the process until the issue is resolved. ACCOUNTAB ILITY: A. All nurses who are responsible for the delivery of patient care must ensure that the well being of each patient is the highest priority. Nursing staff are expected to take whatever action is necessary and appropriate to ensure that quality care is being provided at all times. Hospital staff is expected to report concerns and follow processes outlined in this policy. B. Nurses and physicians are encouraged to resolve issues on a one-to-one basis. C. All incidents that involve patient care concerns are to be reported to the Director of Risk Management according to the Risk Management Policies and Procedures. D. The Risk Manager is responsible for notifying the Medical/Surgical Committee, Quality Council and the Medical Executive Committee when indicated or warranted, of the action taken on behalf of the patient.
Page 5 of 5 C. An Ethics Committee consultation may be requested, if needed, to facilitate communication and discussion among the members of the health care team. See policy #214.00, Ethics Resolution. Reference: West Virginia Nursing Code and Legislative Rules, West Virginia Board of Examiners for Registered Professional Nurses Reviewed/Revised Dates: 2/97, 8/1/00, 4/27/01, 04/03, 5/05, 5/07, 05/09, 06/11