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Health Information Compliance Alert

SAMPLE DOCUMENT:

ARE YOU READY FOR GUESTS?

Published on Tue Aug 17, 2004

Not sure how HIPAA impacts tour groups or other non-workforce related programs within your organization? Here's a guideline that'll help set you straight:

SAMPLE TOUR POLICY

Allowing individuals and groups to tour hospital facilities is an important tool in educating the public about medical care and raising community awareness, but in the process of a tour or program, a person will likely have access to confidential information in the form of patient medical information, medical committee discussions or reports, personnel information, marketing plans and financial data.  Federal and state laws govern the disclosure of this type of information.  [Your Organization's Name] takes every precaution to protect privacy.
  
1. All precautions will be taken to protect the privacy of each patient.
  

  •  Hosts will receive pre-tour training regarding patient privacy policy issues; 
      
  •  Participants will receive information about patient privacy and sign a Confidentiality Agreement prior to each tour;
      
  •  Participants will be asked to excuse themselves from a discussion if it includes information about a family member, friend or acquaintance; 
  •  Under no circumstances will a tour participant have access to patient records; and 
      
  •  At no time should a patient's HIV/AIDS status be discussed or disclosed when a participant is present.

    2. Tours must be planned and coordinated so they do not interfere with patient services or day-to-day operations.  An agenda should be made available to all lead coordinating parties.

    3. Participants will not be allowed to take photographs or video in patient care areas without prior consent.
     
    4. All patients who are likely to be in the affected hospital area must be informed of the tour and have the   opportunity to opt-out of being included. If a parent or legal guardian is not present to sign an opt-out form, the patient must automatically be opted out of the tour for the protection of the patient and the hospital. All patients who have opted out of the tour must be shielded from view so even inadvertent inclusion in the tour will not be possible.
     
    5. Physicians and staff will be notified when a tour will be entering a patient care area.
     
    6. The committee chair should be informed that a guest will attend the meeting.
      
  •  Before the meeting begins, the chair should inform the committee that a guest is participating and that, when possible, patient-identifying information should not be disclosed. The chair should remind the participant that all information discussed during the meeting is confidential. No documents that contain patient identifying information should be provided to the guest. The committee members may refer to the patient by a medical record number or initials.
      
  •  The committee minutes should reflect that the participant is an invited guest at the meeting, has signed a confidentiality agreement and the participant's attendance is not a waiver of confidentiality or privilege.
     
    7. At the conclusion of the tour or program, the participants should be given an opportunity to ask questions about the information received and to clarify any confidentiality issues.
     
    8. Behavior by tour participants that is disrespectful, disruptive or intrusive to patients or staff will not be tolerated. Any such behavior will result in immediate conclusion of the tour.


    Source: Printed with permission of Lois Wischkaemper, general counsel for the UMC Health System in Lubbock, TX.

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