by Alex Dores, BSN, RN, CJCP
Accreditation Advisor

The COVID-19 pandemic has brought forth great uncertainty to many nations around the globe and it is certainly an opportunity to ponder and reflect on the value of life and justice. As our nation adjusts to a new reality, we begin to hear of health care practices and life-or-death decisions once thought unfathomable. News abounds regarding shortages in life-saving equipment, patients being cared for in hallways, family members prevented from holding their loved ones during their last breath and morgues at full capacity. However, as overwhelming as this may be, it is also an important time to reflect on human rights and the rights of patients.

On March 28, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) issued a bulletin to ensure that entities governed by civil rights authorities keep in mind their obligations under laws and regulations that prohibit discrimination on the basis of race, color, national origin, disability, age, sex, and exercise of conscience and religion in HHS-funded programs, including in the provision of health care services during COVID-19.

For hospitals accredited by The Joint Commission (TJC) or certified by the Centers for Medicare and Medicaid Services (CMS) and required to meet the Conditions of Participation (CoPs), this is an exceptionally important time to remind ourselves of standards and requirements which exist to protect patients and their rights. The following list is by no means all-inclusive but I hope that it will support your organization as you evaluate new practices in response to COVID-19 patient influx, keeping at the forefront the need to ensure that patient rights are observed and preserved:


As hospitals and health care facilities reach physical capacity, expanding patient care units and/or placing patients in locations not primarily designed to house them may be necessary. However, it is important to consider and uphold patient privacy and the privacy of protected health information, regardless of location. Good practices to follow include ensuring that patients are adequately covered with appropriate bed sheets, blankets and gowns and that protected health information is stored out of public sight.


To contain the spread of the COVID-19 virus, many hospitals have changed their visitation policies or restricted visitors altogether. This is a good time to reassess how these policies are being shared with patients and families to ensure that patients’ rights are respected, protected and promoted. If they haven’t already, hospitals should consider alternate ways for patients to contact their families or loved ones by providing remote or virtual options.    


During times of great upheaval, when health care workers are likely practicing beyond capacity, attitudes and opinions can be significantly impacted. Even so, minority and/or vulnerable patient populations, such as geriatric or pediatric patients, patients with disabilities or non-English speaking patients must continue to be protected. Strategies include frequent security assessments of new or modified environments of care and ensuring the availability of language or interpretation services in all locations to maintain awareness.

Environment of Care® and Life Safety

Environmental changes, such as expanded medical units or alternate sites, may be extensive and frequent because of the high influx of patients in response to the demands of a pandemic, however the environment and any associated fire risks must be evaluated and safety maintained. Strategies include adequate pre-occupancy assessments of new areas from an Environment of Care and Life Safety perspective, ensuring there are alternate means of egress, and that fire extinguishers and medical gas shut-off valves are accessible. 

Patient care

Changes in protocols may be implemented in response to the COVID-19 pandemic, yet it’s essential to remember that assessments, reassessments, pain management and fall prevention strategies should be closely monitored to ensure that patient needs are met for all patients.

Infection prevention and control

While hospitals are faced with unprecedented infection prevention and control challenges during the COVID-19 pandemic, it bears repeating that even at a time of personal protective equipment (PPE) shortages, basic infection prevention practices should, to the best of our ability, be prioritized and maintained as a patient’s right.

In summary, patient rights stretch far beyond the Rights of the Individual chapter of TJC requirements, they should be observed and applied in any time and space. As health care workers and providers, we must help uphold and safeguard those rights for our patients.

For helpful information and valuable resources during this pandemic, visit the Vizient COVID-19 resources page.

About the author. An advisor on the Vizient Accreditation Advisory Services team, Alex Dores provides content expertise on CMS Conditions of Participation and The Joint Commission Accreditation Standards interpretation to member organizations. Prior to joining Vizient she served as director of accreditation and clinical regulatory for a large multi-state health system that included acute care hospitals, ambulatory surgery centers, cancer centers and assisted living facilities. Dores has also served in various capacities as a registered nurse in both clinical and leadership roles, working in the emergency and pediatric perioperative settings.