NorthShore University HealthSystem (“NorthShore” as defined below), including but not limited to Evanston Hospital, Glenbrook Hospital, Highland Park Hospital, Skokie Hospital and Swedish Hospital, is dedicated to our patients and ensuring that each patient is treated with dignity and as a partner in care. We will care for you with skill, compassion, and respect. We believe that our patients receive the best possible care when they participate with our medical staff in their medical treatment. Toward that goal, please be aware of your rights and responsibilities as a NorthShore patient, or when you are a parent, guardian, representative, or legally authorized decision-maker of a patient.
As a patient, you have the right to:
You will have access to medical treatment, care, and services that are available or medically indicated, regardless of race, color, ethnicity, national origin, sex, age, mental or physical disability, sexual orientation, genetic information, socioeconomic status, religion, culture, language, gender identity or expression, source of payment, or any other status protected by relevant law. You may contact and speak with the physicians overseeing your care. Disrespect and discrimination are not tolerated at NorthShore. You will have access to information regarding existing laws prohibiting disrespectful or discriminatory treatment, and an appropriate amount of time to fully discuss any concerns or questions you may have about any disrespectful or discriminatory treatment. Your treatment will occur in a clean and safe setting consistent with NorthShore policies, programs and applicable laws, rules, and regulations relating to environmental health and safety, including the protection of vulnerable patients such as newborns and children and patients at risk of self-harm or harm to others.
You have the right to a choice of health care providers that is sufficient to ensure access to appropriate and high-quality healthcare. You have the right to efficient care, within NorthShore’s capacity and policies, and an explanation of delays in treatment. You have the right to expect that, within NorthShore’s capacity and policies, it will reasonably respond to your request for appropriate and medically indicated care and services, and that NorthShore will provide evaluation, service, and/or referral as indicated by the urgency of your case. When medically appropriate and legally permissible, or when you have so requested, you may be transferred to another facility, if such facility accepts you for transfer. You will have comprehensive information and any relevant explanation concerning the need for, risks, benefits, and alternatives to such transfer. You will be informed of any continuing healthcare requirements. You have the right to know the reasons for your transfer, either within or outside the NorthShore.
You have the right to contact and speak with the physicians ordering your care. You will have access to protective services, and may ask your nurse to contact a social worker to assist you, as needed. You will have the right to care consistent with sound medical practices, to be informed of the name of the physician responsible for coordinating care as well as any other information regarding such physician applicable to your treatment, to receive information concerning your condition and proposed treatment, and to refuse any treatment to the extent permitted by law. You will have access to people outside of the hospital, including but not limited to a spouse, a domestic partner (including a same sex domestic partner), another family member, friend, or legal representative whether through visits, verbal contact, or written contact, including private telephone conversations as appropriate to the clinical setting as required by law and NorthShore policies. You have the right to withdraw or deny your consent to receive visitors at any time. NorthShore will not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. There may be instances where NorthShore asks that your support person not be present. These times may include but are not limited to: (i) when you are undergoing a care intervention or procedure; (ii) when there may be an infection control issue; (iii) when you need rest or privacy; (iv) when there are existing court orders restricting contact of which the hospital is aware; or (v) a visitor becomes disruptive, threatening, or violent. Please check with your care provider for any unit-specific visitation guidelines.
You have the right to receive certain information about NorthShore within NorthShore’s capacity and policies, including the corporate form of the facility, accreditation status, whether specialty programs meet established guidelines, the volume of certain procedures performed at the facility, consumer satisfaction measures, clinical quality performance measures, service performance measures, procedures for registering a complaint and achieving a resolution of such complaint, the availability of translation or interpretation services for non-English speakers and people with communication difficulties, numbers and credentials of providers of direct patient care, whether the facility’s affiliation with a provider network would make it more likely that a consumer would be referred to health professionals or other organizations within that network, and whether the facility has been excluded from any Federal health programs.
You have the right to have your symptoms treated in the event of a life-limiting illness. NorthShore will work with you to prevent or manage pain and discomfort, and to provide you and your family support for your concerns related to dying and grief. To achieve optimal pain management, it is important to communicate your pain management needs with your physician and others responsible for your care.
II. Respect and Dignity
You will obtain considerate and respectful care. You have the right to have your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected. You have the right to access pastoral care (spiritual care) services. You will be treated as an individual, with unique needs and desires. You have the right to be free from mental, physical, sexual, and verbal abuse, neglect, harassment, and exploitation. You will be free from restraint and seclusion except as otherwise required by law or NorthShore policies.
III. Information Disclosure
You will receive from direct caregivers relevant, current, accurate, and understandable information concerning diagnosis, treatment, and prognosis within NorthShore’s capabilities. You have the right to review the records pertaining to your medical care and to have the information explained or interpreted as necessary, except when restricted by law, and to request amendments to your medical record in accordance with NorthShore policies. You have the right to receive this information, once requested, within a reasonable timeframe. You will receive information pertaining to NorthShore’s experience performing relevant procedures and services, accreditation status, comparable measures of quality and worker and consumer satisfaction, procedures for resolving complaints, and community benefits provided. You have the right to examine and receive a reasonable explanation of the total bill for services rendered by your health care provider, including itemized charges and a reasonable explanation for the specific services provided.
You have the right to know the identity of physicians, nurses, and others involved in your care, as well as when those involved are students, residents, or other trainees. You have the right to know the immediate and long-term financial implications of treatment choices, to the extent that such implications are known at the time of treatment. You may ask and be informed of the existence of business relationships among NorthShore, educational institutions, other health care providers, or payers that may influence your treatment and care. You may discuss with NorthShore personnel factors such as methods of compensation, ownership of or interest in health care facilities, or matters of conscience that could influence advice or treatment decisions.
You have the right to be informed of NorthShore policies and practices that relate to your care, treatment, and responsibilities. You have the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available to you, as applicable. You have the right to be informed of NorthShore’s charges for services and available payment methods. You have the right to have a family member or representative of your choice and your own physician notified promptly of your admission to the hospital.
If you are a Medicare beneficiary, you have a right to be provided with the standardized notice “An Important Message from Medicare (IM)” within two days of admission, and again in advance of discharge, but no more than two calendar days before discharge, unless the initial IM is delivered within two calendar days of the discharge.
IV. Participation in Treatment Decisions
You have the right to meaningfully participate in all decisions related to your healthcare, including but not limited to the development and implementation of your plan of care. If you are unable to meaningfully participate in treatment decisions, you have the right to be represented by a parent, guardian, family member, or other conservator, as permitted by applicable law. Except in emergency situations where you lack decision-making capacity and the need for treatment is urgent, you are entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risks involved, the possible length of recuperation, and the medically reasonable alternatives and their accompanying risks and benefits. You will be provided with explanatory information and an opportunity to decide among treatment options consistent with the informed consent process and NorthShore policies. NorthShore personnel will discuss all treatment options with you in a culturally competent manner, including the option of no treatment at all, and will ensure that, if you have a disability, you have effective communications in making such decisions. NorthShore personnel will discuss all treatments you may be undergoing, including those alternative treatments that are self-administered, if applicable, as well as risks, benefits, and consequences of treatment and nontreatment, and give you the opportunity to refuse treatment and to express preferences about future treatment decisions. NorthShore will abide by your decisions and/or those of your designated representatives, if applicable, consistent with the informed consent process, NorthShore policies, and applicable laws, rules, and regulations. You have the right to read carefully and make sure that you understand any form before signing.
You have the right to make decisions about the plan of care prior to and during the course of treatment, and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy, and to be informed of the medical consequences of this action. In the case of such refusal, you are entitled to other appropriate care and services that NorthShore provides or to transfer to another hospital. NorthShore will advise you of any policy that might affect your choice within NorthShore, to the extent known by NorthShore.
You may consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. If you are unable to consent, your guardian, spouse, parent, or authorized agent may have the opportunity to consent. If you or your agent, as applicable, declines to participate in research or experimentation, you are entitled to the most effective care that NorthShore can otherwise provide.
You have the right to confidentiality of records, and to expect that all communications and records pertaining to your care will be treated as confidential, except as otherwise required, authorized, or permitted by applicable law or NorthShore policy. NorthShore will abide by its privacy policies, which are available to you.
VI. Continuity of Care
You have the right to know who is in charge of your care, and the identities of your physicians, other caregivers, and their respective roles in your care, including the reasons for any proposed change in the professional staff responsible for your care. You will receive continuity and consistency of care within our medical facilities. You have the right to expect continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.
VII. Advance Directive
You have the right to an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker to the extent the intent of such directive is permitted by law and NorthShore policy. You may discuss such advance directive with NorthShore personnel. Your access to care, treatment, and services, however, is not dependent upon whether or not you have an advance directive.
You have the right to every consideration of privacy except as otherwise provided by applicable law, rule, or regulation. Case discussion, consultation, examination, and treatment shall be conducted so as to protect your privacy. NorthShore will abide by its privacy policies, which are available to you.
IX. NorthShore Affiliated Covered Entity
For purposes of the Health Insurance Portability and Accountability Act of 1996, and its regulations (“HIPAA”), certain operations and affiliates of NorthShore University HealthSystem (including but not limited to Evanston Hospital, Glenbrook Hospital, Highland Park Hospital, Skokie Hospital and Swedish Hospital) have designated themselves as a single integrated enterprise known as the “NorthShore Affiliated Covered Entity” or “NorthShore ACE”. The NorthShore ACE designation may be amended periodically to modify its participants. NorthShore ACE participants may share or have access to your health information at their locations as permitted by law. You may consult our Notice of Privacy Practices for the list of NorthShore ACE participants. The terms “NorthShore”, “we,” and “our” in this document refer to the NorthShore ACE participants collectively.
NorthShore will work to educate you about the appropriate use of emergency department services as applicable. You have the right to a fair and efficient process for resolving grievances with NorthShore, as provided in NorthShore’s policies.
As a patient, you have certain responsibilities to ensure effective and appropriate care, which include but are not limited to:
I. Following Rules and Regulations
You are responsible for abiding by the rules and regulations of NorthShore, including but not limited to those pertaining to concealed carry and non-smoking. You and your visitors are responsible for being considerate of NorthShore personnel and property and for being considerate of the needs of other patients by helping to control noise and other disturbances.
II. Information Disclosure
You are responsible for providing accurate and complete information about your illnesses, hospitalizations, medications, and other matters related to your health status. You are responsible for providing necessary information for insurance claims and working with NorthShore to make payment arrangements, when necessary. You are responsible for providing a copy of your advance directive and a list of home medications upon admission. You and your family are responsible for reporting any perceived risks that may affect your care and any unexpected changes to your condition.
III. Complying with Treatment Plans and Following Instructions
You are responsible for complying with the treatment plans and instructions for your care as provided by your caregivers. If you do not understand the instructions or what you are expected to do, you should ask questions and seek clarification.
IV. Remaining Informed
To participate effectively in decision making, you must take responsibility for requesting additional information or clarification about your health status or treatment when you do not fully understand the information and instructions provided by healthcare personnel. You are responsible for ensuring that NorthShore has a copy of any applicable advance directive, and for informing your physicians and your caregivers, as applicable, if you anticipate problems in following any prescribed treatment.
A person’s health depends on much more than health care services. You are responsible for recognizing the impact of your life-style on your personal health.
V. Reasonable Accommodations
NorthShore has an obligation to be reasonable, efficient and equitable in providing high quality care to other patients and the community. NorthShore’s rules and regulations are designed to help it meet these obligations. You and your family and caregivers, as applicable, are responsible for making reasonable accommodations to the needs of NorthShore, other patients, medical staff, and hospital employees.
Greater individual involvement in your health care increases the likelihood of achieving the best outcomes and helps support a quality improvement, cost-conscious environment. You have the obligation to otherwise assist NorthShore in its provision of care to you in ways that are reasonably requested by NorthShore personnel. You should: (i) become involved in specific healthcare decisions; (ii) work collaboratively with health care providers in developing and carrying out agreed-upon treatment plans; (iii) avoid knowingly spreading disease; (iv) recognize the reality of risks and limits of the science of medical care; and (v) make a good faith effort to meet financial obligations, and abide by administrative and operational procedures of NorthShore.
An environment of mutual respect is essential to maintaining a quality health care system, and accordingly, you agree to treat all individuals you encounter in any NorthShore facility with respect and dignity, including respect for other patients’, visitors’ and hospital staff’s rights in order to maintain a safe and quiet patient care environment, and respect of property belonging to the hospital or persons within the hospital. Patients are also expected to refrain from language or behavior (physical or non-physical) that is offensive, abusive, or intimidating.
If you have concerns:
In compliance with hospital policies and relevant laws, rules, and regulations, NorthShore provides the opportunity for all patients to express their concerns about the quality of care, language assistance services, or premature discharge through a grievance mechanism. The hospital has established a process for the prompt investigation and resolution of patient grievances. First, we encourage you to share your concerns with your providers so that they can assist you in resolving your concerns. The patient or a representative may also contact NorthShore’s patient services team at: 224.364.4968 or email: email@example.com for further assistance.
If you would like to take your grievance to a third party, you may contact:
The Illinois Department of Public Health
525 W. Jefferson St.
Springfield, Illinois 62761-0001
Telephone (hearing impaired use): 1.800.547.0466
With respect to a NorthShore location:
The Joint Commission, Office of Quality and Patient Safety
One Renaissance Blvd.
Oakbrook Terrace, Illinois 60181
With respect to a Swedish location:
Healthcare Facilities Accreditation Program
c/o Complaint Department
506 North Clark, Suite 301
Chicago, IL 60654
or via online complaint form at: https://www.hfap.org/resources/complaint-information/
If you are a Medicare beneficiary, you or your representative may file a grievance regarding the quality of care or coverage decisions, or appeal a premature discharge with LIVANTA LLC (A Medicare-approved Quality Improvement Organization) at 1.888.524.9900 or online at: https://livantaqio.com/en/beneficiary/quality_of_care.
If you have concerns about our compliance with our non-discrimination policies, you may contact the United States Department of Health and Human Services, Office of Civil Rights Complaint Portal, available at http://ocrportal.hhs.gov/ocr/portal/lobby.jsf or mail or by phone:
U.S. Department of Health and Human Services
200 Independence Avenue SW
Room 509F, HHH Building
Washington, DC 20201
Complaint forms are available at: www.hhs.gov/ocr/office/file/index.html
Updated September 29, 2020