Equal Visitation Overview
Why an Equal Visitation Policy?
Research and experience have shown that a patient’s access to visitors is a crucial part of the healing process. Yet LGBTQ people have been denied the same access to their loved ones as other patients and visitors. To help remedy this discriminatory practice, President Obama issued a memorandum in April 2010 ordering the Department of Health and Human Services to guarantee the visitation rights of LGBTQ people, inspired by the tragic experience of Janice Langbehn, Lisa Pond and their children, who were kept apart by discriminatory hospital officials as Lisa lay dying.
When inpatient healthcare organizations explicitly guarantee equal visitation to LGBTQ patients, they offer vital assurance to patients and clear guidance to employees.
The Joint Commission and CMS Standards
In 2011, in response to the President’s memorandum, the Centers for Medicare and Medicaid Services (CMS) revised their CMS Conditions of Participation to require covered facilities to “not restrict, limit or deny visitation privileges” based on sexual orientation or gender identity. The Joint Commission simultaneously aligned its visitation standards (see RI.01.01.01 EP 2 Note) with the CMS requirements. Revisiting Your Hospital’s Visitation Policy, a joint publication from HRC and the American Health Lawyers Association, details the CMS’ and The Joint Commission’s requirements and provides a wealth of other background information, as does The Joint Commission LGBT Field Guide. In addition, some state laws guarantee equal LGBTQ visitation.
CMS explicitly requires that hospitals must adopt written policies and procedures concerning patients’ visitation rights, including any clinically reasonable and necessary restrictions or limitations on visitation. Additionally, hospitals must provide notice to patients or support persons of their visitation rights, including the right to receive visitors designated by the patient. Hospitals may not deny visitation privileges based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
The Joint Commission also requires hospitals to have written policies that address procedures regarding visitation rights, aligned with the same CMS standards of allowing the presence of a support individual of the patient’s choice, and prohibiting discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.
To receive credit in the HEI:
- An organization must document that it has an LGBTQ-inclusive equal visitation policy
- The policy is communicated to patients in at least two of the following ways:
- Posted on facility website
- Posted or displayed in waiting rooms and other public areas of the facility
- In materials routinely given to patients at admitting/registration
- In materials routinely given to patients at other time(s)
- In materials routinely available for take-away in waiting areas
- Posted in waiting area(s)
- An organization must inform its employees of its equal visitation policy in at least one of the following ways:
- Posted on facility intranet site
- Posted in employee work area(s)
- In materials routinely given to employees at orientation
- Reviewed in in-person employee training
- Reviewed in online employee training