Status Active PolicyStat ID 13130512

Original 08/1988 Owner Sandy George:

VP Quality/Risk
Approved 03/2023
Mgmt/Safety
Last Revised 03/2023
Policy Area LD - Leadership
Next Review 03/2026
Applicability Orange Park
Medical Center

Chain of Command, LD.0010

SCOPE:

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This document applies to all employees of Orange Park Hospital (OPH).

PURPOSE:
A. To provide a Chain of Command for healthcare providers, when physicians or others are not
responding to a patient's condition or in the event there is a disagreement or lack of action
regarding patient care.
B. The policy is designed to provide appropriate direction for the prompt handling of patient care
issues.
Note: This policy makes available a formal line of communicating for staff members who have
concerns that a prescribed treatment plan (or lack thereof) or a medical decision or other
medical act might adversely affect the welfare of a patient or that of the hospital.
C. The Policy provides guidelines for staff to report the following items as they pertain to our
patients:
1. Changes in patient's condition
2. Ethical issues
3. Compliance issues
4. Other concerns related to patient care, safety or quality.

Definitions:
A. Chain of Command: The lines of authority and responsibility within the hospital administration
and 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 dare issue or hospital issue.

Chain of Command, LD.0010. Retrieved 01/2024. Official copy at http://hca-orangepark.policystat.com/policy/13130512/. Page 1 of 4

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 B. Duty of Care owed by a Nurse: In general, a professional nurse has the duty to exercise the
degree of care and skill ordinarily employed under same or similar circumstances, by the
members or his/her profession in good standing in the same or similar community or locality,
and to use reasonable care and diligence, along with exercise of professional judgment.
C. Duty of Care owed by all other professional licensed and/or certified staff:
The same standard as required of nursing and individual licensing and certification boards.

POLICY:
A. Orange Park Hospital (OPH) Nursing, Professional (licensed/certified) 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. In the event a physician or other healthcare provider is unresponsive to concerns about the
patient's condition, or is making patient care decisions that are not consistent with accepted
standard of care or in the event there is a disagreement, lack of action or concern for a
patient's safety, nurse's and all other professional licensed/certified staff have a duty to
advocate for the patient through the organization Chain of Command.

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1. It is the responsibility of the nurse caring for the patient to initiate the Chain of
Command.
2. This is done in consultation with the Charge Nurse, Nurse Manager, Administrative
Supervisor, Director and if necessary the Chief Nursing Officer (CNO) or the Chief
Operations Officer (COO) for OR, Administrator-On-Call and the Chief of Staff.
3. For other professional licensed/certified staff, this is done in consultation with the
Supervisor, Manager, Administrative Supervisor, Director and if necessary the "O"
(COO, CFO, VP of Operations, CNO, CMO) responsible for the department,
Administrator-On-Call and the Chief of Staff..

PROCEDURE:
A. After the Nurse nurse's and all other professional licensed/certified staff (hereinafter referred
to as Nurse) evaluates the patient or care request within the scope of his/her practice
expertise and the prescribed treatment regimen and makes the determination that there is a
patient management issue, he/she shall contact the attending physician to obtain clarification
of the orders or prescribed treatment.
B. If, after discussion with the attending physician, the Nurse remains concerned that compliance
with the order would pose a clear risk of harm to the patient 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. The Nurse should inform the healthcare provider that he/she has care
considerations and will be invoking the Chain of Command.
2. If no satisfactory response is received, the nurse would:
a. Advise and consult the Charge Nurse (Supervisor);
b. Advise and consult the Nurse Manager (Manager), Administrative

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 Supervisor or Director of the situation.
c. 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 while invoking the
Chain of Command process.

C. In emergent situations (Life Threatening) the Nurse may call the on-site Intensivist to evaluate
the patient and/or medical orders and take appropriate action as needed.
1. The Intensivist will call the attending physician to discuss the case.
2. If the Intensivist is not available the nurse may initiate the Rapid Response Team.
3. Advise and consult the Charge Nurse (Supervisor), Nurse Manager (Manager),
Administrative Supervisor or Director of the situation.
Note: Document such notification in the patient's medical record, including date,
time and person notified and what was communicated or decided during the
exchange.

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D. In non-emergent situations, the Charge Nurse (Supervisor), Nurse Manger (Manager),
Administrative Supervisor or the Director will investigate the issue and contact the following:
1. Attending physician
2. Chairman of the department of the physician involved
3. Chief of Medical Staff, if the Chairman of the department is involved

E. If no resolution is reached after collaboration by the Nurse leaders, advise and consult the
CNO (or appropriate "O") and Administrator-On-Call will be notified.
F. The CNO (or appropriate "O") and Administrator-On-Call, in conjunction with Medical Staff
Leadership will provide a resolution to both Nursing and physician's satisfaction.
G. In situations of interdepartmental conflict, the Charge Nurse (Supervisor), Nurse Manager
(Manager), Administrative Supervisor or the Director will investigate and contact:
1. Director of the department involved
2. Administrator on call

H. All incidents that involve patient care concerns are to be reported to the Director of Risk
Management (RM).
Note: An online RM Notification detailing the Chain of Command issues will be completed by
the Nurse (Staff) involved before the end of the shift on which the event occurred.
I. Documentation:
1. The Nurse (Staff) who is responsible for initiating the chain of command process
will document the patient care assessment factors involved, the conversation with
the patient's physician and the Charge Nurse (Supervisor), Nurse Manager
(Manager), Administrative Supervisor or Director and any other pertinent facts
related to the process, along with date and time, in the patient's medical record.

Chain of Command, LD.0010. Retrieved 01/2024. Official copy at http://hca-orangepark.policystat.com/policy/13130512/. Page 3 of 4

Copyright © 2024 Orange Park Medical Center
 2. All previous documentation will be reviewed for complete verification of the process.

REFERENCES:
A. (2013) Joint Commission e-Edition. LD.2.20 pg LD10
B. HCA Chain of Command Sample Policy. Retrieved from website: http://atlas2.medcity.net/
portal/site/atlas
C. The Florida Statutes Chapter 464 Nursing Nurse practice Act (ss.464.001-464.027)

Approval Signatures

Step Description Approver Date

Sandy George: VP Quality/Risk 03/2023

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Mgmt/Safety

Applicability

Orange Park Medical Center

Standards

No standards are associated with this document

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Copyright © 2024 Orange Park Medical Center