Administrative Actions

The acts of administrative personnel are attributed to the hospital because these workers are directly under the control of the senior staff of the hospital. The hospital can be held liable for the following types of actions by administrators:

* intentional acts that harm patients

* negligent acts that directly harm patients

* negligent supervision of employees or medical staff members that results in patient injuries

* failure to comply with laws governing the reporting and management of public health diseases and violent injuries

Intentionally harmful acts, while rare, pose a special legal problem. The person doing the act would clearly be personally liable for any resulting injuries. The legal question is whether the hospital would be liable for actions that were not part of the person's duties as an employee. The degree of the hospital's liability depends on the foreseeability of the actions. While the hospital would have some liability for any harm to the patient, this becomes more important if the hospital should have anticipated the actions. If the hospital does not screen employees for potential mental problems or past episodes of aberrant behavior, its failure to do so would be a serious breach of the duty owed the patient.

Negligent acts that directly harm patients usually involve decisions by administrators that affect health care delivery to a specific patient, as opposed to policy decisions that may influence the care of all patients. Legally, the most dangerous acts are those that involve medical decision making. Administrative personnel are not permitted to direct either physicians or nurses in any activities that require the exercise of their respective professional judgments. If the administrator is expected to supervise the details of a nurse's work, that administrator must be a properly licensed nurse with a professional standing that is at least equal to that of the nurse being supervised. The administrator who is expected to supervise the delivery of physician services must be a licensed physician with hospital staff privileges appropriate to the actions being supervised.

The most common situation in which administrative personnel become involved in medical decision making is in deciding whether a patient will be admitted or treated by the hospital or clinic. The admission of a patient to a hospital is an act of medical judgment. This decision is made by members of the medical staff. However, in most facilities, administrative personnel review the decision through a determination of whether the patient has sufficient resources to pay the hospital bill. This puts the administrator in the position of being able to veto the admission of the patient. If a patient's admission is denied, there could be liability for any harm that results from the denial. In most cases, the decision to hospitalize a patient is an elective decision, and delaying the admission will not harm the patient.

The problem then shifts to the admitting physician. The physician may delay the admission until the patient can raise a deposit, may send the patient to a charity hospital, or may demand that the hospital reconsider its decision and admit the patient. If the physician chooses to either delay the admission or send the patient elsewhere, the hospital is absolved of its responsibility for the patient; the physician will be liable for any injury that the delay causes. However, by ratifying the hospital's decision not to admit the patient, the physician has reassumed the responsibility for the decision. If the physician chooses to demand that the patient be admitted, the hospital must either admit the patient or accept the responsibility for any harm that results from the denial of medical care. This is a difficult position to defend. The only acceptable ground for an administrative decision to deny a patient admission to the hospital is that there is not enough room for the patient or that the patient would pose a physical threat to the other patients. If the hospital relies on one of these grounds, it must be careful to document the exact circumstances of the refusal to admit the patient.

If the refusal is based on the patient's inability to pay (or other nonmedical criteria), the hospital must be able to document that the patient's condition did not require immediate hospitalization. To do this, the administrator must find a member of the medical staff who is willing to examine the patient and determine the seriousness of the patient's condition. If the physician is willing to certify that the patient is not in need of immediate hospitalization, the liability for delaying the patient's admission will shift from the hospital to the physician. In the absence of this second opinion, the hospital has no defensible course other than to admit the patient.

The central problem in allowing administrative personnel to make (or veto) medical decisions is that there is no effective legal defense if the decision is wrong. A physician who makes an incorrect decision can present testimony by other physicians to show that the decision was reasonable under the circumstances. The administrator is not allowed this defense because it is illegal for anyone other than a properly licensed physician to make a medical treatment decision. The administrator is limited to establishing that the mistake was not the proximate cause of the patient's injuries.

The most important area of liability for administrative decisions is in the establishment and maintenance of hospital protocols. These may be infection control protocols, incident reporting protocols, or any other protocols that influence the quality of medical care services. If a patient is injured because a protocol is negligently drafted or enforced, the hospital will be liable for any patient's injuries resulting from the negligence. As previously noted, there must be cooperation between the hospital administration and the nursing and medical staffs if the hospital protocols are to be effective. The administration must ensure that all proposed protocols embody proper professional standards and that all members of the medical and nursing staffs are acquainted with the protocols.

The most common violation of the public health laws is the failure of the hospital to ensure that proper reports are made when a reportable condition is treated. Most states require the reporting of gunshot wounds, communicable diseases, venereal diseases, and possible child abuse. These reporting laws create a duty for both the physician and the hospital because the hospital's duty to report is usually independent of the physician's duty. While many of the reporting laws carry only token penalties for a failure to report, their violation can also result in civil liability. This is especially true of the venereal disease and child abuse reporting laws.

A health care provider who is in violation of a public health reporting law is considered to be negligent per se. This means that the provider is assumed to have acted negligently and will be liable for damages if the plaintiff can prove that the negligence caused an injury. For example, if a provider suspected that a child under the provider's treatment was suffering from child abuse, in many states the provider would have a duty to report the possible abuse to the authorities. If the provider failed to report the possible abuse and the child was later seriously injured, a representative of the child could sue the provider for negligence.

Another legally significant problem involves the treatment of venereal disease. If the health care provider fails to report a case of syphilis, the provider could be liable to those contacted by the treated person because those persons could be liable to those contacted by the treated person because those persons could have been warned if the disease had been reported. This could be very damaging in the case of a married man seeking to have his syphilis treated clandestinely. If his wife is also infected, there would be a significant chance that any subsequent children would be born with congenital syphilis (a terrible condition with permanent sequelae). In this situation, the wife and child would have a strong cause for action against the provider. This type of liability can result from the violation of any of the laws that protect the public welfare.