Inappropriate delegation of authority can refer either to the delegation of too much authority or to the delegation of too little. Over delegation of authority is most serious when it results in nonphysicians exercising medical judgment. This can arise either in the process of directly delivering care or during the establishment of administrative rules governing the delivery of health care. The most common direct care problems involve nurses who are put in the position of screening patients' requests to see a physician. These may be patients seeking care at the emergency room or patients on the floor who wish to see a physician. In the first case, the hospital must be careful that no patient is turned away from the emergency room without seeing a physician. Even in states that do not statutorially require the rendering of emergency medical care there can be substantial liability for refusing care in a situation where a patient has relied on the hospital's representation that it offers emergency medical care. This problem can be prevented by logging in each patient on a computer, then using the computer to ensure that the patient is not ignored.
The hospitalized patient who requests to see a physician presents a special problem because there is a duty to care for the patient and because a hospital is clearly liable if the nursing staff injures a patient by denying the patient access to a physician. This is an example of the type of problem that must be explicitly addressed in the nursing protocols. As discussed later, a major quality control activity is the reviewing and updating of nursing protocols to eliminate risks. This is not enough, however. There must also be an educational program to ensure that all nursing personnel, especially contract nurses, are aware of all changes in the protocols. This educational function is critical to an effective quality control program, because it ensures that the staff members (both medical and nursing) understand their roles in the quality control program.
The problem of too little delegation of authority arises when questions that require timely answers are reserved for high-level administrators or medical staff committees. If, for example, the decision to admit an emergency patient without insurance is left to the chief administrator, there will be many times when that administrator is unavailable to make the decision. This can create severe legal problems if the administrative delay results in injury to the patient. This problem is exacerbated when the decision is left to a committee, because it is extremely difficult to have committee meetings on short notice. It is thus essential to ensure that all decisions that must be made in a timely manner are not dependent upon personnel who may be unavailable. The quality control program should always be structured as a "fail-safe" system, in which the inability to find the proper person to make a decision will not interfere with the rendering of needed medical care.
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