Medjuris M2L4 Hospital Regulation PDF

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REGULATION OF HOSPITALS ATTY. MAMENTA

JANUARY 21, 2019

Outline I. Definition of Hospitals II. Classification of hospitals as to ownership, scope of service and functional capacity III. Role of the Department of Health- Health Facilities and Services Regulatory Bureau IV. Overview of DOH-mandated standards V. Civil liabilities VI. Doctrine of Respondent Superior VII. Doctrine of Apparent Authority VIII.Doctrine of Corporate Negligence IX.BP 702 as amended by RA 8344 and RA 10932 and its Implementing Rules and Regulations X.RA 9439 and its Implementing Rules and Regulations

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Italics – Transers Note- Mej mahirap sundan ung lecture ni attorney ☹

Definition of Hospitals Hospital •

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A place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other medical nursing care. Any institution, building or place where there are installed beds, or cribs, or basements for 24-hour use or longer by patients in the treatment of disease, injuries, etc.

Classification of Hospitals According to Ownership Government o Operated and maintained either partially or wholly by the government, or by aby department, division, board, or other agency of the government. o Government hospital created by law (DOH AO 2012-0012, Rule V. B. 1. a. 1) • Private o Privately owned, established, and operated with funds raised or contributed through donations, or by private capital of other measures. (Hospital Licensure Act (RA 4226)) •

REGULATION OF HOSPITALS State Regulation o Statutory basis; Hospital Licensure Act (RA 4220) and its implementing rules and regulations. • Self-Regulation o For discipline, order, convenience and other reasons that governing board of the hospital decides. •

DOH Mandated Standard • • o • o

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According to Scope of Service General o Provides services for all kinds of illnesses, diseases, injuries and deformities. o Equipped with service capabilities needed to support medical specialists and other licensed physicians rendering various clinical services, emergency services, outpatient services and ancillary and support services. ▪ Clinical services ✓ Family Medicine ✓ Pediatric ✓ Internal Medicine ✓ Obstetrics and Gynecology ✓ Surgery • Specialty o Specializes in a particular disease or condition or in one type of patient

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Every health facility shall be organized to provide safe, quality, effective and efficient services for patients Personnel Adequate number of qualified, trained and competent staff to ensure efficient and effective delivery of quality services. Physical facilities With adequate areas to safely, effectively and efficiently provide health services to patients as well as members of the public as necessary. Equipment and Instruments Available and operational equipment and instruments consistent with the services it will provide. Services delivery Ensure that services delivered to patients comply with the standard quality embodied in the Assessment Tool for licensure or accreditation of health facilities, other policy guidelines and/or related issuances. Quality improvement and activities Establish and maintain a system for continuous quality improvement activities. Information management Maintain a system of communication, recording and reporting of results of examinations. Environmental management Ensure that the environment is safe for its patients and staff including members of the public as necessary.

According to Functional Capacity • • •

Civil Liabilities

Level 1 Level 2 Level 3

Transcribed by: Moldez

• • Checked by: THs

Doctrine of Respondent Superior -indirect Doctrine of Apparent Authority- indirect Page 1 of 4

HOSPITAL REGULATION

Doctrine of Corporate Negligence

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Suitability and Liability: Government vs Private Hospitals Government Hospital- State owned May not be sued “ without its consent” (Art. XVI, Sec 3, Constitution) o If it consents, it may be held liable only if it acts through a special agent. (Art 2180, Civil Code) • Private Hospital o Charitable ▪ Pays no dividend, has no capital stock, seeks no profit ▪ May be granted immunity at best (since they would bill patients lower) o Operating for profit ▪ No immunity •

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Vicarious/Indirect Liability: Respondeat Superior Doctrine “Let the master answer” Art. 2176, Civil Code. Whoever by act or omission causes damage to another, there being fault of negligence, is obliged to pay for the damage done. o Art. 2180, Civil Code. The obligation imposed by Article 2176 is demandable not only for one’s own acts or omissions, but also for those persons for whom one is responsible. So, for this doctrine, you pay for the damage that you caused but its not only the person who caused the damage that can be held liable, it can also be its superior, its employer, its principal. o Art 2180, Civil Code. The owners and managers of an establishment or enterprise are likewise responsible for damages cause by their employees in the service of the branches in which the latter are employed or the occasion of their functions. Meaning as long as the employee did the act or omission within the scope of its responsibility or scope of service, the employer shall be held liable for the damages caused by the employee acting within the scope of its assigned task. o …Employers shall be liable for the damages caused by their employees… acting within the scope of their assigned task. • Requisites: Employer- Employee Relationships o Employee was chosen by the owner, manager or employer personally or through another. o The services of the employee are to be rendered in accordance with the orders which the employer has authority to give at all times. If pasaway lang talaga si empleyado, unfair naman kay employer to be held liable. o The wrongful act of the employee was on the occasion or by reason of the functions entrusted to him/her. • Four-Fold Test (Determining Employer-Employee Relationship) o Selection and engagement of services “The power to hire” o Payment of wages or salaries o The power to fire; and o The power to control conduct If one is missing there’s no employer-employee relationship o

Employee Relationship Nursing staff • Nursing student • Staff RN • Special duty RN

Transcribed by: Moldez

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Medical staff • Medical intern • Resident Physician* • Consultant Physician

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The relationship of the Special duty RN is between the patient and the nurse on duty. It was the patient who hired the nurse, not the hospital. CASE 1- Employer-Employee Relationship Calamba Med vs NLRD GR 176484 According to this case the control test or the number 4 requirement of the four-fold test. An employment relationship exists between a physician and a hospital if the hospital controls both the means and the details of the process by which the physician is to accomplish his task. Also, a person who works for another who does so more or less at his own pleasure is not subject to definite hours or conditions of work. So, meaning that person can go to work anytime he wants, like a consultant, there is no employer-employee relationship. For the control test to apply it is not essential for the employer to actually supervise over the employee being enough that they have that power. As long as you have sorts of control over your employee like a code of conduct but if your employee is not covered by your code of conduct then you can say that you don’t have any control over that person. Case 2- Employer- Employee Relationship. GR 134354 In this case the hospital was held solely liable with its consultant because there was no Employer- Employee relationship between the Hospital and the Consultant who was at fault. The Hospital argued it does not hire or engage the services of a consultant but accredits the latter and grants him privilege of maintain a clinic and admitting patients to the hospital upon showing by the consultant that he possesses necessary qualifications such as accreditation by the appropriate board. The hospital was acquitted in this case because they were able to prove that there was no Employer-employee relationship between the hospital and the consultant neither is there any showing that the hospital which pays any of its consultant for medical services rendered by the latter to the respective patients. In cases where a disciplinary action is lodged against a consultant, the sign?? Is initiated by the department to whom the consultant concerned belongs and filled with the ethics committee consisting of the department’s specialty heads. The medical director, hospital administrator merely acts as officiant members of the said committee so there’s no power to fire. • Independent Contractor Theory o Independent Contractor- one whose physical activities in the performance of services is not controlled by, or subject to the control of the principal- which is the hospital. o The Independent contractor alone is liable for his wrongful acts; the hospital is exempt. Case ng buntis na pinadala ng isang consultant who needed the hospitals facilities to operate since emergency. There was negligence on the part of the consultant. The hospital was not to be held liable because of the negligence of the consultant because he/she is not an employee of the hospital but an independent contractor. • Borrowed Servant Doctrine o Hospital employees (e.g. resident doctors, nurses, etc.) are by fiction of the law borrowed from the hospital by whoever has temporary control and supervision over them while performing their duties.

Checked by: TH

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HOSPITAL REGULATION

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The new employee or master must be held liable for wrongful acts of the hospital employees committed under their temporary control and supervision where these wrongful acts were done in their service. (this is a defense available for the hospital daw) Art. 2180, Civil Code. The responsibility treated of in this article shall cease when the person herein prove that they observed all the diligence of a good father of a family to prevent damage. (i.e. the hospital observed ordinary care and diligence in the selection and supervision of the employee then they can be held not liable) This one applies particularly in the operating room, and is related to the captain of the ship doctrine. It says that upon the start of the operation it is the surgeon who has control over everything during the operation. A nurse who is part of the operation is a borrowed servant of the surgeon. The surgeon is the master even if the nurse is an employee of the hospital. So, whatever happens during the operation, the surgeon can be held liable for the negligent acts of the nurse.

Doctrine of Apparent Authority • •

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“Holding Out” Theory, Ostensible Agency, Agency by Estoppel Art. 1869, Civil Code. Agency may be express, or, implied from the acts of the principal, from his silence or lack of action, or his failure to repudiate the agency, knowing that another person acting on his behalf without authorit y. Its implied agency when the hospital made it appear that there are people who are not really its employees but by implied acts of the hospital it appears to patients that these persons hospital employees. So, there is no expressed admission with regards to who the principal’s agent is. Liable hospital dito pag may negligence sa mga agents nila. Express agency, you will say that “I am the principal, this is my agent and whatever the actions or omissions of my agent, I will be held accountable.” Art. 1431, Civil Code. Through estoppel, an admission or representation is rendered conclusive upon the person making it, and cannot be denied or disproved against the person relying thereon. So, if the patient relied on that agency then the hospital cannot disprove that. If you remember as a rule, a consultant is not an employee of the hospital, so it cannot be held liable under the respondeat superior doctrine because that requires employee-employer relationship. Tho, it can be held liable under the doctrine of apparent authority as an exception, the hospital will be liable for the physician’s negligence-> Where a hospital, by its actions, has held out a particular physician as its agent and/or employee and a patient has accepted treatment from the physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the physician’s negligence. Imposes liability, not as the result of the reality of a contractual relationship, but rather because of the actions of a principal or an employer in somehow misleading the public into believing that the relationship or the authority exists. So, if there was that misleading perception and the hospital did not do anything to correct that perception, then the hospital can be held liable.

Two Factors in Determining Apparent Authority Hospitals Manifestations ▪ Whether the hospital acted in a manner which would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital Some sort of implied manifestation from the hospital. Like in a form of listing down all your consultants, putting it in a bulletin board or newspaper, or whatever. o Patient’s reliance ▪ Whether the patient acted in reliance upon the conduct of the hospital or it’s agent, consistent with ordinary care and prudence. It’s like, if not for the implied actions from the hospital, the patient would not have chosen that doctor. *pro hac vice case* the decision is only applicable in this case due to a special circumstance. PSI vs Agana. So, the negligence here was when there were 2 gauzes left inside the patient which left to complications. The surgeon, no question was held liable, but in this case even the hospital was held liable since it admitted that it has corporate negligence. First factor- Hospital manifestation. The hospital publicly displays in the lobby of the medical city the names and specializations of the physicians accredited by it, including those doctors involved in the case Second factors- reliance of the patient. When the husband of the patient testified as to what compelled him to chose doctor A, it was clear that his decision was significantly influenced by the impression that the doctor was a staff member of The Medical City. Doctor A was not independent of but as integrally related to the hospital. •

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Direct Liability: Doctrine of Corporate Negligence • • •

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Transcribed by: Moldez

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“Doctrine of Corporate Responsibility” Those arising from failure of the hospital to fulfill its direct corporate obligations. Proceeds from the reality that in those modern times, the duty of providing quality medical services is no longer the sole prerogative and responsibility of the physician. Hospitals now tend to organize a highly professional medical staff whose competence and performance need to be monitored by the hospitals commensurate with their inherent responsibility to provide quality medical care. Primary Duties of Hospitals (Solis PP) Furnish a safe and well-maintained building and ground Furnish adequate and safe equipment Exercise reasonable care in the selection of the members of the hospital staff Corporate duties of Hospitals (Jurisprudence) Having sufficient number of trained nurses attending the patient Requiring a consultation with or an examination by members of the hospital staff Reviewing treatment rendered to the patient Using of reasonable care in the maintenance of safe and adequate facilities and equipment Selection and retention of only competent physicians Oversee and supervise as to patient care all persons who practice medicine within its walls and all its medical staff Formulation, adoption and enforcement of adequate rules and policies that ensure quality of care for its patients.

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HOSPITAL REGULATION

PSI vs Ag ana- Hospital liability was based on doctrine of apparent authority and corporate negligence, so the medical city was held liable on two grounds. Diba nakaiwan ng gauze, and there was evidence of that. The hospital has a corporate duty even after the operation to ensure the patients safety. The hospital admitted that it could have followed up the patient, but it did not do that duty to correct the negligence, there was inaction. Right there it failed its own standard of hospital care committing corporate negligence.

officer. Since the director is part of the hospital board wherein they elect the officers of the hospital kaya ayun.

Republic Act of 9349 •

Batas Pambansa 702 amended by RA 8344 and RA 10932 An act penalizing refusal of hospitals and medical clinics to administer appropriate initial medical treatment and support in emergency and serious cases. AKA “anti-hospital deposit law.” • Emergency- a condition or state of a patient wherein based on the objective findings of a prudent medical officer on duty for the day there is immediate danger and where delay in initial support and treatment may cause loss of life or cause permanent disability to the patient, or in the case of a pregnant woman, permanent injury or loss of her unborn child, or would result a non-institutional delivery • Serious case- a condition of patient characterized by gravity or danger wherein based on the objective findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause permanent disability to the patient, or in the case of a pregnant woman, permanent injury, or loss of her unborn child. • Unlawful acts in Emergency and Serious cases o Requesting, soliciting, demanding or accepting any deposit or any other form of advance payment as a prerequisite for administering basic emergency care, or for confinement or medical treatment of a patient. o Refusing to administer medical treatment and support as dictated by a good practice of medicine to prevent death or permanent disability or in the case of a pregnant woman, permanent injury or loss of her unborn child or noninstitutional delivery. • Other measures o The hospital must prominently display a copy of the Batas Pambansa 702 as amended at the hospital ER, counters, medical premises o The billing and collection procedures for treatment and confinement shall not commence until the essential, appropriate treatment has been completed. The hospital can collect after the emergency case has been treated or the serious case has been abated. What RA 10932 did was to increase the penalty • Penalties for official, medical practitioner, or employee o Imprisonment of not less than 6 months and 1 day but not more than 2 years and 4 months OR o Fine of not less than 100,000.00 but not more than 300,000.00 OR o Both • Penalties for Directors or Officers o Imprisonment of 4 to 6 years OR o Fine of not less than 500,000.00 but not more than 1,000,000.00 or o Both You might be confused bat may official tapos meron pang officer , wala daw mistake in part of the law, when we say director or officers here, the officer refers to the director of the hospital who is also an •

Transcribed by: Moldez

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An Act prohibiting the detention of patients in hospitals and medical clinics on grounds on non-payment of hospital bills or medical expense Before they require deposit just in case eventually walang pambayad si patient. Yung ibang hospital na hindi nag rerequire ng deposit, what they do is hindi nila pinapaalis hangat hindi bayad. This law actually excepts patients who were a...