Quality Aspects: Prof'l Licensing, Institution Licensing,
Internal Q Control, Hosp. Liab.
Prof'l Licensing of Practitioners
- License Bd
- Similarly Sit'ed Prof'ls
- License & set entry reqts 2 protect pub.
- Discipline 4 incompetence / malpract.
- Using Expert Testi.
- No need if specif. reg. being viol'ed
- Need experts otherwise
- Draw Line & Approp. Scope of Pract.
- Evid. Stand. 2 Revoke Dr.'s License
- Clear & convincing stand.
Licensing of Institutions
- License v. Certif.
- Can care 4 patients (pat.'s)
- Process 2 get paid 4 Medicaid/care/cal
- Joint Commission on Accreditation of Healthcare
- Priv., 4 profit, & vol. accreditation of
health care facilities
- Dif. Institutions
- Acute Care Hospitals
- Pat.'s very sick & not stay long
- Meet basic serv. & needs reqts
- Dept of Health Serv's 4 CA (DHS)
- Rev. phys. structure & operation
- Survey health facility
- Fed. certif. 2 partic. in Medicare/caid prog.
- Pract'ly need b/c
- Lots of pat.'s R under the prog.
- HMO K w/hosp's w/certif.
- HCFA K w/DHS so DHS surveys 4 them 2
- Fed Survey
- Pat. care oriented so look @ need, actual care
prov'ed, & pub. survey instrument in reg.
- Looks @ severity & scope of viol.
- Enforce by
- Term. Medicare prov'er
- Receiver / temp. mgmt
- Deny payment of any pat.
- Ban any new adm'ing pat.
- Civil $
- JCAHO's accreditation, then deemed status so
not need sep. survey 4 certif. of Medicare
- Full 3 yrs
- Conditionally accredit
- Less than full
- Type 1 accreditation where need 2 fix prob. w/in
- No / low oversight after license & accredit
- Transitional Care / Sub Acute Care (CA)
- Interm btwn acute & SNF
- Lwr in cost than acute
- Skilled Nursing Facilities (SNF)
- Long term care
- Less sick than acute
- Dr. only comes every 30 days
- Gen'ly sep. from acute but could B in hosp. as
- License is same reqt as acute care
- Fed survey certif.
- Filed w/in 14 days when res.'s enter
- Compl'ed 4X / yr / when res.'s conditin changes
- Res. assessment protocal (RAP) focus on specif.
- Actual written care ID'ing prob's, goals, &
- Operational dif. from acute
- No org.'ed med. staff
- Mostly C.N.A. & LVN instead of RN's
- Need licensed skilled adm. by bd of examiners
of nursing home adm'or (BENHA)
- Disciplinary Axns
- Interm. Sanctions of Citation Sys. in CA (only
- Class B
- Dir. / imm. rel. 2 health, safety, / sec. of
- Fine from $0-1k
- Class A
- Imm. dang. / subst'l probability of death /
- Serious harm 2 res.'s
- From $1k - 10k
- Class AA
- Class A req's +
- Viol. was dir. prox. cause of res.'s death
- 1st viol. in 1 yr, $10k - 25k
- Repeat viol. of same reg., fine can B 3X
- Can start license revocation
- Impact of Citation
- In priv. civil litig., est. neg. per se, inference
of neg., / rebuttable presumption (CA)
- DHS has rt. 2 revoke license
- Citation on adm'ors record
- Incentive 2 pay fine w/in 15 days, b/c then pay
- Appealing Citations
- Class B
- Appeal w/in 15 busi. days
- Go 2 informal citation rev. conference (CRC)
- Adm. law judge (ALJ) evid. hrg
- Can appeal CRC 2 ALJ
- If dislike ALJ
- Elect binding arb. by AAA /
- File writ of adm. mandamus
- Rev's adm. records w/subst'l evid. stand.
- Upholds dec. if any credible evid. in record
- Class A / AA
- CRC w/in 15 days /
- File axn / appeal 2 municipal ord. ct.
- File w/in 60 mo. that DHS ans's
- No rt 2 jury
- Appeal 2 superior ct. then appellate
- K'al Arb. Cl. of Condition of Adm. Form 4 SNF
& Other Institutions
- Binding & can't appeal unless fraud by arb'or
- No cap on damages
- Either in CCC / AAA form
Internal Quality Control
- Risk Mgmt
- All Hosp's Have This
- Look @ all potential source of liab.
- Quality Assurance (QA)
- Subset of Risk Mgmt
- Focus only on clinical care prov'ed
- ID prob's in care & way 2 improve
- Peer Rev.
- Subset of QA
- CA hosp's have aff. legal duty 2 take rsbl steps
2 ensure Dr's competence
- Must B ongoing
- Chart rev. / random med. selected & rev'ed
- Screening mech. by clinical indicators w/QA
process described in next section)
- Can't B Waived
- CEC §1157
- Record & prcg of med. staff & hosp. 4
incr.'ing care is immune from discov.
- Immunizes any entity of peer rev. under B &
P Code 805 (QA & peer rev.)
- Med. / prof'l staff
- Healthcare serv. plan reg.'ed / tech'l legal
- Any med., psychological, dental / podiatric prof'l
soc. w/25% eligible licentiates & nonprofit
- Committee org.'ed by entity of more than 25 licentiates
of same class fn.'ing 4 purpose of rev'ing
- Exception if
- Case is Dr's clinical priv. being revoked
- Med. bd. of CA (CMA) can access record through
- Blab loophole where peer rev.'er can vol'ly discl.
- Communication Immunities
- Abs. immunity 4 anyone communicating w/ peer
rev. 2 aid eval. of qualif., fitness, charact., / insurability
of dr. / others (CA Code 43.8)
- Abs. immunity 4 comm'n in initiation / course
of any prcg auth'ed by law & rev'able by chp. 2 of civ pro
(CA Civil §47)
- For Credentialing / disciplining, med. bd / peer
- Dr's D/P hrg rts.
- HCQIA (Health Care Q Improvement Act)
- Optional 2 comply but can give peer rev. immunity
from civil lawsuits
- Peer Rev. Activities Immune in Suit 4 $ Against
- After jud'al rev. of peer rev. + overturn dec.
- Abs. immunity 4 proced.'ly fair & subst'l
- Even if not, still immune if axn was taken
- W /o malice
- After rsbl effort 2 get fact +
- Rsbl belief axn was warranted
- Even if not, still immune from all liab. except
econ. damages if
- A 805 report was made
- After record of med. staff +
- Axn not knowingly & intentionally taken 4
purpose of injuring a person / infringing person's rts
- Insitutional Neg. & Corp. Neg.
- Institutional Neg. 4 Hosp's Own Neg.
- Fail 2 follow own policy & proced. / stand.
- Est'ing stand. of care
- Expert W
- Gen'ly from same spec.
- CA, only req. as long as render testi. helpful
- CA, if ER, then must B 1 who actively pract.'ed
in ER as last 5 yrs. as expert testi.
- Prof'l stand.
- Pharm. by description
- Clinical pathways / guidlines
- Own hosp. proced. & policy
- Corp. Neg.
- Hosp. has legal duty 2 take rsbl steps 2 insure
med. staff's competence
- Must investig. about dr.'s perf. in hosp. / other
- Credentialing peer rev. / initial appt'ment
- JCAHO req's reappt. every 2 yrs. & QA every
- Med. bd. licensture axn not dispositive
- Hosp. can prevail even if med. bd. didn't b/c
hosp. has higher stand.
- Hosp. can pursue indep'ly as long as rationally
rel'ed 2 pat. care
- Legal duty 2 hosp. only if pat. was in hosp.
- Vicarious Liab.
- Liab. of Institutional D 4 Dr's Neg.
- HMO gen'ly liab.
- Hosp. liab.
- IPA s.t. liab.
- Dif. Theories 4 Hosp's Liab.
- Control Test
- Rel. btwn dr. & hosp. 2 see control
- Terms of K
- Not have 2 B empl. rel.
- Ostensible agency / apparent auth. (CA)
- Expectation of pat.
- Holding out by hosp. of dr. as ee & treat
as ee 2 the world
- Pat. looks 2 hosp. as care, not 2 indiv. dr.
- Recharact. of Indep. K'or as Empl. Rel.
- If indep. k'or can B charact'ed as empl. rel.
- Rt 2 control test by factors
- Work 4 1 Er.
- Dir. of ee
- Integ.'ed 2 busi.
- Er. req. render serv. pers'ly
- Inherent Fn.
- Hosp's basic serv. like ER, pathology, radiology,
etc. is inherent so hosp. liab. 4 dr's neg.
This material is copyrighted by the author. Use of the material
for profit is strictly prohibited without the written permission
from the author.
May 6, 1997
Ms. Haeji Hong
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