Hospital Administrator Expert Witness

Hospital administrators are tasked with ensuring the safety, efficacy, and financial solvency of their hospital. This means that they must vigilantly monitor the hospital at all times so that everything is in accordance with safety laws, codes, and standards. In a medical malpractice case, a hospital administrator will review the hospital’s policies and procedures based on the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). A hospital administrator can determine whether or not the hospital’s specific actions are in compliance with the JCAHO standards. If the standards outlined by the JCAHO have not been upheld by all of the hospital’s physicians, nurses, and staff members, that is considered a departure from the standard of care. A hospital administrator can be a key expert witness in a medical malpractice case by identifying actionable areas of negligence or medical error. For your interest, four medical malpractice articles written by one of our Senior Hospital Administration Experts have been provided as a complimentary service to you. The Emergency Department and Corporate Responsibility The evaluation of patient care in the hospital emergency department often focuses only on the care itself and the practitioners that delivered that care. Too often, the responsibilities of the hospital in providing that care is overlooked or not looked at from the perspective of their corporate responsibilities. This is where a Hospital Administration Expert will answer those questions and fill the need from the corporate perspective.It is usually well understood that the hospital must comply with the standards promulgated by federal, state, and local authorities, including such things as the federal Emergency Medical Treatment and Active Labor Act and regional trauma regulations; the hospital must also comply with the standards of the Joint Commission if they are an accredited hospital. These Joint Commission standards are widely accepted in the United States as the standard of care for the provision of inpatient and ambulatory hospital care, and describe the accountability and responsibility of hospital leaders in the delivery of care at their facilities. Joint Commission standards require that hospital leaders establish a governance structure and management systems to oversee that appropriate rules, regulations, infrastructure, credentialing, and communication processes are in place to deliver high quality and safe care to their patients. The hospital is further required to establish systems to monitor the effectiveness of care and to correct any deficiencies. Ultimately, the hospital is responsible for the oversight of all professional services provided by its medical staff, employees, and any others that it credentials or contracts with to practice at the hospital, including emergency department contract physicians. Joint Commission standards are also used by the federal Centers for Medicare and Medicaid to determine compliance with the requirements of these programs, and are also used and accepted as the standard of care for hospital licensure in many states. It is increasingly common for hospitals to contract for emergency department physician services and presume that the contract with the physician company addresses all their responsibilities. This is not the case, as the hospital remains responsible for all patient care services that take place, and they must have the required policies and procedures in place to direct that care and, most importantly, must make certain that those policies are followed by the contract staff and all hospital employees as well. In the emergency department, these policies often focus on such things as timely care, accurate performance of diagnostic tests, and the communication of critical test result information to clinicians and patients. A common problem that occurs is the test result that comes back after the patient is discharged that is never communicated to the patient or their primary care physician. Another situation that may happen in many smaller hospitals is the use of part-time staff to read test results and this may be delayed due to the hours that the staff is present. In the evaluation of emergency department cases, it is recommended that risk managers and legal counsel, both defense and plaintiff, look at whether the hospital has fulfilled their corporate responsibilities in providing care and not just look at the medical care itself.Evaluating Hospital Corporate Responsibilities in Medical Malpractice Cases Medical malpractice cases require stringent and comprehensive clinical review and attorneys always employ medical experts to review their cases. Often overlooked is the use of a hospital administration expert who can add significantly to the case by evaluating the corporate responsibilities of the hospital involved in the matter. It is important to utilize a person who has actually worked as a hospital administrator and, indeed, some states require a person actively engaged in the field. While many physicians feel that they have hospital administrative experience, it may not be adequate to evaluate hospital compliance with accreditation standards, licensure regulations, and administrative policy and procedures. As a person with nearly 40 years of hospital and healthcare administrative experience, I review cases for both defense and plaintiff attorneys and have found this to be of value to all parties involved. The hospital or healthcare organization always has an interest in every malpractice case as patient safety and the quality of care are central to their mission. Additionally, the discovery of systemic problems, adverse publicity, potential financial loss, and poor staff morale are extremely important to the hospital’s leadership. The attorney can best determine the hospital’s corporate responsibilities through engaging an experienced healthcare executive to evaluate the case. The administrative expert relies on the physician experts to determine if clinical errors were made and utilizes this information to perform a review of hospital policies and licensure and accreditation standards. The hospital administrative expert will review the appropriate Joint Commission Hospital Accreditation Standards manual to evaluate the degree of compliance of the hospital with the standards. For example, in a case where a wrong site surgery took place, I was able to determine that the hospital did not follow the required Joint Commission standards regarding the identification of the patient and the surgery site, nor did they perform the mandatory time-out procedure prior to starting the operation. Hospital employees could have and should have made certain that the surgeon followed the correct procedures. Clearly, in this case, there were indications of corporate negligence and the hospital had some responsibility in the case. Another important review performed by the administrative expert is to look at hospital policies and procedures. This evaluation includes determining if the hospital has the required up-to-date policies in place, and then ascertaining if they actually followed them. A case I recently reviewed involved policies for the handling of critical test results and it was readily apparent that the hospital had the required policies in place and that they did follow them when a radiology examination showed a life threatening situation for an emergency department patient. In this case, the hospital followed the accreditation standards and had no corporate liability in the matter. I am frequently asked to review the credentialing procedures of hospitals to evaluate if they complied with the appropriate standards. This is another often overlooked area of investigation as the hospital must comply with very definitive standards for initial credentialing and re-credentialing physicians and other licensed independent practitioners. It is important to evaluate if the correct procedures were carefully followed, particularly as the standards have been changed in recent years and focus more on an ongoing review process rather than the familiar bi-annual review. Another area of focus is that of new procedures and new equipment. Did the hospital formally approve the new procedure or the new piece of instrumentation used in the procedure? Were hospital staff members adequately trained in the new procedure? Did the materials management department purchase the new equipment per their policy or did the physician or surgeon bring it in – something I have seen more than most would expect? Have the surgeon’s privileges been expanded to include this new procedure? Many hospitals do this extremely well and others do not. It is important to review this area thoroughly. Reviewing corporate responsibilities should take place in nearly all medical malpractice cases and can benefit patient care, as well as providing clarity as to the hospital’s compliance with their responsibilities. For many attorneys, the Joint Commission standards are unfamiliar and an administrative expert can assist them in navigating these voluminous and constantly changing standards. I would also note that a hospital administrative expert can often assist in developing the strategy of the case through explaining the inner workings of the hospital, the internal politics of medical staff relationships, and the rules regarding the use of independent contractors just to name a few. It is usually best to bring the administrative expert into the case as early as possible to help in formulating discovery requests and also in the specific questions to ask hospital representatives in the deposition process. Much time, effort, and expense can be avoided by utilizing a hospital administrative expert to perform an early review of the case. Both defense and plaintiff attorneys can benefit from this review and assist them in their efforts to resolve the case successfully.
Role of Joint Commission on Accreditation of Healthcare Organizations Standards in Med Mal Cases Lawyers often ask me to explain how I use the JCAHO standards in evaluating medical malpractice cases and whether this evaluation will assist them in their pursuit of justice for their clients. I usually start my explanation with a brief history of the Joint Commission and its role in hospital operations and reimbursement. The JCAHO was formed in 1951 by several professional organizations: the American Hospital Association, the American College of Physicians, the American College of Surgeons, and the American Medical Association. Its mission is “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value”. To accomplish this mission, the JCAHO has developed standards for accrediting hospitals and other types of healthcare organizations that focus on the delivery of the highest possible quality patient care as well as ensuring a safe environment for patients and staff. While a hospital’s participation in the JCAHO accreditation is technically voluntary, the federal government requires hospitals to meet their standards in order to receive reimbursement from the Medicare and Medicaid programs. Obviously, this requirement essentially mandates that all hospitals meet the JCAHO standards or one of the few other organizations that are included in this payment mandate. While the process is voluntary, it is important to understand that the standards are mandatory and that receiving a full accreditation from the JCAHO is still the gold standard for a hospital’s quality of care. The JCAHO is continuously updating their standards and issues a new standards manual each year. While the actual changes made each year may be minimal, they often occur as a result of information sent to the JCAHO by hospitals regarding medical errors under the so-called Sentinel Event standard. For our purposes, it is important to use the correct annual edition of the standards in evaluating a medical malpractice case. The accreditation process focuses on following randomly selected actual patients care from admission to discharge. The strength of this process is that it does look at actual care processes rather than the former process which only looked at whether the hospital complied with the standards on paper. Its weakness is obviously that most patient care is performed correctly and most patients receive high quality care, while being accredited does not mean that every standard was complied with and some important processes may not be evaluated in the every three year survey process. Hence, a fully accredited hospital may have some issues and problems that the accreditation process does not uncover. With this background in mind, I recommend using the standards to evaluate the hospital’s corporate responsibilities in delivering care to their patients. The standards include such things as the board’s responsibility to lead the hospital, the administrator’s job requirements, how physician credentialing should be accomplished and the overall delineation of the way patient care should be delivered. The standards require the hospital to have a number of policies and procedures in place and further require that they be actually followed uniformly for all patients regardless of their ability to pay or the type of insurance they have. While it is important to note that these policies must exist, the JCAHO does not typically prescribe how the hospital should accomplish the required activities. Each hospital has a great deal of latitude in how they do things and this often provides us with key insights in how seriously the hospital takes this process. For example, the hospital should look at all key policies annually and update them as needed based on their own experience as well as industry information regarding changing processes. Hospitals often do not do this on a regular basis and it is not unusual for me to see policies that have not really been changed for many years In today’s complex health care delivery environment it is crucial for a hospital to understand that its corporate responsibilities must be taken seriously and I often counsel hospitals on how to improve their risk management processes. Conversely, in my work with patient’s counsel I look for evidence that any deviation in implementing these corporate responsibilities caused the hospital to bear some responsibility for a medical malpractice event. In my opinion, this evaluation should take place in every case in order to determine if the hospital has essentially participated in the process that caused the case to occur. How to Increase Recovery in Your Medical Malpractice Cases – Keep the Hospital in the Case Medical malpractice cases obviously require clinical review and lawyers realize that they must employ medical experts to review their cases. Often overlooked is the use of a hospital administration expert who can add significantly to the case by looking at the corporate responsibilities of the hospital. Adding this type of expert to your team provides the opportunity to increase your recovery by including the mandated insured capacity of the hospital in the case. In addition, the hospital always has an interest in the results of the case and can provide leverage on the involved physicians as the case moves forward. Adverse publicity, as well as potential financial losses, are both extremely important to the hospital leadership. The attorney can best determine the hospital’s responsibility through employing an experienced hospital administrator to evaluate the case. The administrative expert relies on the physician experts to determine if clinical errors were made and utilizes this information to determine what hospital policies and licensure and accreditation standards were violated as well. A seasoned hospital administrator will review the appropriate Joint Commission on Accreditation of Health Care Organizations (JCAHO) manual to evaluate the degree of compliance of the hospital with the standards. For example, in a recent case where a wrong site surgery took place, I was able to determine that the hospital did not follow the required JCAHO standards for identifying the patient and the surgery site, nor did they perform the required time-out procedure prior to starting the operation. Had hospital employees made certain that the surgeon followed the correct procedures, the entire incident would have been avoided. Clearly, in this case, corporate negligence took place and the hospital was certainly a party to the case. Ultimately, this case had a much higher recovery then it would have if only the surgeon was pursued. Another important review performed by the administrative expert is to look at hospital policies and procedures. This evaluation includes determining if the hospital has the required policies in place, and then ascertaining if they actually followed them. A recent case I reviewed looked at policies regarding the handling of critical test results and it became apparent that the hospital neither had a policy in place as they should have nor did they follow the required procedures when a radiology examination showed a life threatening situation for an emergency department patient. Again, the hospital had committed a violation of accreditation standards and had liability in the matter. I am frequently asked to review the credentialing procedures of hospitals to evaluate if they complied with the appropriate standards. This is another often overlooked area of investigation as the hospital has strict standards they must follow in credentialing and re-credentialing physicians and other independent practitioners, and in determining their privileges. It is very common to find that steps were skipped as the processes very often become rote as hospital staff perform this important task. I look at such things as the composition of the credentials committee. Was the appropriate clinical specialist involved in evaluating the applicant physician? Did they collect all of the required original documentation? Did they truly follow their own credentialing policies? A particular area of interest is that of new procedures. Did the hospital actually approve the new procedure or new piece of instrumentation used in the procedure? Were hospital staff trained in the new procedure Did the materials management department purchase the instrument per their policy or did the surgeon bring it in? Were the surgeon’s privileges expanded to include this new procedure? It is amazing to see how many times the hospital does not do this correctly and then finds the physician is involved in a malpractice case. Utilizing a hospital administrative expert can strengthen the case. The hospital, through its board and management, has significant impact on the quality of care delivered by its medical and nursing staff and has the ability to reduce medical errors by holding staff accountable to their policies and standards. Reviewing this should take place in most medical malpractice cases and can benefit and improve patient care for all, as well as providing an additional and large source of funds for the patient who was injured. For many attorneys, the JCAHO standards are unfamiliar and a hospital administrative expert can assist them in navigating these voluminous and sometimes confusing standards. I would also note that a hospital administrator can often assist in the strategy of the case through explaining the inner workings of the hospital, the internal politics of medical staff relationships, and the rules regarding the use of independent contractors. It is usually best to bring the administrative expert into the case as early as possible to help determine what is asked for in discovery and also in the types of questions to ask hospital representatives in the deposition process.