When is a hospital, a Hospital?

The 2007 annual report of the Hospitals Board tabled in Parliament last December raises some important public interest issues.                           

One of those issues is whether the Hospitals Board has the ability to function as a regulator of private hospitals and clinics under the Hospital and Health Care Facilities Act, 1998.

For example, the Hospitals Board has a duty under the Act to investigate a complaint into the “management, diagnosis, and treatment” of a patient in a hospital or clinic licensed by the Hospitals Board.

But it seems the Hospitals Board’s view is that it licenses the building and its facilities, and not the quality of health care services provided.   The Act itself defines a hospital as "a building where beds are available for the admission of persons requiring treatment for any sickness”.

Experts say this description is not adequate. It does not require a central legal entity that is responsible and accountable for all medical services provided under its roof. That structure, according to advisors, would be in the best interest of the community for the obvious reasons of safety and ethics. There is a disconnect here which can adversely affect quality assurance in medical treatment.   

Medical advisors to Bahamas Patient Advocacy see a hospital as an institution which accepts patients for medical treatment, within an organization with a centralized authority responsible for quality assurance in the delivery of healthcare services. 

It should be the medical services that are being licensed - not just the building - in order to properly reflect the modern concept of what a hospital is. The public needs a single source of accountability in healthcare facilities, and a licensing board to enforce it. On this basis, a “hospital”, together with its medical services, needs a regulatory definition as a single (legal) entity.

Under current law, private hospitals may function as a collection of independent physicians providing medical services, by having practicing privileges, in a building providing beds and nursing services, among other things. The patients would then be admitted as patients of the individual physician. Sections of the building may be leased or managed by different corporate entities, providing other medical services.

This structure diffuses authority and accountability. For instance, the Act requires that a healthcare facility should (among other things) provide sufficient numbers of  qualified staff who can administer appropriate care to the patients admitted.

But if a hospital is a building with beds, without medical management authority, and medical services are provided by independent doctors, can “the hospital” exercise authority to restrict admissions to only those patients that “hospital” is able to treat?

Or can a private hospital make the appropriate medical staff available, if there is no overall authority that employs or manages medical professionals at the hospital?

BPA advisors say that a new institutional definition is required, making it clear that a hospital is a single interest entity accountable for the medical services provided there. A hospital has to uphold its own interest beyond the interests of independent professionals and entities within it.   This would place the hospital in a proper position to oversee the safe delivery of healthcare services.

A hospital also needs to have an internal quality management structure, which can immediately respond to any concerns arising. To do this, a hospital needs to collect data on all patients admitted in order to know whether its operating units are doing a good job, and it needs sufficient qualified staff to enable it to respond. 

The interests of the patient, the doctors, and the hospital, must be one seamless and single interest, to improve patient outcomes. That is the purpose of a hospital.     

Usually a hospital has a Chief of Medical Staff, or Chief Medical Officer (CMO). The CMO has the authority to ensure the competency of the doctors practicing there.

The CMO also has responsibility for the integrity of the hospital system. That integrity would include an effective “call” system, to ensure that all patients have medical care available 24/7, so no patient, in crisis, is left unattended.

In public health care, a CMO would, or should, resign in the event of such a “systems failure”. Should a private heath care facility, not also be held to a similar standard of accountability?  

The licensing board of hospitals and clinics should require an independent audit of their health care services by an outside review body. This external accreditation could also be used by a hospital to enhance its credentials and image. The Hospitals Board could thus carry out its quality assurance- oversight function at no expense to the Board, or challenge to its limited resources.

But the 2007 report proposes changes to the Act that would seriously weaken the Hospitals Board as an oversight body.

The Board wants the Government to amend the Act to remove the provision for investigation of complaints, eliminate the need to provide notifications of deaths, and reduce penalties for failure to comply with licensing requirements.

But at the same time, the Hospitals Board is also proposing a new and extensive set of hospital regulations. So, on the one hand, the Board says it wants to reduce its oversight responsibility, but on the other hand, it wants to increase regulatory requirements? 

The BPA advocates that the Board’s oversight capacity be strengthened, and that the Hospital Board embrace its oversight function of quality assurance, as per the petition on its website below.

We urge our Parliamentarians to consider the Hospitals Board’s report in terms of the public interest in a safe system of health care, and oversight assurance of this.

Good business sense should dictate that the more confidence the public has in our local institutions -including statutory boards- the less likely we will be to spend our money abroad for medical care.

Comments

[larry w bowleg]

What are judges saying about this "definition" and "classification"? To me, it is simple, borrowing a principle from Lord Templeman in Antonaides v. Villiers 1988 where judges intervened to prevent landlords from dodging the consequences of the Rent Restrictions Act by unfairly classifying a lease as a license. Obviously this comes from property law, however, the principle is sound and demonstrates the flexibility judges have in bringing order in the midst of chaos. Their failure to see through the sham the medical providers seek to create would be a poor reflection on the judiciary. No doubt, and as with many specialized areas such as healthcare, government may rely upon the healthcare providers to "draft" the legislation or contribute significantly to its primary function...similarly for insurance legislation. To me, it would be an absurdity that Parliament would have intended to establish legislation that would allow a medical institution to unfairly discharge its obligations under such a corporate structure. There will have been more than sufficient connection between the hospital, its staff, and the doctors acting as agents of the hospital:
1) the building under which the doctors and hospital staff operates is called Doctors Hospital, causing any right thinking individual to assume it is a hospital and not a building leased to his or her doctor;
2) the nurses and other staff assisting the doctor are not employees of the private doctor and therefore one has to assume that the nurses belong to the hospital;
3) the doctor and the hospital have a financial arrangement and in some cases such doctors may be shareholders of the hospital;
4) other staff of Doctors Hospital will turn a patient away that does not have the requisite insurance or cash or bill the private doctor directly;
5) Doctors Hospital provides supplies and bill the patients directly for the use of such supplies;
6) Doctors Hospital bills the patient for the use of the OR and recovery room;
7) Doctors Hospital bills the patient for use of any other specialized services such as x-ray, MRI, etc.

If the private doctor never arrives, would Doctors Hospital and its agents be immune from the consequences of allowing a patient to become gravely ill or die? Once again, if this was the intention of Parliament, this would be a grave injustice on the community, particularly by entities set up to maximize profits...