Hospital Liability

Primary Duties of a Hospital1. The use of reasonable care in the maintenance of safe

and adequate facilities and equipment;

2. The selection and retention of competent physicians;

3. The overseeing or supervision of all persons who practice medicine within its walls; and

4. The formulation, adoption and enforcement of adequate rules and policies that ensure quality care for its patients.

(PROFESSIONAL SERVICES, INC. vs. NATIVIDAD and ENRIQUE AGANA G.R. No. 126297)

Hospital liability vs. Medical Negligence and Malpractice

Hospital Liability Medical Malpractice Medical Negligence

Hospital liability happens when the hospital violated the accepted standard of care by not requiring adequate supervision to all its medical practitioners, by not giving safe and adequate facilities, and deviating from its own policies in ensuring quality care for its patients.

It is defined as a professional negligence by act or omission by a health care provider in which there is a total deviation from the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error.

Medical negligence occurs when a medical professional fails to provide the care or does not comply with standard of medical care which is expected in each case.

Hospital Liability in the Philippines

• Hospital Liability in the Philippines is based on quasi-delict and vicarious liability under Articles 2176 and 2180

• Over the years, at least 8 different bills with different authors have been filed in the senate and Lower House seeking to legislate and criminally penalize medical malpractice, but not one of the bills has become law

• Nevertheless there have been Various Civil groups whose main advocacy is to pressure Congress to legislate medical malpractice laws.

• Before, only physicians and those directly involved in the Medical Profession were made liable for negligent acts or omissions causing injury to patients.

• It was only when the case of Ramos vs. CA, decided in 1999 when a hospital was impleaded as defendant in a medical negligence case.

• Not all hospitals may be sued, in the Philippines, hospitals may be run either by the government or by private individuals or corporations.

• Government Hospitals are immune from suit. The basis of immunity is the recognition that government charity hospitals are performing a governmental function. Because of this function, said hospitals would fall within the rule that the state cannot be sued without its consent.

Applicable Doctrines in Hospital Liability

The issue of whether a Hospital can be held liable may be determined by applying the following doctrines:

1. Doctrine of Corporate Negligence2. Doctrine of Apparent Authority3. Doctrine of Vicarious Liability

Corporate Liabilities are those arising from the failure of the hospitals as corporations to provide necessary accommodation and facilities or observe the standard of conduct to which corporation should conform.

Examples:

• Failure to furnish safe and well-maintained buildings and facilities.

• Failure to provide safe and reliable equipments.• Failure to make careful selection, review and

supervision of independent physicians who are permitted to practice in the hospital

Doctrine of Corporate Negligence

is the legal doctrine that holds health-care facilities, such as hospitals, responsible for the well-being of patients.

If the hospital fails to maintain a clean and safe environment, hire competent and properly trained employees, oversee care and implement safety policies, it can be held liable for any harm to patients.

Under the Doctrine of Corporate Liability, the Hospital can be found liable even if the surgeon was an independent contractor.

Corporate Negligence provides for a form of direct liability that subjects a hospital to civil liability for its own failures to adopt appropriate policies and procedures to protect patients.

Doctrine of Corporate Negligence

Doctrine of Vicarious Liability

Vicarious liabilities refer to the liabilities of hospitals for the acts of its employees provided under Article 2180 of the Civil Code.Vicarious liability, under the Civil Code, is anchored on Articles 2180 in relation to Article 2176.based on respondeat superior or “let the master answer”

However, Article 2180 requires as sine qua non the existence of an employer-employee relationship, they rely on proving the existence of an apparent agency.

3 distinct legal relationships that are established when a patient goes to a hospital:

1. Between the doctor and the patient2. Between the hospital and the patient; and3. Between the doctor and the hospital

In Philippine jurisprudence employer-employee relationship is established based on the primary test of hiring, firing, payment of wages, and control.

It has been consistently held that in determining whether an employer-employee relationship exists between the parties, the following elements must be present:

1. Selection and engagement of services; 2. Payment of wages; 3. The power to hire and fire; and 4. The power to control not only the end to be achieved, but

the means to be used in reaching such an end.(Ramos vs. CA)

General Rule: Hospitals are NOT liable for the negligence of an independent contractor-physician

Exception: Doctrine of Apparent Authority

(Nogales vs. Capitol Medical Center)

Doctrine of Apparent Authority

a hospital can be held vicariously liable for the negligent acts of a physician providing care at the hospital, regardless of whether the physician is an independent contractor, unless the patient knows, or should have known, that the physician is an independent contractor.

(Nogales vs. Capitol Medical Center)

Doctrine of Apparent Authority

there are cases where a person may be deemed an agent of a principal based on the latter’s act of clothing the former with apparent authority. Under these circumstances, the principal cannot be permitted to deny the authority of such person to act as his or her agent, to the prejudice of innocent third parties dealing with such person in good faith and in the honest belief that he is what he appears to be.

For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that:

(1) the hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital;

(2) where the acts of the agent create the appearance of authority, the plaintiff must also prove that the hospital had knowledge of and acquiesced in them; and

(3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence."

Illustrative Cases

PSI vs. CA

Facts:

Nogales vs. CMCFacts:

Rogelio and his wife specifically chose Dr. Estrada to handle Corazon’s delivery not only because of their friend’s recommendation, but more importantly because of Dr. Estrada’s connection with the reputable hospital (CMC).

Dr. Estrada is granted by the CMC staff privileges and extended medical staff and facilities.

Rogelio signed consent forms printed on CMC letterhead. The letters did not mention that Dr. Estrada was an independent contractor-physician.

During the operation, Dr. Estrada was assisted by doctors of CMC. The baby came out in an apnic, cyanotic, weak and injured condition and had to be incubated and resuscitated by Drs. Enriquez and Payumo.

Corazon’s blood pressure dropped, she had continuous vaginal bleeding, was administered hemacel and undergone immediate hysterectomy. Eventually, she died at 9:15 a.m. with “hemorrhage, post partum”.

Hence, a complaint for damages was filed.

Issue: Whether or not CMC is vicariously liable for the negligence of Dr. Estrada under Art. 2180 in relation to Art. 2176 of the Civil Code.

Held:

Dr. Estrada is an independent contractor. Applying the control test, there is no evidence to CMC’s exercise of control over Dr. Estrada’s treatment and management of Corazon’s condition. The patient was under the exclusive prenatal care of Dr. Estrada. CMC merely allowed Dr. Estrada to use its facilities when Corazon was about to give birth, which CMC considered an emergency.

But, even if Dr. Estrada is not an employee of CMC, still CMC is vicariously liable under the doctrine of apparent authority.

the doctrine of apparent authority is an exception to the general rule that a hospital is not liable for the negligence of an independent contractor-physician.

The hospital acted in a manner that would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital.

the act of CMC giving Dr. Estrada staff privileges and extended medical staff and facilities is enough reason for the spouses to believe that CMC had authority over Dr. Estrada.

Ramos vs. CAFacts:

Erlinda Ramos, a 47-year old robust woman, was normal except for her experiencing occasional pain due to the presence of stone in her gall bladder. She was advised to undergo an operation for its removal.

The results in the examinations she underwent indicate that she was fit for the operation. She and her husband Rogelio met Dr. Hosaka, one of the defendants, who advised that she should undergo cholecystectomy. Dr. Hosaka assured them that he will get a good anaesthesiologist.

At 7:30 a.m. on the day of the operation at Delos Santos Medical Center, Herminda Cruz, Erlinda’s sister-in-law and the dean of the College of Nursing in Capitol Medical Center, was there to provide moral support. Dr. Perfecta Gutierrez was to administer the anaesthesia.

Dr. Hosaka arrived only at 12:15 p. m. Herminda saw Dr. Gutierrez intubating the patient, and heard the latter say “Anghirap ma-intubate nito, maliyataangpagkakapasok. O, lumalakiangtiyan.” Herminda saw bluish discoloration of the nailbeds of the patient..

She heard Dr. Hosaka issue an order for someone to call Dr. Calderon. The doctor arrived and placed the patient in trendelenburg position, wherein the head of the patient is positioned lower than the feet, which indicates a decrease of blood supply in the brain.

Herminda knew and told Rogelio that something wrong was happening. Dr. Calderon was able to intubate the patient. Erlinda was taken to the ICU and became comatose.Rogelio filed a civil case for damages

ISSUE:Whether or not the Hospital is liable

Held:Hospitals hire, fire and exercise real control over their attending and visiting "consultant" staff. While "consultants" are not, technically employees, a point which respondent hospital asserts in denying all responsibility for the patient's condition, the control exercised, the hiring, and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship, with the exception of the payment of wages.

In assessing whether such a relationship in fact exists, the control test is determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of allocating responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians.

The basis for holding an employer solidarily responsible for the negligence of its employee is found in Article 2180 of the Civil Code which considers a person accountable not only for his own acts but also for those of others based on the former's responsibility under a relationship of patria potestas.

Such responsibility ceases when the persons or entity concerned prove that they have observed the diligence of a good father of the family to prevent damage.

In the instant case, respondent hospital, apart from a general denial of its responsibility over respondent physicians, failed to adduce evidence showing that it exercised the diligence of a good father of a family in the hiring and supervision of the latter. It failed to adduce evidence with regard to the degree of supervision which it exercised over its physicians.

In neglecting to offer such proof, or proof of a similar nature, respondent hospital thereby failed to discharge its burden under the last paragraph of Article 2180.

Having failed to do this, respondent hospital is consequently solidarily responsible with its physicians for Erlinda's condition.