The Hospital


The hospital inpatient setting is the most structured of the health care settings. The premise is that meeting specified structural requirements strengthens the ability of an organization to deliver good quality care (or, alternatively, to prevent poor care) (Palmer and Reilly, 1979).

Driven partly by risk management concerns and partly by requirements of the Joint Commission for Accreditation of Healthcare Organizations (the Joint Commission),1 systems for recommending medical staff for appointment and reappointment and for determining clinical privileges (and hence, for denying such appointments and privileges) are, by and large, well developed and set forth in medical staff bylaws. Similarly, data gathered on practitioner-specific performance for reappointment and privileging are increasingly refined. These structural characteristics are considered among the leading first-line defenses against poor care, because the implications for physicians of losing staff or clinical privileges are considerable.2 It is important to distinguish, however, between the ability to revoke privileges and the practical feasibility of undertaking such actions.

Hospitals are typically divided into services, each with clinical directors or department chiefs. Each will have policies and procedures in addition to general hospital policies and procedures regarding professional and staff obligations and responsibilities. In recent years, the emphasis on accountability, lines of authority, and similar structural variables within the hospital setting has grown tremendously. Particular stress has been placed on the responsibilities of governing boards, especially since the landmark ruling in Darling v. Charleston Community Hospital (1965) that established a hospital’s direct corporate liability for medical staff quality problems about which it knows (or should know), even when the physicians are not employed by the hospital.

Policies and procedures designed to protect hospital patients from medication errors, misidentification, and numerous other potentially adverse events have evolved over many years. There are well-developed systems for documenting the course of patient care in medical records, for instance, nurses’ notes, attending physician notes, operative notes, admission and discharge summaries, and results and interpretations of clinical tests, procedures, and examinations. Finally, issues of patient adherence to treatment plans are minimal in hospitals as compared with other settings of care; the physical environment is within the organization’s control and patient compliance is easier to monitor and ensure.

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