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Substandard quality of health care is duly recognized as a major form of medical crises with potential to jeopardize the functioning and purpose of the American health care system. Whereas on the one hand medical costs of treatment are rising, on the other malpractices and non compliance on the part of medical professionals and institutions compounds the problem and seriously questions the quality of health care being provided to citizens.However, before proceeding further it’s important to understand what is exactly meant by the substandard quality of care. The substandard quality of care implies that one or more of the requirements mandatory under the federal regulations 42 CFR 483.13 involving resident behavior and facility practices, 42CFR.15 involving quality of life or 42CFR 483.25 regarding quality of care are not complied with leading to actual jeopardy to the resident health or safety or having potential for causing more than minimal harm (HealthCare information, 2007). Any nursing home found with delivering substandard quality of healthcare or carrying significant deficiencies in its healthcare treatment plans would be required to immediately address the issue.A case of substandard health careThe following case presents an example of injuries from utilization control healthcare delivered resulting in grievous and permanent injuries to the patient (Flannery, 2007).The case presented here is about Lois Wickline who was diagnosed with Leriche’s syndrome, which is a vascular occlusion.  Upon diagnosis, her doctor recommended surgery where a part of an artery was to be replaced with a Teflon graft. The program providing medical care to Ms. Wickline was California’s medical assistance program, Medi-Cal that was responsible for controlling costs and authorizing treatment. As such, the approval and authorization from state was a requirement to perform surgery.When Ms, Wickline’s doctors sought approval from Medi-Cal for the surgery, Medi-Cal agreed and also allowed ten days of post-surgery treatment in hospital. However, Ms. Wickline’s recovery did not take place as estimated and a day before due discharge date, the surgeon and his assistant felt that Ms. Wickline required additional eight days of recuperation in hospital. Medi-Cal was again approached for the approval for this extended stay, butt on this occasion Medi-Cal differed from surgeon’s recommendations for eight days extension. The Medi-Cal representative, who was himself a certified surgeon, merely consulted a Medi-Cal nurse on phone, and after evaluating progress of Ms. Wickline on basis of her temperature, diet and bowel function, declined the request and approved only four day extension. In the process he neither reviewed any documents related to the case nor consulted any other vascular-surgery specialist (Flannery, 2007).On denial by Med-Cal, the surgeon attending the case of Ms. Wickline decided not to push for the additional days of care and complied with Med-Cal directives by discharging her at the end of the stipulated period. Both the surgeon and the assistant admitted in their testimonial that they did not push for the extension as they thought Medi-Cal would not approve their request, given its concern with controlling the costs.Ms. Wickline developed serious problems with the Teflon graft within a short time after her discharge. She reported clotting, loss of circulation and infection and she had to be re-operated nine days after her discharge. However, the premature discharge had taken its toll and her leg had to be amputated.Case analysisThe chief liability for the permanent injuries caused to Ms. Wickline comes to rest with Medi-Cal that, despite being a medical program company, completely failed to appreciate the condition of Ms. Wickline and in the haste to save cost, compromised with her health. The consultant of the company overlooked, ignored or did not deem it necessary to collect crucial information on her treatment status and made his recommendation without any substantial data.   In its decision, the appellate court also recognized the fact that negligence and dereliction of duty was committed on the part of the surgeon. The court observed that as Wickline was directly under the care and supervision of the doctor, therefore it was the responsibility of the doctor to ensure whether she was fit for discharge. If the doctor was convinced that her case merited prolonged hospital care, he should have duly reported and requested Medi-Cal again, appraising them completely on patient’s condition.The case of Ms Wickline addresses two of the major issues affecting healthcare system in USA. The first is a doctor’s direct responsibility in delivering care. There are some  basis minimum standards of practices that must be firmly adhered with. Any deviation from them should not be allowed and any physician violating these standards should be held accountable under malpractice norms (Flannery, 2007). The doctrine against malpractice also mandates physicians to impart their services irrespective of the cost consideration. Once they accept a patient under their treatment it becomes their moral and ethical duty to care for the patient notwithstanding the patient’s ability to pay their medical charges.In the shifting economic paradigms and increasingly complex medical –liability atmosphere, insurance companies and medi-care program companies are also recognized as parties responsible for ensuring adequate treatment to their clients, and if in haste to cut costs they demand early release of the patient, they are liable to be held responsible for any injury to the patient resulting due to the premature discharge.

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