Systems-Based Hospital Policies and the Lenient Expert Report Standard Under the TMLA:
Commentary on Bush v. Columbia Medical Center of Arlington Subsidiary, L.P.

I. Introduction

In Jared Bush, Jr. v. Columbia Medical Center of Arlington Subsidiary, L.P. d/b/a Medical City Arlington and HCA Inc., No. 23‑0460 (Tex. May 23, 2025), the Supreme Court of Texas revisits—and significantly clarifies—the threshold showing required in expert reports under the Texas Medical Liability Act (TMLA), Tex. Civ. Prac. & Rem. Code ch. 74, particularly when a plaintiff’s theory is that a hospital’s systems-based policies and protocols were deficient.

The decision firmly reaffirms that:

• The TMLA expert report standard is intentionally lenient and is designed to weed out only frivolous claims, not to adjudicate their merits.
• An expert report can adequately allege direct negligence by a hospital for failing to adopt and enforce appropriate protocols—such as a “Triple Rule Out” protocol—without violating Texas’s prohibition on the corporate practice of medicine.
• At the report stage, an expert need not anticipate and rebut every potential defense (for example, that certain policies would improperly intrude on physicians’ independent medical judgment).

By reversing the Fort Worth Court of Appeals and reinstating the trial court’s refusal to dismiss, the Court clarifies how causation, standard of care, and breach may be fairly summarized in reports that target hospital-level system failures rather than (or in addition to) individual provider negligence.

II. Case Background and Procedural History

A. Factual Background

The decedent, 35-year-old Ireille Williams‑Bush, presented to Medical City Arlington with:

• Chest pain,
• Shortness of breath, and
• Severe syncope (fainting).

These symptoms, coupled with her being a woman in her mid‑30s on oral contraceptives with no other cardiac risk factors, were, in the expert’s view, “classically associated with pulmonary embolism” (a blood clot in the lungs). Nevertheless:

• The emergency physician’s working diagnosis was a non‑ST‑elevation myocardial infarction (a type of heart attack).
• A consulting cardiologist performed a cardiac catheterization but never ordered workup to rule out pulmonary embolism.
• She was discharged in “stable” condition with follow‑up instructions.
• Three days later she was found struggling to breathe, was rushed back to the hospital, and died; autopsy revealed extensive clotting in her heart and lungs.

Her husband, Jared Bush, sued:

• The hospital entities (Medical City Arlington and HCA Inc.), and
• Multiple individual physicians and their practice groups.

The Supreme Court’s opinion concerns only the direct negligence claim against the hospital, specifically the allegation that it failed to have and/or enforce adequate policies, protocols, and procedures to ensure proper evaluation, testing, communication, and diagnosis for acute cardiovascular patients like Williams‑Bush.

B. Litigation History

1. The initial expert report and Bush I

Bush timely served an expert report from Dr. Cam Patterson, a cardiologist and experienced hospital administrator. The hospital challenged the report’s adequacy under Tex. Civ. Prac. & Rem. Code § 74.351, arguing:

• Dr. Patterson was unqualified to opine on hospital policies, or his qualifications were stated conclusorily; and
• His standard-of-care, breach, and causation opinions were conclusory.

The trial court denied dismissal, but in Columbia Med. Ctr. of Arlington Subsidiary, L.P. v. J.B. (“Bush I”), 2021 WL 5132535 (Tex. App.—Fort Worth 2021, no pet.), the court of appeals reversed, holding:

• The report did not adequately establish Dr. Patterson’s qualifications to address hospital standards of care.
• His opinions were conclusory, especially in suggesting that hospital policies regarding diagnostic testing and discharge decisions would not amount to the hospital “practicing medicine.”

The court also read this Court’s prior decision in Columbia Valley Healthcare System, L.P. v. Zamarripa, 526 S.W.3d 453 (Tex. 2017), to require more explanation of how a hospital’s policies could influence a physician’s independent decisions.

The case was remanded to give Bush an opportunity to cure under § 74.351(c).

2. The amended report

On remand, Bush served an amended report from Dr. Patterson, which:

• Expanded his qualifications in clinical cardiology and hospital administration.
• Described in detail systems-based policies that hospitals treating acute cardiovascular patients must have—particularly “Triple Rule Out” protocols to ensure aortic dissection, pulmonary embolism, and coronary artery disease are all considered and ruled in or out for patients with chest pain, shortness of breath, and syncope.
• Articulated how the absence of such policies at Medical City Arlington allegedly led to a failure to perform appropriate testing (e.g., CT angiography) and to communicate critical diagnostic information to the treating physicians, resulting in misdiagnosis and death.

The hospital again moved to dismiss, now focusing on causation. The trial court again denied dismissal.

3. The second appeal (Bush II)

In its second opinion, Columbia Med. Ctr. of Arlington Subsidiary, L.P. v. Bush, 692 S.W.3d 606 (Tex. App.—Fort Worth 2023), the court of appeals:

• Limited its analysis to causation.
• Held that the amended report remained conclusory because it failed to explain “how the mere presence of standard order sets, policies, procedures, or protocols would have overridden the actual medical decisions, diagnoses, and treatment orders of the doctors.”
• Identified “analytical gaps” such as:
  • What happens if a physician ignores a protocol?
  • Can nurses order tests if the physician does not?
  • What chain of command would be triggered, and how long would it take?
• Remanded with instructions to dismiss Bush’s claims against the hospital with prejudice, as Bush had already been given a chance to cure.

The Supreme Court granted review and reversed.

III. Summary of the Supreme Court’s Opinion

Justice Huddle, writing for the Court, held:

1. The amended expert report made an objective good‑faith effort to provide a “fair summary” of Dr. Patterson’s opinions on:
   • The applicable hospital standard of care,
   • The hospital’s alleged breach in failing to adopt and enforce appropriate systems-based policies (including a Triple Rule Out protocol), and
   • The causal relationship between that failure and Williams‑Bush’s death.
2. The report adequately explained “how and why” the hospital’s policy failures caused the patient’s death, thereby satisfying the TMLA’s causation requirement at this preliminary stage.
3. The court of appeals impermissibly heightened the statutory standard by:
   • Requiring the expert to explain in detail how the hospital could enforce policies without engaging in the corporate practice of medicine.
   • Demanding that the expert anticipate and refute potential defenses, such as independent physicians disregarding protocols.
   • Weighing the believability and ultimate evidentiary value of the causation theory, rather than merely assessing whether it was non-frivolous and adequately linked to specific facts.
4. The report also adequately set out the standard of care and breach as to the hospital’s duty to formulate, implement, and enforce appropriate systems-based procedures.
5. The trial court did not abuse its discretion in denying the hospital’s motion to dismiss; the case should proceed in the trial court.

A dissent by Justice Bland (joined by Justice Devine) would have affirmed dismissal, emphasizing concerns that the majority’s approach blurs the line between hospital administration and physician decision-making and effectively imposes vicarious liability on hospitals for independent physicians.

IV. Detailed Analysis

A. Statutory Framework: The TMLA’s Expert Report Requirement

Under Tex. Civ. Prac. & Rem. Code § 74.351:

• A claimant must serve each health care defendant with an expert report within 120 days, or risk dismissal with prejudice.
• An “expert report” is not full-blown evidence; it need only provide a “fair summary” of:
  • Applicable standards of care,
  • How the care at issue failed to meet those standards, and
  • The causal relationship between that failure and the plaintiff’s injury. § 74.351(r)(6).
• The trial court must dismiss only if the report does not represent an “objective good‑faith effort” to provide that fair summary. § 74.351(l).

The Supreme Court reiterates established themes:

• This is a “low threshold”, “lenient standard,” designed to “weed out frivolous malpractice claims,” not to adjudicate the merits.
  • Scoresby v. Santillan, 346 S.W.3d 546, 549 (Tex. 2011).
  • American Transitional Care Ctrs. v. Palacios, 46 S.W.3d 873, 877–79 (Tex. 2001).
  • Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 223 (Tex. 2018).
• A report is adequate if it:
  • Informs the defendant of the specific conduct at issue, and
  • Provides a basis for the trial court to conclude the claims have potential merit (are not frivolous). Baty v. Futrell, 543 S.W.3d 689, 693–94 (Tex. 2018).
• The report need not:
  • Marshal all proof,
  • Meet summary‑judgment or trial evidentiary standards, or
  • Anticipate and rebut every possible defense. Palacios, 46 S.W.3d at 878–79; Owens v. Handyside, 478 S.W.3d 172, 187 (Tex. App.—Houston [1st Dist.] 2015, pet. denied).
• Appellate review is for abuse of discretion; “close calls must go to the trial court.” Larson v. Downing, 197 S.W.3d 303, 304 (Tex. 2006).

In Bush, these principles drive the Court’s conclusion that the trial court, not the appellate court, was entitled to resolve close questions about the sufficiency of Dr. Patterson’s causation explanation.

B. Precedents and Authorities Cited and Their Role in the Court’s Reasoning

1. The evolution of the “fair summary” / “good‑faith effort” standard

• Palacios (2001) – The foundational case:
  • Established that a report must “set forth specific information about what the defendant should have done differently; that is, what care was expected, but not given.”
  • Introduced the “fair summary” concept.
  • Clarified that the information in the report need not match summary-judgment-level proof.
• Samlowski v. Wooten, 332 S.W.3d 404 (Tex. 2011):
  • Plurality opinion defining “good faith effort” as a report that does not have a “material deficiency.”
  • Adequate if it includes all required elements and explains their connection to the defendant’s conduct “in a non‑conclusory fashion.”
• Scoresby (2011) and Abshire (2018):
  • Emphasize the low threshold and that reports should not be struck for minor or curable deficiencies.
  • Abshire is especially important in causation analysis:
    • Requires experts to explain “how and why” the breach caused the injury by linking conclusions to specific facts.
    • But reiterates that the report need only make a good‑faith effort to explain, factually, how proximate cause is going to be proven.
• E.D. v. Texas Health Care, P.L.L.C., 644 S.W.3d 660 (Tex. 2022):
  • Refines the “how and why” requirement.
  • Warns courts not to “exceed the scope of the fair-summary standard by impermissibly weighing the credibility of the expert’s opinions.”
  • Confirms that the expert report standard is not an evidentiary standard; the ultimate evidentiary value of the opinions is for later stages.
• Miller v. JSC Lake Highlands Operations, 536 S.W.3d 510 (Tex. 2017):
  • Reiterates that expert reports need not meet summary-judgment standards.
  • The trial court is not, at this stage, deciding whether a defendant is liable; it only decides whether the claim is non‑frivolous.

Bush synthesizes these authorities to underscore that courts must not convert the expert report requirement into a mini‑trial on causation or standard of care. Instead, the report must simply connect facts, breach, and injury with a non‑speculative narrative.

2. Proximate cause and the role of Zamarripa

• Doe v. Boys Clubs of Greater Dallas, Inc., 907 S.W.2d 472 (Tex. 1995), and Nixon v. Mr. Property Mgmt. Co., 690 S.W.2d 546 (Tex. 1985):
  • Provide the classic definitions:
    • Cause in fact: the negligent act is a “substantial factor” without which the harm would not have occurred.
    • Foreseeability: the “general character” of the injury could reasonably have been anticipated.
• Zamarripa, 526 S.W.3d 453 (Tex. 2017):
  • Facts: A pregnant woman was transferred in an unsafe condition; the expert asserted the hospital was negligent by “permitting and facilitating” the transfer ordered by a physician.
  • Holding: The expert report was conclusory because it did not explain how the hospital had the right or means to alter or veto the physician’s transfer decision.
  • Result: The report failed to show how hospital conduct was a substantial factor in bringing about the injury.

The Fort Worth court of appeals heavily relied on Zamarripa to insist that Dr. Patterson explain how policies would “override” or constrain physicians’ diagnostic and discharge decisions. The Supreme Court in Bush rejects this extension, distinguishing Zamarripa:

• In Zamarripa, the expert alleged only that the hospital “permitted and facilitated” a physician’s transfer order—without any factual explanation of how the hospital could have influenced or changed that decision.
• In Bush, Dr. Patterson:
  • Described specific policies (e.g., Triple Rule Out protocols).
  • Explained how those policies would ensure tests and communication that would have given physicians crucial information.
  • Did not suggest that the hospital would countermand or veto physicians’ decisions, but that it would provide additional diagnostic information to inform those decisions.

Thus, Bush repositions Zamarripa as a case about the inadequacy of a bare assertion of “permitting and facilitating” a physician’s order, not as a general rule that hospitals cannot be directly liable for policy failures that deprive physicians of needed information.

3. Hospital duties, policies, and the corporate practice of medicine

• Hospital’s duty to adopt policies:
  • Courts of appeals have long recognized that a hospital owes a duty to use reasonable care in formulating policies and procedures that govern its staff:
    • Reed v. Granbury Hosp. Corp., 117 S.W.3d 404, 409 (Tex. App.—Fort Worth 2003, no pet.).
    • Chesser v. LifeCare Mgmt. Servs., L.L.C., 356 S.W.3d 613, 628–29 (Tex. App.—Fort Worth 2011, pet. denied).
• Corporate practice of medicine:
  • Texas law bars corporations and hospitals from “practicing medicine”; only licensed physicians may diagnose and treat:
    • Tex. Occ. Code § 151.002(a)(13) (defining “practicing medicine” as diagnosis and treatment).
    • Tex. Civ. Prac. & Rem. Code § 74.001(a)(19).
  • Drs. Hosp. at Renaissance, Ltd. v. Andrade, 493 S.W.3d 545 (Tex. 2016), reiterated that health care institutions may provide health care, but only physicians can provide “medical care” in the sense of making medical-judgment decisions.
• Standing orders and permissible delegation:
  • The Occupations Code expressly allows physician delegation and standing orders:
    • § 157.005 – A properly delegated person is not “practicing medicine” by performing the delegated act.
    • § 157.054 – Governs standing orders and protocols in hospitals and medical facilities.
    • § 157.003 – Allows delegation of certain acts in emergency settings.
  • Mercy Hosp. of Laredo v. Rios, 776 S.W.2d 626 (Tex. App.—San Antonio 1989, writ denied), addressed standing orders as part of hospital operations.
  • El Paso Healthcare Sys., Ltd. v. Monsivais, 2019 WL 5616973 (Tex. App.—El Paso 2019, pet. denied):
    • Held that an expert improperly asked nurses and EMTs to independently diagnose, admit, and treat—acts that would be the unauthorized practice of medicine absent proper delegation.
    • However, it distinguished such conduct from following “standing orders” or preauthorized protocols that direct limited tests or actions before a physician evaluates the patient.
• Other hospital policy cases upholding expert reports:
  • Fortner v. Hospital of the Southwest, LLP, 399 S.W.3d 373 (Tex. App.—Dallas 2013, no pet.) – upheld a report faulting a hospital’s failure to adopt and implement appropriate policies directed at non‑physician staff.
  • Texas Children’s Hosp. v. Knight, 604 S.W.3d 162 (Tex. App.—Houston [14th Dist.] 2020, pet. denied) – accepted expert opinions faulting a hospital’s lack of post‑operative assessment policies.
  • Methodist Richardson Med. Ctr. v. Cellars, 2019 WL 6486246 (Tex. App.—Dallas 2019, no pet.) – deemed adequate a report asserting that the hospital should have involved itself indirectly in transfer decisions through policies and procedures.
  • Methodist Hosps. of Dallas v. Yates, 2022 WL 202988 (Tex. App.—Dallas 2022, no pet.) – upheld a report premised on the hospital’s failure to adopt a policy requiring scans to rule out certain conditions before discharge.
  • Marsillo v. Dunnick, 683 S.W.3d 387 (Tex. 2024) – referenced by Bush as a case in which a physician followed a hospital’s snakebite-treatment protocol.

Bush synthesizes these authorities to emphasize that there is a recognized, legitimate sphere of systems-based hospital responsibility—designing, implementing, and enforcing policies for testing and communication—distinct from making medical diagnoses or prescribing specific treatments.

4. Cases limiting policy-based causation theories

The Court also distinguishes decisions such as:

• Hendrick Med. Ctr. v. Conger, 298 S.W.3d 784 (Tex. App.—Eastland 2009, no pet.), and
• Hickory Trail Hosp., L.P. v. Webb, 2017 WL 677828 (Tex. App.—Dallas 2017, no pet.).

Those cases found reports conclusory where the expert simply asserted that the existence of certain policies would have “reduced the likelihood” of error, without providing a factual explanation tying the missing policy to what, concretely, would have happened differently in the plaintiff’s case.

By contrast, Dr. Patterson:

• Identified a specific protocol (Triple Rule Out),
• Linked it to Williams‑Bush’s particular symptom profile,
• Explained what tests that protocol would trigger (e.g., CT angiogram),
• Described what those tests would likely have shown (massive bilateral pulmonary embolism), and
• Explained how that information would lead to particular life‑saving interventions (anticoagulation, thrombolytics, and/or surgery) during her admission.

The Court holds that this level of explanation suffices at the report stage.

C. The Court’s Legal Reasoning

1. Adequacy of causation: the “how and why” requirement is satisfied

The majority concludes that Dr. Patterson’s amended report adequately explains “how and why” the hospital’s failure to adopt systems-based protocols caused Williams‑Bush’s death. In summary, the report’s causation chain is:

1. Standard of care: Hospitals treating acute cardiovascular patients must have systems-based policies, including Triple Rule Out protocols, that:
   • Require specific imaging and lab work when a patient presents with chest pain, shortness of breath, and syncope, particularly in a young woman on oral contraceptives without other cardiac risk factors.
   • Ensure interdisciplinary communication of critical results.
2. Breach: Medical City Arlington:
   • Did not have, or did not enforce, such protocols.
   • Failed to ensure that testing to rule out pulmonary embolism was completed.
   • Failed to ensure effective communication between providers.
3. Causal mechanism (cause in fact):
   • Because these policies were absent, “a proper workup was never completed,” and critical diagnostic imaging (CT angiography) was not performed.
   • Had the protocol been in place and followed, it would have triggered tests that “would have confirmed the presence of the massive bilateral pulmonary embolism while [she] was in the hospital and at a time when appropriate and life-saving intervention could have easily been undertaken.”
   • Those life-saving interventions (anticoagulation, thrombolysis, surgery, and monitoring) would have prevented the fatal thromboembolic event.
4. Causal mechanism (foreseeability):
   • Williams‑Bush’s symptoms were “classically associated with pulmonary embolism,” one of the “most life‑threatening critical conditions of chest pain.”
   • Failure to test for and treat pulmonary embolism in such a patient foreseeably risks sudden death from untreated clotting.

The Court emphasizes:

• This is not a “bare conclusion” that “if there had been better policies, the patient would not have died.”
• It is a concrete, fact‑linked explanation that:
  • Ties specific missing protocols to specific diagnostic tests,
  • Ties those tests to specific likely findings, and
  • Ties those findings to specific interventions that would prevent death.

At the report stage, that is enough. Whether the expert’s predictions about what would have happened are ultimately credible or provable is a merits question for summary judgment or trial.

2. Rejecting the appellate court’s attempt to require policy-enforcement detail and corporate-practice explanations

The Fort Worth court essentially imposed two additional requirements:

1. The expert had to explain how the hospital could lawfully enforce such protocols without engaging in the corporate practice of medicine.
2. The expert had to detail the specific internal enforcement mechanics:
   • Who would override a physician?
   • Can nurses independently order tests?
   • What chain of command would be triggered, and how quickly?

The Supreme Court rejects both as inconsistent with the TMLA:

• No obligation to pre‑litigate defenses. Nothing in § 74.351 requires an expert to:
  • Anticipate defenses,
  • Resolve disputed legal questions (such as the scope of the corporate practice doctrine), or
  • Describe with engineering-level precision how internal policy enforcement would work in every hypothetical scenario.
• Corporate practice questions are merits questions. Whether a given policy would unlawfully infringe on physician independence is a matter:
  • To be developed through discovery, and
  • To be resolved at later procedural stages.
• The expert’s proposal is not facially unlawful. Far from mandating that non‑physician staff diagnose or treat, Dr. Patterson’s report contemplates:
  • Policies that trigger certain diagnostic tests and communications,
  • Standing orders—a concept expressly recognized in the Occupations Code and case law,
  • Protocols that assist, but do not replace, physician judgment.

The Court also notes that the court of appeals’ “analytical gaps” critique overstepped its role by:

• Focusing on hypothetical factual scenarios not contained in the four corners of the report (e.g., what if a physician refuses to follow the protocol?), and
• Turning the sufficiency inquiry into a test of how persuasive the expert’s causation story is, rather than whether it is articulated at all in a non‑conclusory way.

3. Direct hospital liability vs. vicarious liability and independent contractors

The dissent, as summarized by the majority, argues that:

• The report fails to identify any particular hospital employee whose negligence caused the harm.
• The theory effectively seeks to hold the hospital responsible for an independent cardiologist’s diagnostic errors.

The majority responds:

• The claim is one of direct negligence by the hospital’s administrators in failing to adopt and implement appropriate protocols, not vicarious liability for physicians’ medical decisions.
• At this stage, an expert is not expected to know the names or titles of the internal decision-makers responsible for policy formulation.
• Cases such as Dow Chemical Co. v. Bright, 89 S.W.3d 602 (Tex. 2002) (on control over independent contractors) are not triggered because:
  • Dr. Patterson does not propose that the hospital control or override physician judgment.
  • Instead, he proposes policies for non‑physician staff that would generate information for physicians to use.

In short, Bush clarifies that a hospital can be directly liable for defective systems—policies and protocols—even where physicians are independent contractors, so long as the hospital is not being faulted for substituting its judgment for theirs.

4. Standard of care and breach: sufficiency of the hospital-policy theory

Having already held the report sufficient on causation, the Court addresses (for efficiency) the hospital’s challenges to the standard-of-care and breach opinions. It concludes the report:

• Clearly articulates the standard of care:
  • Ordinarily prudent hospitals treating acute cardiovascular patients must “have systems-based policies, protocols and procedures to ensure patients are treated and managed appropriately.”
  • Specifically, for patients like Williams‑Bush, the standard of care required policies that:
    • Triggered Triple Rule Out testing (e.g., CT angiography) when certain symptoms and risk factors are present.
    • Ensured “appropriate development, implementation, training and enforcement of policies and procedures regarding the evaluation, identification and communication related to treating acute cardiac patients.”
• Clearly states the breach:
  • The hospital “violated the standard of care by not having appropriate policies, procedures, guidelines or protocols in place to ensure proper evaluation, assessment, testing, treatment and diagnosis.”
  • It failed to “have and enforce the Triple Rule Out protocol to be activated under appropriate conditions, such as this.”

This level of specificity—identifying what policies should exist and how they should function in patients with symptoms like the decedent’s—is sufficient at the expert report stage.

D. Simplifying Key Concepts and Doctrines

1. What is a TMLA expert report, practically?

A TMLA expert report is not full evidence. It is more like:

• A detailed, medically informed preview of the plaintiff’s theory of liability.
• Its role is to:
  • Notify the defendant of the specific criticisms of its conduct, and
  • Show the trial judge that there is at least one non‑frivolous path by which the plaintiff might prove negligence and causation.

It does not have to:

• Resolve all factual disputes,
• Rule out all alternative causes, or
• Establish liability by a preponderance of the evidence.

2. Proximate cause: cause in fact and foreseeability

• Cause in fact means:
  • The negligent act (or omission) was a substantial factor in bringing about the injury.
  • But for that act, the injury would not have happened.
• Foreseeability means:
  • The general type of harm that occurred was reasonably predictable as a result of the negligence, even if the precise sequence of events was not.

In an expert report, an expert satisfies the causation requirement if they:

• Explain the medical mechanism linking the breach to the injury (cause in fact), and
• Explain why that outcome was a known risk of the breach (foreseeability), even if not using those exact legal labels.

3. “Analytical gaps”

An “analytical gap” exists when there is a missing logical step between facts, opinion, and conclusion. For example, if a report simply says:

“The hospital should have had better policies; therefore, the patient would not have been injured.”

without explaining what specific policies, what they would have required, and what would have happened differently, that is an analytical gap.

In Bush, the Court says the Fort Worth court misused the “analytical gap” label to demand:

• Explanations of how hypothetical policy disputes with physicians would be resolved, and
• Details of enforcement chains that go far beyond what is necessary to show a plausible causal chain at the report stage.

4. Corporate practice of medicine vs. hospital policies

Texas prohibits hospitals and corporations from:

• Diagnosing patients, or
• Making treatment decisions.

Only licensed physicians can do that. But hospitals can and must:

• Design systems (policies, protocols, standing orders) that:
  • Ensure urgent tests are performed promptly,
  • Standardize responses to common presentations (e.g., chest pain, sepsis, stroke), and
  • Facilitate communication among providers.
• Empower nurses and other staff to perform certain predefined tasks under standing orders adopted by the medical staff.

The key distinction is:

• It is lawful to have policies that generate information and trigger time‑sensitive steps before the physician sees the patient.
• It would be unlawful for the hospital to dictate diagnoses or override physician treatment choices.

Bush squarely holds that Dr. Patterson’s proposed protocols fall in the first, permissible category.

5. Standing orders, protocols, and the Triple Rule Out

A “standing order” or “protocol” is essentially a:

Pre‑approved procedure that staff must follow for patients with certain symptoms or risk factors, unless there is a clinical reason not to.

Examples:

• Automatically obtaining an ECG in any patient presenting with chest pain.
• Initiating sepsis bundles (labs, cultures, antibiotics) when specific vital sign thresholds are met.
• Activating a stroke code when there is sudden focal neurologic deficit.

Dr. Patterson’s “Triple Rule Out” protocol fits within this framework:

• When a patient presents with chest pain, shortness of breath, and syncope (especially with certain risk factors), staff should:
  • Initiate order sets that include cardiac labs and imaging (like CT angiography),
  • Communicate results promptly to the physicians, and
  • Ensure all three major life‑threatening causes—coronary disease, pulmonary embolism, aortic dissection—are actively considered and ruled in or out.

These protocols guide and support physician decision‑making; they do not supplant it.

E. Likely Impact and Future Litigation

1. For plaintiffs: clearer roadmap to survive dismissal on hospital policy claims

Bush makes it easier for plaintiffs to survive § 74.351 challenges when alleging hospital-level failures in systems of care. An expert report will likely be adequate if it:

• Identifies specific policies or protocols that should have been in place (e.g., stroke protocol, sepsis bundles, Triple Rule Out for chest pain).
• Explains, with reference to the patient’s exact presentation, what those policies would require:
  • What tests or steps would be triggered,
  • What communication would occur, and
  • How they would reasonably have unfolded in time.
• Links those steps to:
  • The likely or possible diagnostic findings, and
  • Concrete interventions that would more likely than not have prevented the adverse outcome.

The expert does not have to:

• Show that physicians would certainly have followed the protocol in every respect, or
• Address, in detail, every potential way in which the protocol might not have affected the outcome (e.g., physician non-adherence).

2. For hospitals: exposure on systems-based negligence theories

Hospitals should recognize that:

• They may face direct negligence claims for failing to:
  • Adopt appropriate protocols for common high-risk presentations,
  • Implement and train staff on those protocols, and
  • Enforce them through reasonable administrative mechanisms.
• Such claims can proceed even when the allegedly negligent physicians are independent contractors, as long as the theory does not rest on the hospital controlling their medical decisions.

However, Bush does not hold that:

• Such protocols are always required in every context, or
• Hospitals are liable whenever a protocol exists but is not perfectly followed.

Those remain factual and medical standard-of-care questions to be resolved on a fuller record.

3. Appellate courts: reinforced deference and limits on “analytical gaps” review

Bush sends a clear signal to courts of appeals:

• The expert report stage is not the place to:
  • Test the expert’s theory against every legal doctrine (like the corporate practice ban), or
  • Demand exhaustive logistical details on how a hospital would enforce internal policies.
• Where the trial court finds a report adequate, and the report:
  • Identifies the challenged conduct, and
  • Presents a coherent, fact-based “how and why” causal chain,
  appellate courts should be cautious before reversing for “analytical gaps.” Close calls go to the trial court.

4. Corporate practice of medicine as a defensive theme

Hospitals frequently argue that certain standards of care proposed by plaintiffs’ experts would, if adopted, constitute the corporate practice of medicine. Bush indicates that:

• That argument remains available as a substantive defense on the merits.
• But it is not a basis, at the report stage, to demand that the expert:
  • Legally prove that the proposed protocols are compliant with the corporate practice doctrine, or
  • Explain in detail the legal hierarchical relationships between independent physicians and hospital administrative policies.

In practice, this means:

• Hospitals can still argue at summary judgment that specific protocols would unlawfully intrude on physicians’ independent judgment.
• But they cannot use that argument to block patients from even reaching discovery if the expert’s theory is otherwise medically and factually coherent.

V. Conclusion

Bush v. Columbia Medical Center of Arlington is a significant reaffirmation and clarification of Texas law on the adequacy of expert reports under the TMLA, especially in the context of hospital systems-based liability.

Key takeaways include:

• The expert report threshold remains low. Reports must provide a fair summary, not full proof; their role is to screen out frivolous suits, not to adjudicate contested medical theories.
• Hospitals can be directly liable for failing to adopt and enforce reasonable policies, protocols, and systems of care—such as Triple Rule Out protocols—so long as these systems guide and support, rather than supplant, physician judgment.
• Experts need not in their reports:
  • Resolve complex legal defenses (e.g., corporate practice of medicine), or
  • Describe in minute detail the internal enforcement mechanics of hospital protocols.
• Zamarripa remains good law but is limited to reports that provide only bare assertions of causation (e.g., “permitting and facilitating a physician’s decision”) without explaining how the hospital actually had the right or means to affect the outcome.
• Appellate courts must give deference to trial courts on close calls and avoid using “analytical gaps” as a vehicle to weigh the persuasiveness of an expert’s opinion at this preliminary stage.

For practitioners, Bush provides both a template and a warning:

• For plaintiffs: a detailed, systems-based expert narrative that explains what policies were required, what would have changed, and how that change would have prevented the injury can satisfy § 74.351, even in the face of complex institutional and corporate practice issues.
• For defendants: challenges to such reports should focus on truly missing links, not on demanding fully litigated merits arguments at the outset of the case.

In the broader context of Texas medical malpractice jurisprudence, Bush continues a trend of preserving meaningful access to the courts for non‑frivolous claims while maintaining the TMLA’s gatekeeping function. It does so by carefully distinguishing between hospital-level systemic responsibilities and physicians’ individual medical judgments, and by reinforcing that the expert report requirement is a doorway, not a gauntlet.