Key Points

  • CRNAs failed to allege INOVA was a joint employer under the nine-factor Butler test, as the hospital lacked hiring/firing authority and day-to-day supervision.
  • A hospital's control over patient-care protocols and provision of facilities/training does not, standing alone, indicate an employment relationship in the healthcare setting.
  • A plaintiff's private letter to the EEOC that does not result in a formal amended charge or notice to the employer cannot satisfy Title VII or ADA exhaustion requirements.
  • The decision reinforces a staffing agency as the sole employer for contracted clinicians, limiting vicarious liability for hospitals that merely credential and permit work at their facilities.

The Fourth Circuit, in a published opinion by Judge Rushing, affirmed the dismissal of Title VII, ADA, and state-law discrimination suits brought by two certified registered nurse anesthetists (CRNAs) against INOVA Health Care Services after they were terminated for refusing COVID-19 vaccinations. The panel held that the plaintiffs failed to plausibly allege that INOVA was their joint employer and that one plaintiff, Kelly Hoffman, had not exhausted administrative remedies against her staffing-agency employer, North American Partners in Anesthesia (NAPA).

The cases, consolidated on appeal, stem from INOVA's 2022 COVID-19 vaccine mandate. Hoffman and Lorraine Austin, both CRNAs employed by a NAPA subsidiary working exclusively at INOVA facilities, were denied religious and medical exemptions. INOVA suspended their clinical privileges in August 2022, and NAPA terminated them two months later.

Applying the nine-factor joint-employer test from Butler v. Drive Automotive Industries of America, Inc., the court found that the plaintiffs' amended complaints failed to show INOVA had the 'authority to hire and fire' them, exercised 'day-to-day supervision' over them, or possessed their employment records—the 'most important' factors under Fourth Circuit precedent.

"Plaintiffs have not plausibly alleged that Inova was their employer," Judge Rushing wrote. The court highlighted that Hoffman's employment contract with the staffing agency gave the agency, not INOVA, discretion to terminate her based on the hospital's demand. INOVA's general authority over medication protocols and one ambiguous instance of a staff member telling the CRNAs to leave early did not constitute the level of control necessary for joint-employer status.

The court distinguished the facts from Butler, where the putative employer had directed the staffing agency to replace the plaintiff. Here, by contrast, the plaintiffs did not allege that INOVA directed NAPA to fire them or had the authority to do so.

INOVA's provision of equipment, facilities, and mandatory federal training was deemed standard in the healthcare context and not indicative of an employment relationship. The court quoted its earlier holding in Cilecek v. Inova Health Sys. Servs., noting that a 'measure of control' over medical services is necessary for a hospital to discharge its professional responsibility to patients and is thus not a reliable indicator of employment.

Turning to Hoffman's claims against NAPA, the court held that her failure to name NAPA in her original EEOC charge precluded suit. A letter to the EEOC eight months after the initial charge, not resulting in an amended charge or notice to NAPA, did not satisfy administrative exhaustion.

"It would be objectively illogical to view a private letter from a complaining party to the EEOC as constructively amending a formal charge," the court wrote, quoting Sloop v. Memorial Mission Hosp., Inc. The court also rejected Hoffman's argument that a separate questionnaire filed with the state agency was sufficient, finding the argument waived for lack of development.

The panel affirmed the district court's dismissal of all claims against INOVA and NAPA. The opinion provides a template for hospitals and staffing vendors faced with discrimination claims from contracted clinicians, particularly in the wake of vaccine-mandate terminations. The rigorous application of the Butler factors and strict exhaustion requirements underscore the hurdles plaintiffs face when a formal employer is the staffing agency, not the facility where they work.