Summary 2011 WY 31

Summary of Decision February 24, 2011

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Case Name: Guier v. Teton County Hospital District

Citation: 2011 WY 31

Docket Number: S-09-0259

URL: http://wyomcases.courts.state.wy.us/applications/oscn/DeliverDocument.asp?CiteID=461777

Appeal from the District Court of Teton County, Honorable Nancy J. Guthrie, Judge

Representing Appellant (Petitioner): Anna M. Reeves Olson and Weston W. Reeves, Park Street Law Offices, Casper, Wyoming.

Representing Appellee (Respondent): Mark A. Kadzielski, Fulbright & Jaworski, Los Angeles, California; Janet Lewis, Janet Lewis, Jackson, Wyoming; Thomas E. Lubnau, II, Lubnau Law Office, Gillette, Wyoming

Date of Decision: February 24, 2011

Facts: Appellant appeals from an order of the district court affirming a decision by Appellee to revoke his medical staff privileges.

Issues: Whether the burden of proof was applied appropriately in Appellant’s hearing? Whether there was substantial evidence to support the Board’s final decision. Whether Appellee provided Appellant procedural due process. Whether Appellee acted arbitrarily and capriciously.

Holdings: A hospital board may prescribe reasonable rules and regulations to be followed by physicians using the hospital facilities. However, a physician may not be excluded by rules, regulations, or acts of the hospital’s governing authorities which are unreasonable, arbitrary, capricious, or discriminatory.

Appellant asserts that the burden of proof in his contested case hearing is controlled by the Wyoming Administrative Procedure Act, and that the hearing examiner erred by applying the burden of proof identified in the Medical Staff Bylaws. The language of the WAPA does not expressly provide a standard of proof in contested case hearings. The Court has previously recognized that the standard applicable to an adjudicatory hearing before an agency, unless otherwise stated, is the “preponderance of the evidence” standard customarily used in civil cases. A “preponderance of the evidence” is defined as “proof which leads the trier of fact to find that the existence of the contested fact is more probable than its non-existence.” However, the Court has also recognized that the preponderance of the evidence standard generally does not adequately protect the property interest one has in a professional license, and have instead required a licensing board to prove its disciplinary cases by clear and convincing evidence. However, the present case involves the revocation of medical staff privileges, not the revocation of a medical license.

Although medical staff privileges may be “in the nature of” a license, there is a clear and important distinction between hospital privileges and a medical license. Medical staff privileges allow a physician to use hospital facilities and be assisted by hospital staff. As Appellant points out, this includes the authority to admit and treat patients. A medical license, however, confers a general right to practice medicine within the boundaries of a particular jurisdiction. The distinction between a medical license and staff privileges is acknowledged in Wyoming, as indicated by the fact that licensing and privileging decisions are granted to different administrative bodies.

Pursuant to statute, the Wyoming Board of Medicine, not the Judicial Review Committee or the Boards of Trustees of individual hospitals, oversees physician licensing matters. Medical staff privileges, on the other hand, are addressed in the Wyoming Public Health and Safety statutes relating to hospitals and other care facilities. The statute governing hospital privileges expressly entrusts matters of staff admissions and privileges to hospital administration. Staff privileges, in contrast to medical licenses, are specific to individual hospitals, and decisions regarding staff privileges are within the discretion of hospital management. In this case, Appellant faced the revocation of his medical staff privileges. The Hospital, pursuant to its prerogative, decided that privileging decisions would be subject to a burden of proof expressly identified in the Bylaws, and the burden of proof set forth in those Bylaws was applied at the contested case hearing. Appellant agreed to be bound by the Bylaws when he initially sought hospital privileges and in his subsequent application for reappointment. The Bylaws do not require a clear and convincing burden of proof and do not require the burden of proof to be carried by the Hospital.

Appellant also asserts that his loss of privileges is similar to the loss of his medical license because it has impacted his ability to earn a living by practicing medicine. He stated that the termination of his privileges was reported to the National Practitioner Database as required by federal law. As a result of the reporting and subsequent notification to other hospitals, Appellant stated that he had lost privileges at a nearby hospital, and was called to hearings before the Wyoming and Montana Boards of Medicine. Appellant did not provide details of those hearings and did not testify that revocation of his hospital privileges resulted in revocation of his license to practice medicine in Montana or Wyoming. The fact that there may be additional consequences to a physician who loses staff privileges, however, does not impair the ability of a hospital to establish reasonable bylaws and requirements for physicians seeking hospital privileges at its facility, and does not transform a privilege to practice at a particular hospital into a medical license.

The WAPA does not mandate a clear and convincing burden of proof for suspension of hospital privileges. Wyo. Stat. 35-2-113 provides broad discretion to a hospital in determining requirements for the ability to practice at a particular hospital. A hospital is entitled to great deference in the management of its facility and he Court will afford great deference to the hospital’s determination of standards relating to hospital privileges. In sum, the Hospital was entitled to establish the burden of proof to be applied. While it is not the level of proof that every hospital might adopt, the standard applied in the present action is not unreasonable or does not conflict with the WAPA.

Appellant also argues that, even if a clear and convincing standard of proof does not apply, the bylaws are not reasonable because they place the burden on the physician facing charges to show that the adverse recommendation should be rejected or modified. Pursuant to the Bylaws in question, the Medical Executive Committee (MEC) has the burden of producing evidence supporting its recommendation. Once that evidence is produced, the burden shifts to the medical staff appointee to persuade the review committee that the action should not be taken. Appellant asserts that the burden-shifting under the Bylaws logically requires him to carry both the burden of production and the burden of persuasion, and that the practical effect of requiring the MEC to produce “some evidence” supporting its decision does not in any way assuage his burden. However, since the Hospital has discretion to enact reasonable and uniform rules and regulations, based on an express statutory grant of that power, the Hospital’s decision to place the burden of proof on the medical staff appointee, and to require that the burden be met by a preponderance of the evidence, is not unreasonable.

The Appellant’s Medical Staff Bylaws require a medical staff member to “agree to work harmoniously with others;” to “work[] cooperatively with members, nurses, Hospital Administration and others so as to promote high quality patient care;” and to adhere to a professional code of conduct, which includes “the ability to relate to others in a civil, collegial, and courteous manner.” The record contains ample evidence of Appellant’s inability to work cooperatively with others, to relate to others in a civil, collegial, and courteous manner, and to refrain from disruptive conduct. The review committee as the trier of fact, was in the best position to determine the credibility of the witnesses and to weigh the evidence. Upon weighing the evidence, the review found that “Appellant failed to meet his burden of proving, by a preponderance of the evidence, that the decision of the Medical Executive Committee to permanently suspend his privileges should be reversed or modified.” The review committee found that the documentary and testimonial evidence demonstrated that Appellant engaged in unacceptable personal conduct. Given the extensive testimony regarding Appellant’s conduct in the operating room, and the ample documentation produced by the investigations of the ad hoc committee and the Hospital’s CEO, it cannot be concluded the review committee erred in determining that Appellant had not met his burden of proof.

The Appellant’s Medical Staff Bylaws require a medical staff member to “agree to work harmoniously with others;” to “work[] cooperatively with members, nurses, Hospital Administration and others so as to promote high quality patient care;” and to adhere to a professional code of conduct, which includes “the ability to relate to others in a civil, collegial, and courteous manner.” The record contains ample evidence of Appellant’s inability to work cooperatively with others, to relate to others in a civil, collegial, and courteous manner, and to refrain from disruptive conduct. The review committee as the trier of fact, was in the best position to determine the credibility of the witnesses and to weigh the evidence. Upon weighing the evidence, the review found that “Appellant failed to meet his burden of proving, by a preponderance of the evidence, that the decision of the Medical Executive Committee to permanently suspend his privileges should be reversed or modified.” The review committee found that the documentary and testimonial evidence demonstrated that Appellant engaged in unacceptable personal conduct. Given the extensive testimony regarding Appellant’s conduct in the operating room, and the ample documentation produced by the investigations of the ad hoc committee and the Hospital’s CEO, it cannot be concluded the review committee erred in determining that Appellant had not met his burden of proof.

The arbitrary and capricious standard remains as a “safety net” to catch agency action that prejudices a party’s substantial rights or that may be contrary to the other WAPA review standards yet is not easily categorized or fit to any one particular standard. In determining whether the action of an agency is arbitrary, capricious, or an abuse of discretion, it must be ascertained whether the agency has abided by the rules it has promulgated. The failure of an agency to abide by its rules is per se arbitrary and capricious.

Appellant contends that the Board’s decision was per se arbitrary and capricious because the Medical Executive Committee did not follow the notice procedures provided for in the Reappointment Agreement or the Hospital’s internal Disruptive Practitioner Policy. The Disruptive Practitioner Policy provides that if disruptive behavior is reported, the Chief-of-Staff and CEO shall meet with the practitioner, discuss the incident, and document all meetings and conversations concerning the behavior. However, the of the policy also provides that at any time an issue pertaining to a practitioner’s disruptive conduct may be referred to the Medical Executive Committee. Such referral may lead to a formal investigation and corrective action as set forth in the Medical Staff bylaws. Nothing in this policy shall be interpreted to prevent the Medical Executive Committee from exercising its prerogatives in these matters. This policy presents an informal approach to dealing with a disruptive practitioner, which does not replace the right of the Medical Executive Committee to exercise its powers as set forth in the Medical Staff bylaws. The MEC chose to bypass the Hospital’s Disruptive Practitioner Policy, and opted to address the disruptive conduct under the Bylaws, which was its right under the policy and its decision to do so was not arbitrary or capricious. The Medical Executive Committee was required to follow the formal procedures provided for in its Bylaws, which were promulgated pursuant to statute. The record reflects that it did that.

Although he does not expressly argue that the Medical Executive Committee violated his due process rights, Appellant makes much of the fact that the MEC did not notify him immediately of each incident of inappropriate behavior. However, Appellant received notice of the charges against him, a hearing before an impartial tribunal, representation by counsel, the opportunity to cross-examine witnesses and to present evidence, and the opportunity to inspect documentary evidence against him. In light of the ample process that was provided to contest the decision of the MEC, the Board’s decision was not arbitrary or capricious. While it may have been possible to resolve informally under the methods of conflict resolution identified in the Disruptive Practitioner Policy, the fact that the MEC did not follow its recommended procedures does not violate Appellant’s due process rights.

Affirmed.

J. Burke delivered the opinion for the court.