Title: Ex parte Mobile Infirmary Association d/b/a Mobile Infirmary Medical Center.

State: alabama

Issuer: Alabama Supreme Court

Document:

REL: May 25, 2018
Notice: This opinion is subject to formal revision before publication in the advance
sheets of Southern Reporter.  Readers are requested to notify the Reporter of Decisions,
Alabama Appellate Courts, 300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334)
229-0649), of any typographical or other errors, in order that corrections may be made
before the opinion is printed in Southern Reporter.
SUPREME COURT OF ALABAMA
OCTOBER TERM, 2017-2018
_________________________
1160731
_________________________
Ex parte Mobile Infirmary Association d/b/a Mobile Infirmary
Medical Center
PETITION FOR WRIT OF MANDAMUS
(In re:  Connie McLain Snow, as Administrator of the Estate
of Rhonda Lynn Snow, deceased
v.
Mobile Infirmary Association d/b/a Mobile Infirmary Medical
Center)
(Mobile Circuit Court, CV-15-902232)
_________________________
1160815
_________________________
Ex parte Mobile Infirmary Association d/b/a Mobile Infirmary
Medical Center
PETITION FOR WRIT OF MANDAMUS
(In re:  Connie McLain Snow, as Administrator of the Estate
of Rhonda Lynn Snow, deceased
v.
Mobile Infirmary Association d/b/a Mobile Infirmary Medical
Center)
(Mobile Circuit Court, CV-15-902232)
SHAW, Justice.
In these petitions, which we have consolidated, Mobile
Infirmary Association d/b/a Mobile Infirmary Medical Center
("MIMC"), the defendant below, seeks a writ of mandamus
directing the Mobile Circuit Court to vacate portions of its
May 5, 2017, discovery orders.  More specifically, in case no.
1160731, MIMC seeks mandamus review of the portion of the
trial court's order compelling MIMC to produce certain
documents previously submitted to the trial court for in
camera review on the ground that the documents are protected
from discovery under § 6-5-551 and/or § 22-21-8, Ala. Code
1975.  In case no. 1160815, MIMC seeks mandamus review of
another May 5, 2017, order denying MIMC's motions seeking
reconsideration of, or, alternatively, a protective order
2
1160731, 1160815
respecting, the trial court's November 10, 2016, order
compelling MIMC's response to various discovery requests.  In
each case, we grant MIMC's petition and issue the writ.
Facts and Procedural History
MIMC operates a general medical/surgical facility in
Mobile ("the medical center").  On September 4, 2015, the
plaintiff/respondent, 
Connie 
McLain 
Snow 
("Connie"), 
filed, 
in
his capacity as administrator of the estate of Rhonda Lynn
Snow ("Rhonda"), deceased,1 a complaint in the Mobile Circuit
Court 
against 
MIMC 
and 
numerous 
fictitiously named 
defendants. 
Connie's complaint alleged a single count of negligence2
pursuant to Alabama's Medical Liability Act ("the AMLA")3 in
connection with Rhonda's treatment at the medical center on
December 10-11, 2013, for surgery on her right foot. 
1Connie was Rhonda's husband; following Rhonda's death,
Connie 
obtained 
letters 
of 
administration 
naming 
him
administrator of her estate.
2The negligence count contains, among other allegations,
allegations that MIMC negligently failed to monitor Rhonda;
negligently failed to train, educate, and make the medical
center's staff aware of the need for extra precautions in
high-risk patient populations; and negligently failed to
properly train and supervise medical personnel.  
3See  § 6–5–480 et seq., Ala. Code 1975, and § 6–5–540 et
seq., Ala. Code 1975.
3
1160731, 1160815
According to the complaint, Rhonda was, on December 10, 2013,
transferred following surgery to an inpatient room "for pain
control and further management of antibiotics."  At around
5:50 a.m. on December 11, 2013, Lateedra Barnes, R.N., an
employee of MIMC, allegedly administered a dose of Dilaudid to
Rhonda; thereafter, at 6:40 a.m. Rhonda was found "non-
responsive" in her room and the staff at the medical center
were unable to resuscitate her. Rhonda remained on life
support until her death on January 3, 2014.  In his complaint,
Connie alleged that MIMC was negligent in 
developing effective
policies and procedures regarding, and in training its
personnel on, 
the 
proper 
"care, 
monitoring, diagnostics and/or
treatment of Rhonda" and that it had breached the accepted
standard 
of 
care 
in 
its 
treatment 
of 
Rhonda. 
More
specifically, 
Connie 
alleged 
that 
MIMC's 
employees 
had 
"failed
to 
appropriately 
monitor 
the 
respiratory depressive 
effect" 
of
Dilaudid on Rhonda following administration of the drug. 
Connie's complaint was accompanied by a combined set of
"First Interrogatories and Requests for Production" of
documents directed to MIMC.  Among the documents Connie sought
from MIMC were documents related to certain MIMC policies and
4
1160731, 1160815
procedures both at the time of Rhonda's treatment and
"currently."  Other requests sought "all" procedural rules
governing the administration of opiate medication to certain
patients, 
including 
those 
suffering 
from 
sleep 
apnea, 
obesity,
or obstructed airways and/or for the "ongoing clinical
monitoring" of such patients, pain-management assessment of
such patients, and "medication errors." In response, MIMC
provided responsive documentation to some requests and
objected to others on the basis that they were "not
discoverable" on various grounds, including that they were
privileged under either § 6-5-5514 and/or § 22-21-8.5
Connie subsequently moved to compel "full and complete
responses" to his first discovery requests and further
requested that the trial court require MIMC to "substantiate"
4Pursuant to § 6-5-551, any complaint filed against a
health-care provider under the AMLA is required to  "include
... a detailed specification and factual description of each
act and omission alleged ... and shall include when feasible
and ascertainable the date, time, and place of the act or
acts."  The section further prohibits any party "from
conducting discovery with regard to any other act or
omission." 
5As discussed below, § 22-21-8 provides that certain
accreditation, quality-assurance, credentialing, and similar
materials are not subject to discovery and are not admissible
evidence.
5
1160731, 1160815
the claimed privileges with a privilege log conforming to the
requirements of Rule 26(b)(6)(A), Ala. R. Civ. P.  MIMC filed
in March 2016 a response in opposition to Connie's motion to
compel and an accompanying request for a protective order as
to the personnel files of certain individuals.  MIMC's
response was accompanied by affidavit testimony from its risk
manager, Linda A. Gamper, aimed at establishing that
communications and documents prepared in response to Connie's
potential claim both were attorney work product prepared in
anticipation of litigation and "were created for quality
assurance purposes to assess the quality of care of all
patients at [the medical center]," rather than in the ordinary
course of MIMC's business.  MIMC later filed, at the apparent
request of the trial court, a supplemental brief discussing
caselaw interpreting and applying both § 6-5-551 and § 22-21-
8. 
Following a hearing, the trial court entered, on April
29, 2016, an order compelling MIMC to respond to Connie's
first discovery requests.  In that order, the trial court
emphasized "the distinction between discoverability and
admissibility" and noted that, although admissibility of the
6
1160731, 1160815
responses would be considered at a later date, it found as
follows on the issue of "discoverability":6 
"6. MIMC shall ... produce indices of all MIMC's
hospital policies and procedures and indices of all
its nursing policies and procedures which pertain to
patient care from 2013 through current date.
"7. With respect to [Connie's] Requests for
Production ... having to do with MIMC's hospital
policies and procedures, MIMC shall ... produce all
such requested policies and procedures as were in
existence in 2013 through the current date.
"MIMC shall ... identify with specificity
whether it has a policy and procedure responsive to
each of [Connie's] Requests for Production. ...
"If MIMC cannot produce or reproduce each such
requested policy and procedure, it shall specify the
specific reason or reasons why said documents cannot
be produced.
"8. With respect to [Connie's] Requests for
Production 
[regarding 
orientation 
materials 
relating
to opioids, including those presented to Barnes],
MIMC shall ... produce all requested orientation
materials in existence from the time ... Barnes was
initially employed through current date concerning
patient care.
"9. MIMC shall ... produce all documents and
things accumulated in its Risk Management Department
concerning care and treatment in December 2013 of
Rhonda 
..., 
including 
investigative 
reports,
sentinel 
event 
reports, 
witness 
statements,
6MIMC makes clear that relief is sought only as to certain
portions of the trial court's April 29, 2016, order, namely
the trial court's findings as set out in paragraphs 6-9, which
were brought forward into one of the May 5, 2017, orders.   
7
1160731, 1160815
photographs, digital or electronic medical data, the
ampules 
of 
Dilaudid 
administered, 
Code 
Blue
resuscitative notes, Hill ROM data concerning each
person who entered [Rhonda's] room on December 11,
2013, and any video surveillance of persons
entering, present in, or leaving [Rhonda's] [r]oom
... on December 11, 2013."
The trial court also ordered MIMC to produce a privilege log
for all documents withheld from production as 
privileged under
either § 6-5-551 or § 22-21-8.  It further directed:
"As for all documents or things withheld, each
and every one of them shall be sequentially Bates
stamped numbered from MIMC ... so the Court can
determine which, if any, of the withheld documents
should be produced for the Court's in camera
inspection and determination of whether any one or
more should be ordered produced in response to
[Connie's] discovery requests."
On May 13, 2016, MIMC filed a "Motion to Reconsider and
Motion for Protective Order" in which, among other relief,
MIMC asked to be excused from certain enumerated provisions of
the trial court's April 29, 2016, order, including, among
other objections, "the production of information protected by
... §§ 22-21-8 and 6-5-551."  
Connie subsequently propounded a second set of requests
for production to MIMC.  Those new requests sought, among
other things, certain "surgical postoperative standard orders
made available to physicians ... from December 2013 to the
8
1160731, 1160815
present."  MIMC objected to producing the requested documents
on grounds including the exemptions in § 6-5-551 and §
22-21-8.  At or around this same time, Connie also propounded
a second set of interrogatories to MIMC that, among other
requests, sought information regarding MIMC's accreditation
status and a third set of requests for production seeking
information pertaining to any documentation evidencing MIMC's
response to "The Joint Commission Sentinel Event Alert #49,
Safe Use of Opioids in Hospitals."  MIMC again objected,
citing § 6-5-551, § 22-21-8, and the attorney-client
privilege.  MIMC did, however, produce certain documentation,
including "all policies and procedures in place in December of
2013."  Connie subsequently propounded to MIMC a fourth set of
requests for production seeking information "from 2012 to the
present" on any and all communications or correspondence
between MIMC and either its employees or other health-care
providers regarding the dispensation of "narcotics, opioids,
Dilaudid and/or Hydromorphone" to patients generally, and to
certain high-risk patients specifically, and regarding the
monitoring of patients following administration of the above-
described substances.  
9
1160731, 1160815
   
On August 12, 2016, the trial court entered an order
requiring MIMC to produce the documents sought by the second
set of requests for production, including reports tracking
Barnes's activities and locations on December 10-11, 2013; any
and 
all 
"surgical 
postoperative 
standard 
orders 
made 
available
to physicians at [the medical center] for management of
postoperative pain from December 2013 to the present";
orthopaedic postsurgical standing orders for Dilaudid; "all
surgical postoperative standard orders made available to
physicians while treating patients at [the medical center]
which provide for the use of continuous pulse oximetry and/or
capnography for monitoring postoperative patients who have
been prescribed opioid medications" from December 2013 to
present; and the precise standardized order used for
postoperative monitoring.  However, as before, the 
trial court
permitted MIMC to provide for the court's in camera review any
documents it objected to producing and a privilege log
establishing the basis of each such objection.  On August 30,
2016, MIMC sought both "reconsideration" and clarification of
the trial court's August 12 production order as well as the
entry of a protective order declaring orders pertaining to any
10
1160731, 1160815
patient other than Rhonda and any time frame other than
December 10-11, 2013, exempt from production pursuant to § 6-
5-551. 
MIMC 
later 
supplemented 
that 
motion; 
in 
its
supplemental filing, MIMC explained that it had produced the
2013 indices of all MIMC policies and procedures and Barnes's
orientation transcript for the period beginning with her
initial orientation and concluding on December 11, 2013. 7 
Thereafter, Connie amended his complaint.  Specifically,
he added allegations that, in relation to Dilaudid's
potentially deadly side effect of respiratory depression
and/or arrest, 16 months before December 2013 medical
literature aimed at helping hospitals formulate and implement
policies for ongoing clinical monitoring of at-risk patients
had been distributed but that MIMC had failed to act
appropriately in response; the amendment identified numerous
ways in which MIMC and the fictitiously named defendants had
allegedly "negligently departed from the accepted standard of
7Among other exhibits, MIMC attached a copy of an order
issued in a separate bad-faith lawsuit Connie had initiated
against his insurance company in the Clarke Circuit Court in
which MIMC had been excused, pursuant to § 22-21-8, from
producing quality-assurance reports and risk-management
documentation Connie had sought to obtain from MIMC by means
of a nonparty subpoena.
11
1160731, 1160815
care applicable to similarly situated healthcare provider
which was in effect at the time."  (Emphasis added.) The
amendment further added a claim alleging spoliation of the
entirety of Rhonda's medical records by MIMC.  At or around
this same time, MIMC filed its answers to Connie's second set
of interrogatories in which it objected to producing
information pertaining to its accreditation status on the
ground that the information was protected from discovery
pursuant to both § 6-5-551 and § 22-21-8. 
Later, Connie moved to compel MIMC's responses to both
his second interrogatories and third requests for production
of documents.  He also moved to require MIMC "to fully and
completely respond to" his fourth requests for production. 
MIMC provided its responses to Connie's fourth requests for
production of documents.  More specifically, MIMC produced
responsive materials that had been provided to Barnes, but
objected to the requests to the extent they also sought
"information about caregivers who were not involved
in [Rhonda's] care and treatment..., information
about facilities other than [the medical center],
... 
information 
for 
a 
period 
of 
time 
that
pre-date[d] ... Barnes'[s] employment at [MIMC], and
as seeking information for a period of time after
the acts and/or omissions made the basis of
[Connie's] Complaint, all in violation of the
12
1160731, 1160815
protection from discovery provided by ... §
6-5-551."  
MIMC further objected to the extent the requests allegedly
sought 
information 
related 
to 
accreditation, 
quality
assurance, credentialing, or similar functions in alleged
violation of § 22-21-8.  
On November 10, 2016, subsequent to a hearing, the trial
court entered an order denying MIMC's motion seeking
reconsideration of the trial court's earlier April 29, 2016,
order requiring MIMC to respond to Connie's first requests for
production 
of 
documents; 
excepting 
documents 
allegedly 
subject
to attorney-client privilege, the trial court directed that
MIMC "prepare a 
privilege log, Bates stamp documents [withheld
based on § 22-21-8 and § 6-5-551] and produce ... said
documents for an in camera review" with an accompanying
privilege log.  Also on November 10, 2016, the trial court
entered a different order denying MIMC's motion for
reconsideration and clarification of the trial court's August
12, 2016, order and its request for a protective order.  In
that order, the trial court directed that MIMC produce the
documentation covered by the August 12, 2016, order and sought
by Connie's second requests for production, subject to a
13
1160731, 1160815
privilege log identifying any withheld documents for 
the 
trial
court's in camera review, including any documents MIMC
continued to maintain were privileged.  In a third order
entered on that same date, the trial court further granted
Connie's 
motion 
to 
compel 
responses 
to 
his 
second
interrogatories and 
third 
requests 
for 
production 
of 
documents
and provided that MIMC file a privilege log regarding all
documents MIMC argued were privileged for the trial court's in
camera review.  Also on November 10, the trial court entered
a fourth order regarding Connie's motion to compel responses
to his fourth requests for production; in that order, the
trial 
court 
ordered 
MIMC 
to 
produce 
the 
requested
documentation but, again, allowed MIMC to provide both a
privilege log and documents for the trial court's in camera
review.   
MIMC filed a motion seeking additional time to comply
with the trial court's November 10, 2016, orders.  The trial
court granted MIMC's motion, providing an additional 21 days
or until December 22, 2016, for MIMC "to comply or otherwise
respond."  
14
1160731, 1160815
On December 22, 2016, MIMC filed notice evidencing that
it had, as directed, submitted over 6,000 pages of documents
and 2 accompanying privilege logs to the trial court for an in
camera review; according to MIMC, these challenged documents
were, because of the parties' resolution of other disputes,
responsive only to Connie's first requests for production –-
namely the documents sought by paragraphs 6-9 of the trial
court's April 29, 2016, order, as set out above.  See note 6,
supra.  On that same date, MIMC also filed an explanation
specifying the privileges allegedly protecting each document
from production and discussing applicable authority. 
MIMC also separately filed motions "to reconsider" and
for a protective order with regard to the November 10, 2016,
orders respectively requiring it to respond to 
Connie's second
interrogatories, third requests for production, and fourth
requests for production.  As with MIMC's previous filings, the
thrust of its objection was primarily that the information
sought was exempt from discovery under § 6-5-551 and/or §
22-21-8.  MIMC also again submitted, as support for the above-
described motions, affidavit testimony from Gamper attesting
that the materials in the risk-management file regarding
15
1160731, 1160815
Rhonda's treatment at MIMC, which had been produced for the
trial 
court's 
in 
camera 
inspection, included 
documents 
covered
by the nonparty subpoena served on MIMC in the separate
insurance litigation, see note 7, supra, as well as certain
policies prepared for quality-assurance purposes.  Gamper
further testified that the release of those documents would be
prejudicial both to MIMC and to all the patients treated
there.  A separate affidavit from Gamper established that
other documents produced for the trial court's in camera
review in response to Connie's first requests for production 
had been prepared in anticipation of litigation.  
Connie both opposed MIMC's motions and announced his
intention to depose MIMC personnel in order to fully and
"substantively" respond to MIMC's claims of privilege.  Upon
the conclusion of Gamper's deposition, Connie filed a lengthy
motion seeking to strike all three of Gamper's affidavits.  He
contended that Gamper's affidavits had been prepared by
counsel and were not based on Gamper's personal knowledge;
that her statements as to the import of the pertinent
documents were conclusory; and that MIMC's counsel had, during
Gamper's deposition, allegedly repeatedly instructed Gamper
16
1160731, 1160815
not to answer questions "about her personal knowledge of the
statements offered by MIMC to substantiate its claims of
privilege."  MIMC opposed Connie's request to strike Gamper's
affidavits.
On May 5, 2017, the trial court entered an order on the
various pending discovery motions remaining before it at that
time.  Specifically, the trial court:
"1. DENIE[D] [MIMC]'s December 22, 2016, Motion
to Reconsider and Motion for Protective Order
Related to Court's November 10, 2016, Order
Compelling [MIMC] to Respond to [Connie's] Second
Interrogatories ...;
"2. DENIE[D] [MIMC]'s December 22, 2016, Motion
to Reconsider and Motion for Protective Order
Related to Court's November 10, 2016, Order
Compelling [MIMC] to Respond to [Connie's] Third
Requests for Production ...; and
"3. DENIE[D] [MIMC]'s December 22, 2016, Motion
to Reconsider and Motion for Protective Order
Related to Court's November 10, 2016, Order
Compelling [MIMC] to Respond to [Connie's] Fourth
Requests for Production ...."
Also on May 5, 2017, the trial court entered another order
identifying by Bates stamp numbers the items among those
provided to the trial court for its in camera review that MIMC
would also be required to produce.8  There is nothing in the
8We note that nothing in the materials before us suggests
that the trial court, in so holding, found MIMC's compliance
17
1160731, 1160815
limited materials before us suggesting that the trial court
granted 
Connie's 
motion 
seeking 
to 
strike 
Gamper's 
affidavits. 
See note 11, infra. 
MIMC sought additional time to comply with the trial
court's production orders as well as additional time to
"otherwise respond," including possibly seeking mandamus
relief from this Court.  The trial court granted MIMC until
May 19, 2017, to act.  MIMC filed, on May 19, 2017, its
initial mandamus petition in case no. 1160731 seeking relief
from the May 5, 2017, order requiring it to produce certain
items MIMC had previously provided to the trial court for in
camera review; MIMC subsequently filed, on June 12, 2017, its
second mandamus petition in case no. 1160815 seeking relief
from the trial court's May 5, 2017, order denying MIMC's
various motions for reconsideration and for protective
orders.9  This Court consolidated the petitions, ordered
with its discovery mandates to be either "recalcitrant" or
procedurally insufficient, as Connie suggests, or that the
trial court's May 5, 2017, orders from which MIMC seeks relief
were in any way intended as a discovery sanction.
9
"[I]n Ex parte Meadowbrook Insurance Group, Inc.,
987 So. 2d 540 (Ala. 2007), this Court reiterated
the prerequisite of a timely filed motion for a
protective order to review by a petition for the
18
1160731, 1160815
answers and briefs, and stayed enforcement of the trial
court's orders pending our review.
Standard of Review
"'Mandamus is an extraordinary remedy
and will be granted only when there is "(1)
a clear legal right in the petitioner to
the order sought, (2) an imperative duty
upon 
the 
respondent 
to 
perform, 
accompanied
by a refusal to do so, (3) the lack of
another adequate remedy, and (4) properly
writ of mandamus:
"'[A] petition [for a writ of mandamus]
challenging an order compelling discovery
is timely only if (1) a protective order is
sought, pursuant to Ala. R. Civ. P. 26(c),
within the time set for compliance with the
order, Ex parte Orkin, Inc., 960 So. 2d
635, 640 n. 5 (Ala. 2006) (citing with
approval Wang v. Hsu, 919 F.2d 130, 131
(10th Cir. 1990)), and (2) the mandamus
petition is filed no more than 42 days
after the denial of the protective order. 
960 So. 2d at 640.'
"987 So. 2d at 546."
Ex parte Terminix Int'l Co., 14 So. 3d 849, 852-53 (Ala.
2009).  The trial court denied MIMC's motions for a protective
order on May 5, 2017, and, on that same date by separate
order, required MIMC to produce the allegedly privileged
documents submitted for the trial court's in camera review. 
Both petitions were filed within 42 days of the trial court's
May 5 orders.  Therefore, the petitions are timely.  See id. 
See also Rule 21(a)(3), Ala. R. App. P.; Ex parte Community
Health Sys. Prof'l Servs. Corp., 72 So. 3d 595, 598 (Ala.
2011) ("[T]he presumptively reasonable time for filing a
petition for a writ of mandamus is 42 days ...."). 
19
1160731, 1160815
invoked jurisdiction of the court."  Ex
parte Alfab, Inc., 586 So. 2d 889, 891
(Ala. 1991).  In Ex parte Ocwen Federal
Bank, FSB, 872 So. 2d 810 (Ala. 2003), this
Court announced that it would no longer
review 
discovery 
orders 
pursuant 
to
extraordinary writs.  However, we did
identify four circumstances in which a
discovery order may be reviewed by a
petition for a writ of mandamus.  Such
circumstances arise (a) when a privilege is
disregarded, see Ex parte Miltope Corp.,
823 So. 2d 640, 644–45 (Ala. 2001) .... 
The burden rests on the petitioner to
demonstrate 
that 
its 
petition 
presents 
such
an exceptional case--that is, one in which
an appeal is not an adequate remedy.  See
Ex parte Consolidated Publ'g Co., 601 So.
2d 423, 426 (Ala. 1992).'
"Ex parte Dillard Dep't Stores, Inc., 879 So. 2d
1134, 1136–37 (Ala. 2003)."
Ex parte Fairfield Nursing & Rehab. Ctr., L.L.C., 22 So. 3d
445, 447 (Ala. 2009).  
"Because discovery involves a considerable
amount of discretion on the part of the trial court,
the standard this Court will apply on mandamus
review is whether there has been a clear showing
that the trial court [exceeded] its discretion.  Ex
parte Clarke, 582 So. 2d 1064, 1067 (Ala. 1991); Ex
parte McTier, 414 So. 2d 460 (Ala. 1982)."
Ex parte Compass Bank, 686 So. 2d 1135, 1137 (Ala. 1996).  
Discussion
I.  Case No. 1160731
20
1160731, 1160815
In this petition, MIMC challenges the trial court's May
5, 2017, order both requiring production of the documentation
previously provided for that court's in camera review and
compelling MIMC's response to Connie's first and second
requests for production. 
A. Section 6-5-551 Exemption 
MIMC first contends that the trial court exceeded its
discretion in 
compelling 
production 
of "policies 
and
procedures, 
educational/training 
material 
and 
physician 
orders
that are not related to the acts and/or omissions alleged in
[Connie's] 
complaint." 
 
More 
specifically, MIMC 
maintains that
the trial court erroneously ordered MIMC to produce, in
response 
to 
Connie's 
first 
and 
second 
requests 
for 
production, as described in more detail above, policies,
procedures, training materials, and physician standing orders
implemented by MIMC after December 10 and 11, 2013, because,
it argues, those items are exempt from discovery under § 6-5-
551.  We agree.
Section 6–5–551 states:
"In any action for injury, damages, or wrongful
death, whether in contract or in tort, against a
health care provider for breach of the standard of
care, whether resulting from acts or omissions in
21
1160731, 1160815
providing health care, or the hiring, training,
supervision, retention, or termination of care
givers, the [AMLA] shall govern the parameters of
discovery and all aspects of the action.  The
plaintiff shall include in the complaint filed in
the action a detailed specification and factual
description of each act and omission alleged by
plaintiff to render the health care provider liable
to plaintiff and shall include when feasible and
ascertainable the date, time, and place of the act
or acts.  The plaintiff shall amend his complaint
timely upon ascertainment of new or different acts
or omissions upon which his claim is based;
provided, however, that any such amendment must be
made at least 90 days before trial.  Any complaint
which fails to include such detailed specification
and factual description of each act and omission
shall be subject to dismissal for failure to state
a claim upon which relief may be granted.  Any party
shall be prohibited from conducting discovery with
regard to any other act or omission or from
introducing at trial evidence of any other act or
omission."
(Emphasis added.)  In Ex parte Anderson, 789 So. 2d 190, 195 
(Ala. 2000), the Court explained:
"If all conditions of the statute are met, then any
other acts or omissions of the defendant health-care
provider are exempt from discovery, and the
discovering party is prohibited from introducing
evidence of them at trial.  See § 6–5–551.  Such
exemptions would include information regarding any
other incidents regarding [the health-care provider
and its] alleged breach of the standard of care."
Here, as in Ex parte Anderson, it appears undisputed that
Connie's complaint falls within the purview of § 6–5–551.  See
Ex parte Coosa Valley Health Care, Inc., 789 So. 2d 208, 217
22
1160731, 1160815
(Ala. 2000) ("This Court's decision in Ex parte McCollough[,
747 So. 2d 887 (Ala. 1999),] recognized that an action against
a health-care provider alleging negligent hiring, training,
and supervision is an 'action ... for breach of the standard
of care' and is thus governed by § 6–5–551 ....").  As such,
as the Court also held in Ex parte Anderson, § 6–5–551
precludes "[d]iscovery of any incidents of malpractice other
than those specifically alleged in the complaint."  789 So. 2d
at 198.  As set out above, Connie's complaint specifically
alleges a breach by MIMC and/or its employees of the
applicable standard of care "on December 10, 2013 and December
11, 2013."  
Despite the allegations in the complaint that the breach
of the standard of care occurred on December 10 and 11, 2013,
MIMC correctly argues that the trial court's May 5, 2017,
order required MIMC to produce, in response to Connie's
requests for production, various previously withheld items
dating from 2013 "through the current date." The order,
therefore, required the production of both nursing policies
and procedures and of physician standing orders pertaining to
the postoperative care of patients other than Rhonda, the
23
1160731, 1160815
administration of drugs other than Dilaudid, and MIMC
personnel other than those involved in Rhonda's care. 
Additionally, the trial court's order required MIMC to 
produce
orientation materials for employees also not involved in
Rhonda's care and that were presented to the employees after
the date on which the alleged breach of the standard of care
occurred, i.e., materials that could have in no way affected
the care Rhonda received at the medical center or MIMC's
alleged breach.  To the extent that the order did so, it was
overbroad.  We agree with MIMC's contention that, under § 6-5-
551 and our caselaw, Connie's discovery requests seeking that
information were, in fact, prohibited.  
"Section 6–5–551, as amended, makes it clear that in
an action against a health-care provider, based on
acts or omissions in the 'hiring, training,
supervision, retention, or termination of [the
health-care provider's employees],' the plaintiff is
entitled only to discovery concerning those acts or
omissions 'detailed specifica[lly] and factual[ly]
descri[bed]' in the complaint and 'alleged by [the]
plaintiff to render the health care provider liable
to [the] plaintiff.'  Thus, if the plaintiff alleges
that the defendant health-care provider breached the
standard 
of 
care 
by 
negligently 
training,
supervising, retaining, or terminating an employee
or by negligently entrusting an employee with an
instrumentality, then the plaintiff may discover
information only concerning those acts or omissions
by those employees whose conduct is detailed
specifically 
and 
factually 
described 
in 
the
24
1160731, 1160815
complaint as rendering the health-care provider
liable.  Consequently, [a plaintiff] is not entitled
to discovery regarding acts or omissions by [the
health-care provider] in the hiring, training,
supervising, retaining, or terminating of employees
other than those employees whose acts he detailed
specifically 
and 
factually 
described 
in 
his
complaint as rendering [the health-care provider] 
liable. ...  Therefore, as to interrogator[ies]
[seeking evidence of other acts or omissions of the
health-care provider and its employees beyond those
alleged in the plaintiff's complaint,] [the health-
care provider]  has shown a clear legal right to
have the trial court's discovery order vacated."
Ex parte Ridgeview Health Care Ctr., Inc., 786 So. 2d 1112,
1116–17 (Ala. 2000).
Similarly, 
as 
to 
any 
discovery 
requests 
seeking
information relevant to the period after December 11, 2013,
those requests do not "contain any information concerning any
of the alleged acts or omissions set forth in the complaint,"
including alleged acts or omissions in the hiring, training,
and/or supervision of employees who tended Rhonda.  Ex parte
Gentiva Health Servs., Inc., 8 So. 3d 943, 949 (Ala. 2008). 
See also Ex parte Coosa Valley Health Care, Inc., 789 So. 2d 
at 218 (holding that, under § 6–5–551, a nursing-home
resident, who alleged that the nursing home had breached a
duty to adequately hire, train, and staff its personnel was
not entitled to discovery regarding acts or omissions by the
25
1160731, 1160815
nursing home in hiring, training, and supervising employees
other than those employees who had provided care and/or
services to the resident). The requests are, therefore,
prohibited by § 6–5–551, and the trial court exceeded its
discretion in ordering MIMC's response.   See Ex parte Gentiva
Health Servs., 8 So. 3d at 949 (vacating a trial court's order
requiring a hospital to produce the resignation letter of its
former employee/codefendant following the incident made the
subject of the plaintiff's complaint on the ground that the
letter failed to reference either the plaintiff's care or the
employee's 
training 
and/or 
supervision). 
Although 
the
materials before us suggest that, in so ordering, the trial
court made a distinction between "discoverability" and
"admissibility," § 6–5–551 makes no such distinction and, in
fact, prohibits "conducting discovery with regard to any ...
act or omission"  other than those detailed in the plaintiff's
complaint.  To the extent Connie appears to argue that
allegations in his amended complaint regarding MIMC's alleged
failure to appropriately respond to a notification calling for
the establishment of clinical monitoring of at-risk patients
to whom opioids have been administered, which was distributed
26
1160731, 1160815
prior to Rhonda's death, establishes his entitlement to
training and procedures implemented after Rhonda's death, we
are unconvinced.  Instead, requiring MIMC to divulge that
information would allow disclosure of materials § 6-5-551
explicitly curtails.  Thus, under § 6-5-551 and the caselaw
cited above, all discovery materials regarding policies,
procedures, orders, training, etc., identified above in this
subsection, that were created or implemented after the 
alleged
breach of the standard of care in December 2013 are not
discoverable.
B.  Section 22-21-8 Privilege
MIMC also contends that the trial court exceeded its
discretion to the extent that its May 5, 2017, orders required
MIMC to produce information in alleged violation of both the
quality-assurance privilege found in § 22-21-8 and the work-
product doctrine.  In particular, MIMC seeks relief from the
trial court's requirement compelling it to produce, in
response to Connie's first requests for production, MIMC's
"Medical/Healthcare Errors Response Policy" and the "Quality
27
1160731, 1160815
and Patient Safety Program Plan."10  MIMC also challenges the
portion of the order requiring it to produce "quality
assurance material from its Risk Management file." Connie
counters that MIMC failed, via its submissions below, to
sufficiently establish MIMC's entitlement to the claimed
privileges.11  
10MIMC also seeks relief from the requirement that it
disclose "certain ... training modules ... created and
provided to ... Barnes [after December 11, 2013,] as part of
the quality assurance process." The production of those
training modules are, however, sufficiently addressed by this
Court's holding in Part I.A., supra.
11More specifically, according to Connie, Gamper's second
and third affidavits were untimely submitted in that they came
after the trial court had already ordered MIMC to produce the
disputed information and 
had 
denied its request for protective
orders; were insufficient to the extent they allegedly failed
to 
establish 
Gamper's 
personal 
knowledge 
or 
clinical
qualification; and were "untested by cross-examination" at
Gamper's ensuing deposition.  As explained elsewhere, the
claim regarding Gamper's alleged lack of personal knowledge
appears based on the fact that MIMC's counsel disclosed during
Gamper's deposition that he had drafted the affidavits that
Gamper ultimately executed.  That fact aside, it appears
undisputed that each of Gamper's affidavits attested to both
her personal knowledge of its contents and her competency to
testify thereto. 
As also noted elsewhere, nothing before this Court
suggests that, before MIMC's filing of the present petitions,
the trial court ruled on Connie's motion to strike Gamper's
affidavits.  To the contrary, Connie represents that the trial
court purposefully did not rule on that motion in light of 
MIMC's mandamus filings and this Court's related review. 
Although, 
as 
discussed, 
Connie 
lodges 
several 
criticisms 
aimed
28
1160731, 1160815
"[The plaintiff's] claim to discovery of
information and materials pursuant to §§ 22–21–8,
34–24–58, 
and 
34–24–59, 
Ala. 
Code 
1975, 
is
absolutely barred, regardless of the fact that such
information and materials might have been gathered
as a consequence of the incident regarding [the
plaintiff].  Section 22–21–8, Alabama's 'peer-review
statute,' reads:
"'§ 
22–21–8. 
Confidentiality 
of
accreditation, 
quality 
assurance
credentialling materials, etc.
"'(a) 
Accreditation, 
quality 
assurance
and similar materials as used in this
section shall include written reports,
records, correspondence, and materials
concerning the accreditation or quality
assurance or similar function of any
hospital, clinic, or medical staff.  The
confidentiality 
established 
by 
this 
section
shall apply to materials prepared by an
employee, advisor, or consultant of a
hospital, clinic, or medical staff and to
materials prepared by an employee, advisor
or consultant of an accrediting, quality
assurance or similar agency or similar body
and to any individual who is an employee,
advisor or consultant of a hospital,
clinic, medical staff or accrediting,
quality assurance or similar agency or
body.'
"This Court elaborated on the confidentiality of
peer-review proceedings in Ex parte Qureshi, 768 So.
2d 374 (Ala. 2000), in which we determined that the
at the sufficiency of Gamper's affidavit testimony, he does
not renew, in this Court, his request to strike those
affidavits.  
 
29
1160731, 1160815
trial court erred in compelling discovery from a
physician and hospitals when they were sued by a
patient for medical malpractice.  That opinion
contains a sound statement of the applicable
public-policy considerations:
"'This Court recently addressed [the
confidentiality of hospital and physician
information] in Ex parte Krothapalli, 762
So. 2d 836 (Ala. 2000).  We wrote:
"'"... Section 22–21–8 was
enacted as Act No. 81–801, Ala.
Acts 1981.  The title to that Act
reads: 
'To 
provide 
for 
the
confidentiality of all written
materials 
and 
activities
concerning 
the 
accreditation,
quality assurance, or similar
function of any hospital, clinic,
or medical staff.'
"'"....
"'"In Cruger v. Love, 599
So. 2d 111 (Fla. 1992), the
Florida Supreme Court, construing
Florida's peer-review statute,
Fla. Stat. Ann. § 766.101(5)
(1989), stated:
"'"'The 
Florida
Legislature 
enacted
these 
peer 
review
statutes in an effort
to 
contro l 
t h e
escalating 
cost 
of
healt h  
c a re 
by
e n c o u r a g i n g
self-regulation by the
medical 
profession
through peer review and
30
1160731, 1160815
evaluation.  In order
to make meaningful peer
review 
possible, 
the
legislature provided a
g u a r a n t e e  
o f
confidentiality for the
peer review process....
"'"'....
"'"'... While we
recognize[] 
... 
that
the discovery privilege
[impinges] 
upon 
the
rights of litigants to
obtain 
information
helpful 
or 
even
essential 
to 
their
cases, we assume[] that
t h e  
l e g i s l a t u r e
balanced that against
the benefits offered by
effective self-policing
by 
th e  
me dical
community.
"'"'We hold that
the privilege provided
by 
[the 
peer-review
statutes] protects any
document considered by
the committee or board
as 
part 
of 
its
d e c i s i o n - m a k i n g
process.  The policy of
encouraging full candor
i n  
p eer 
review
proceedings is advanced
only if all documents
considered 
by 
the
committee 
or 
board
during the peer review
31
1160731, 1160815
o r  
c r e d e n t i a l i n g
process are protected.
Committee members and
t h o s e  
p r o v i d i n g
information 
to 
the
committee must be able
to operate without fear
o f  
r e p r i s a l . 
Similarly, 
it 
is
essential that doctors
s e e k i n g  
h o s p i t a l
privileges disclose all
pertinent 
information
to 
the 
committee.
Physicians 
who 
fear
t h a t  
i n f o r m a t i o n
p r o vided 
in 
a n
application 
might
someday be used against
them by a third party
will be reluctant to
fully 
detail 
matters
that 
the 
committee
should consider.'
"'"599 
So. 
2d 
at 
113–14.
(Citation omitted.)
"'"Similarly, 
the 
South
Carolina Supreme Court, in McGee
v. Bruce Hosp. System, 312 S.C.
58, 
439 
S.E.2d 
257 
(1993),
explained:
"'"'The overriding
public policy of the
confidentiality statute
is to encourage health
care professionals to
monitor the competency
a n d  
p r o f e s s i o n a l
conduct of their peers
32
1160731, 1160815
to 
safeguard 
and
improve the quality of
patient 
care. 
The
underlying 
purpose
b e h i n d  
t h e
confidentiality statute
is not to facilitate
the 
prosecution 
of
civil actions, but to
promote complete candor
and 
open 
discussion
among participants in
the 
peer 
review
process. ...
"'"'....
"'"'We find that
the public interest in
candid 
professional
peer review proceedings
should prevail over the
litigant's 
need 
for
information 
from 
the
m o s t  
c o n v e n i e n t
source.'
"'"312 S.C. at 61–62, 439 S.E.2d
at 259–60. (Citations omitted.)
"'"It seems clear to us, as
it did to the Supreme Courts of
Florida and South Carolina, that
the purpose of a peer-review
statute is to encourage full
candor in peer-review proceedings
and that this policy is advanced
only if all documents considered
by the committee or board during
the peer-review or credentialing
process are protected.  In the
title to Act No. 81–801, the
33
1160731, 1160815
Legislature stated the purpose of
the Act as being '[t]o provide
for the confidentiality of all
written materials and activities
concerning 
the 
accreditation,
quality assurance, or similar
function of any hospital, clinic,
or medical staff.' ...
"'"We note that § 22–21–8(b)
provides:
" ' " ' I n f o r m a t i o n ,
documents, or records
otherwise 
available
from original sources
are not to be construed
as 
being 
unavailable
for discovery or for
use in any civil action
merely 
because 
they
were presented or used
in 
preparation 
of
accreditation, quality
assurance 
or 
similar
materials 
nor 
should
any person involved in
p r e p a r a t i o n ,
evaluation, or review
of such materials be
p r e v e n t e d  
f r o m
testifying 
as 
to
matters 
within 
his
knowledge, 
but 
the
witness 
testifying
should 
not 
be 
asked
about any opinions or
data given by him in
p r e p a r a t i o n ,
evaluation, or review
of 
accreditation,
34
1160731, 1160815
quality 
assurance 
or
similar materials.'
"'"Accordingly, § 22–21–8 does
not protect information if it is
obtained 
from 
alternative
sources.  Hence, a plaintiff
seeking discovery cannot obtain
directly from a hospital review
committee 
documents 
that 
are
available 
from 
the 
original
source, 
but 
may 
seek 
such
documents 
from 
the 
original
source. ..."
"'762 So. 2d at 838–39....'
"768 So. 2d at 377–78. (some emphasis added in
Qureshi, other emphasis added here.)  Section
22–21–8, as explained in Qureshi and Krothapalli,
provides 
that 
under 
our 
peer-review 
statute,
information and documents produced by hospitals,
their agencies, or bodies, in furtherance of their
official duties and activities in regard to the
peer-review process, are not discoverable."
Ex parte Anderson, 789 So. at 199–202.
In support of its initial March 2016 opposition to
Connie's motion seeking to compel responses to his first
requests for production, MIMC submitted, in substantiation of
its assertion of the quality-assurance privilege found in §
22-21-8 
and 
the 
attorney-client and 
work-product 
privileges 
on
which it had withheld certain items from production, the
affidavit testimony of Gamper, who was identified as "the
35
1160731, 1160815
Manager for Infirmary Health System, Inc. Risk Management." 
Gamper's initial affidavit, after testifying to her personal
knowledge and competency to testify to the matters covered
therein, stated:
"The documents prepared by and sent to the Risk
Management Department on or after December 11, 2013,
in addition to being prepared in anticipation of
litigation and constituting work product, were
created for quality assurance purposes to assess the
quality of care of all patients [of MIMC].
Confidentiality of those documents is needed to keep
the investigation of incidents and care of patients
at [the medical center] candid and open.  Production
of documents to those outside [the medical center]
will be detrimental to the quality of care provided
for all patients. Additionally, these documents were
not prepared in the ordinary course of business and
are not a part of the medical records of [Rhonda]."
When MIMC produced the "Medical/Healthcare 
Errors
Response Policy" and the "Quality and Patient Safety Program
Plan" for the trial court's in camera review, it provided
additional, more detailed affidavit testimony from Gamper. 
Specifically, Gamper testified:
"The Risk Management Department of Infirmary Health
Systems, Inc. performs quality assurance functions
for its affiliate [MIMC].  This Department performed
such functions in connection with the review of the
care and treatment of Rhonda ... in December of
2013.
"... 
The 
Risk 
Management 
file 
materials
concerning the care and treatment of Rhonda ... in
36
1160731, 1160815
December of 2013, which this Court has ordered to be
produced for in camera review, are Bates stamped
PL1-PL187.  I am personally familiar with these
documents, and these are the documents which I
described in my earlier affidavit of March 24, 2016
....  
"... On or about December 11, 2013, the Risk
Management Department had reason to believe that
litigation against [MIMC] as a result of the
December 11, 2013 Code Blue event involving Rhonda
... was likely to occur.
"... As I stated in my March 24 affidavit, on
December 12, 2013, the Risk Management Department
notified our third party administrator Western
Litigation, Inc. regarding a potential claim by
Rhonda ... and our Department began to review the
situation in anticipation of such litigation. [MIMC]
formally retained A. Edwin Stuardi and his firm on
December 20, 2013 to represent its interests
regarding Rhonda. ...  The communications between
the Risk Management department, our insurers, third
party administrators and our counsel, made in
anticipation of such litigation, are reflected at
PL001-PL012 and PL025-PL029 of the Risk Management
file.  In further anticipation of litigation, the
Risk 
Management 
Department 
made 
requests 
for
investigation of this matter as contained at PL019
and requested that a report of the event be prepared
by ... Barnes ..., which reports are contained at
PL013-017 and PL030-PL032.  In further anticipation
of litigation and at the request of our litigation
counsel, 
the 
Risk 
Management 
Department 
also
requested that certain information be generated for
review by the Risk Management Department and our
counsel.  The documents that were generated to
report this information are Bates-stamped PL106-129.
Handwritten notes (PL018) and a fax transmittal
sheet (PL043) were also prepared in anticipation of
litigation.
37
1160731, 1160815
"... Other materials in this Risk Management
file, specifically at PL020-PL024, PL033-PL041, and
PL075-PL102, are copies of the subpoena received
from the Clarke County Circuit Court; correspondence
from [Connie's] counsel in the proceedings in that
Court, entitled Connie McLain Snow vs. Liberty Nat.
Life Ins. Co., CV 2014-900084; and documents
prepared or notes generated in response to the
subpoena received from that court or to the written
communications from [Connie's] counsel in that
action.  Thus, all of this material was generated to
prepare for a hearing before that Court on [MIMC's]
responses and objections to that subpoena.
"Further, as described in my earlier affidavit,
many of the documents prepared by and sent to the
Risk Management Department on or after December 11,
2013, as contained in the file materials submitted
in camera to this Court, were requested, prepared,
and/or utilized for quality assurance purposes to
assess the quality of care of all patients at [the
medical 
center]. 
Specifically, 
such 
quality
assurance materials include the documents marked
013-017, 018-019, 022, 025-029, 030-032, 042,
044-074, 106-187.  Confidentiality of these file
materials is necessary in order to keep the
investigation of incidents for quality assurance
purposes candid and open.  Production of these file
materials to those outside the [medical center] will
be detrimental to the quality of care provided to
all patients.  These documents were not prepared in
the ordinary course of business and are not part of
the medical records of [Rhonda].
"... I am also familiar with the Medical
Healthcare Errors Response policy; the Quality and
Patient Safety Program Plan; the Infirmary Health
System Corporate Risk Management Electronic Incident
Reporting System module; the Infirmary Health
Electronic Incident Reporting November 2014; the
Informed Consent Process module; the Informed
Consent Process Version 2 module; the Medical Alarm
38
1160731, 1160815
Safety 
module; 
the 
[Mobile 
Infirmary] 
Joint
Commission Policy Updates 2014 module; the Patient
Safety Education Card module; the Policy Review -
Isolation 
and 
Standard 
Precautions 
[Mobile
Infirmary] LTAC 2015 module; the Policy Review-IV
Administration of Vasoactive and Antiarrythmic
Medications module; the Policy Review-Tube Feeding
Administration Urine Specimen Collection module; the
Preventing Opioid Adverse Events module; the Safety
Alert Tubing Misconnection module; the Strip, Flip
and Pull module; the Ticket to Ride module; the
Trace the Lines module; and the Preventing Infection
from the Misuse of Vials module (including related
video, which is not Bates numbered[)].
"... The Medical Healthcare Errors Response
Policy and Quality and Patient Safety Program Plan
were created directly in relation to the quality
assurance 
function 
of 
[MIMC]. 
 
The 
Medical
Healthcare Errors Response Policy and Quality and
Patient Safety Program Plan provide information to
[medical-center] 
employees 
about 
the 
quality
assurance process.
 
"Similarly, 
the 
Infirmary 
Health System
Corporate 
Risk 
Management 
Electronic 
Incident
Reporting 
System 
module 
and 
Infirmary 
Health
Electronic Incident Reporting November 2014 modules
were created by Risk Management Department to train
[medical-center] 
employees 
about 
the 
use 
of
electronic incident reporting that is done for
purposes of carrying out the quality assurance
function of the hospital.
"... Confidentiality of all of these materials
is 
necessary 
to 
protect 
the 
process 
for
identification of, reporting of, and investigation
of patient care related events.  If these materials
are made available outside of [the medical center],
the quality assurance process will be compromised
and [Connie's] counsel will be given a roadmap to
inquire about and discover information about the
39
1160731, 1160815
quality assurance process at [the medical center]. 
This would be prejudicial to [MIMC] and will be
detrimental to the quality of care provided to all
patients.
"The Informed Consent Process module, Informed
Consent Process Version 2 module, Medical Alarm
Safety module, [Mobile Infirmary] Joint Commission
Policy Updates 2014 module, Patient Safety Education
Card module, Policy Review-Isolation and Standard
Precautions [Mobile Infirmary] LTAC 2015 module,
Policy Review-IV Administration of Vasoactive and
[Antiarrythmic] 
Medications 
module, 
Policy
Review-Tube Feeding Administration Urine Specimen
Collection module, Preventing Opioid Adverse Events
module, Safety Alert Tubing Misconnection module,
Strip, Flip and Pull module, Ticket to Ride module,
Trace the Lines module, and the Preventing Infection
from the Misuse of Vials module (including related
video, which is not Bates numbered[)], were also
created by or in connection with the Risk Management
Department as a result of the quality assurance
process.  These modules and training material were
prepared and presented as a part of [MIMC's] quality
assurance process and are actions taken as part of
the quality assurance process.  The disclosure of
these materials would be prejudicial to [MIMC]
because it would discourage full candor during the
quality assurance process.  It also would have a
chilling effect on [MIMC's] ability to train its
employees 
about 
issues 
recognized, 
discussed,
evaluated 
or 
recommended 
during 
the 
quality
assurance process. This candor is necessary to
protect the public interest."
Connie is correct that we have previously held that "the
party asserting the privilege under § 22–21–8 has the burden
of proving the existence of the privilege and the prejudicial
effect of disclosing the information."  Ex parte Fairfield
40
1160731, 1160815
Nursing, 22 So. 3d at 448.  MIMC contends that, via Gamper's
affidavits, it established both that the reports Connie seeks
to have produced are quality-assurance materials and that
their production would negatively impact MIMC's ability  both 
to properly care for all patients and to train its employees
accordingly.  As to the contents of the risk-management file,
MIMC similarly argues that Gamper's testimony sufficiently
established either that the affected documents were created in
direct response to Rhonda's death or "for, among other
purposes, enabling the 
Risk Management Department to carry out
its quality assurance function." 
Contrary to those claims, Connie asserts that the
documents MIMC was ordered to produce are both created and
used in the ordinary course of a hospital's business and
appears to contend that MIMC failed to produce evidence
demonstrating that the aim of the Risk Management Department
in generating the disputed documents was quality assurance. 
Compare Ex parte St. Vincent's Hosp., 652 So. 2d 225, 230
(Ala. 1994) ("The burden of proving that a privilege exists
and proving the prejudicial effect of disclosing the
information is on St. Vincent's.  St. Vincent's has produced
41
1160731, 1160815
no evidence that the Infection Control Committee served as a
utilization review committee and no evidence that a function
of that committee was accreditation or quality assurance.").
Here, however, as quoted above, Gamper specifically
testified that "[t]he Risk Management Department of Infirmary
Health Systems, Inc. performs quality assurance functions for
its affiliate [MIMC]." Gamper further attested that the
contents of MIMC's risk-management file, including those
submitted for the trial court's in camera review and those
MIMC was ultimately ordered to produce, "were requested,
prepared, and/or utilized for quality assurance purposes to
assess the quality of care of all patients at [the medical
center]." 
Gamper's sworn testimony in her affidavits constitutes
substantial evidence in support of MIMC's claims.  Although
Connie has not disputed the assertions contained in Gamper's
affidavits with his own contrary evidence, he nonetheless
argues that MIMC is improperly applying the term "quality
assurance" outside the context of its intended use and further
observes that other jurisdictions have narrowly construed
statutory exemptions for quality-assurance, accreditation, or
42
1160731, 1160815
peer-review materials.  He additionally criticizes this
Court's conclusion in Ex parte Fairfield Nursing, 22 So. 3d at
452, that "the language of § 22–21–8 does not require that a
quality-assurance 'committee' exist, nor does it limit the
privilege to materials created solely at the direction of such
a committee" and maintains that such a broad "construction" of
§ 22–21–8 as that urged by MIMC would deprive medical-
malpractice plaintiffs of a remedy.12 
We disagree. Instead, the information contained in
Gamper's affidavits appears to be entirely consistent with
information in affidavits previously deemed sufficient to
warrant application of § 22–21–8:
"We 
agree with [the defendant] that the 
evidence
presented in the affidavits submitted in support of
the assertion of the privilege is substantially
similar to the evidence presented in the affidavits
in Kingsley [v. Sachitano, 783 So. 2d 824 (Ala.
2000),] and Ex parte Qureshi.  The affidavits [the
defendant] 
offered 
stated 
that 
the 
requested
documents 
were 
created 
for 
quality-assurance
purposes, that the documents are needed to guarantee
the high quality of care for all residents, and that
the confidentiality of the reports and statements is
necessary.  Section 22–21–8 expressly applies to
'quality assurance' materials.
12Without 
elaboration, 
Connie 
alleges 
that 
this
"construction" would violate §§ 10 and 13 of the Alabama
Constitution of 1901.
43
1160731, 1160815
"The affidavit in Kingsley stated that the
requested documents 'were the subject of quality
assurance, credentialling, and accreditation.' 783
So. 2d at 828.  The affidavit in Ex parte Qureshi
stated that the requested documents were a part of
the hospital's credentialing file. 768 So. 2d at
376.  Additionally, the affidavit in Ex parte
Qureshi stated that 'it was essential that the
materials 
gathered 
by 
the 
hospital 
be 
kept
confidential' to ensure that 'complete and accurate
information' 
would 
be 
provided 
regarding 
the
qualifications of physicians seeking privileges at
the hospital.  768 So. 2d at 376.
"The respondents in 
these present cases 
have not
offered any evidence in opposition to the affidavits
submitted by [the defendant] with its motions to
reconsider."
Ex parte Fairfield Nursing, 22 So. 3d at 450.  The undisputed
evidence submitted to the trial court by MIMC demonstrates
that the disputed documents clearly fall under the protection
of § 22–21–8.  Here, as in Ex parte Fairfield Nursing, supra,
"because 
[MIMC] 
offered 
sufficient 
evidence 
demonstrating 
that
it is entitled to the privilege provided in § 22–21–8, the
trial court exceeded its discretion in ordering [MIMC] to
produce the requested documents in the underlying actions." 
22 So. 3d at 454.
As an additional matter, both Gamper's affidavits and the
dates of implementation of certain modules suggest that at
least some of the disputed materials were created after
44
1160731, 1160815
Rhonda's treatment at the medical center and, therefore, as
discussed in Part I.A., supra, could have no bearing on, nor
by their absence prevent Connie from proving, Connie's own
claims against MIMC regarding its conduct in December 2013 –-
especially where, as here, MIMC has produced in excess of
15,000 pages of documentary evidence during discovery. 
Indeed, there is nothing suggesting that, without the
materials in MIMC's risk-management file, Connie will be
unable to successfully prosecute his claim against MIMC. It is
further immaterial that the information Connie seeks and the
trial court required MIMC to produce from its risk-management
materials "might have been gathered as a consequence of the
incident regarding [Rhonda]."  Ex parte Anderson, 789 So. 2d
at 199.  As to any claim by Connie that this Court has
interpreted the reach of § 22–21–8 too broadly and/or that in
Ex parte Fairfield Nursing, supra, the Court "got off track"
to the extent it rejected the need for "demonstrat[ing] the
existence of an official committee as a part of [the]
assertion of the privilege provided in § 22–21–8," we note
that that decision applies the plain language of § 22–21–8. 
Ex parte Fairfield Nursing, 22 So. 3d at 451, 453-54. 
45
1160731, 1160815
To the extent MIMC presumes that the trial court based
its order compelling production, at least in part, on the
exception 
found 
in 
§ 
22-21-8(b) 
providing 
that 
"[i]nformation,
documents, or records otherwise available from original
sources are not to be construed as being unavailable for
discovery or for use in any civil action merely because they
were presented or used in preparation of accreditation,
quality assurance or similar materials," we note that there is
nothing on the face of the trial court's order substantiating
such a presumption.  In any event, as MIMC also notes, we have
held that, although § 22–21–8 does not protect information 
obtained from alternative sources, a plaintiff seeking to
discover that information cannot obtain it directly from the
health-care provider.  Ex parte Anderson, 789 So. 2d at 201. 
See also Ex parte Krothapalli, 762 So. 2d 836, 839 (Ala. 2000)
("[A] plaintiff seeking discovery cannot obtain directly from
a hospital review committee documents that are available from
the original source, but may seek such documents from the
original source.").  Therefore, even presuming that the trial
court required the production of only information similarly
available from another, alternate source, our caselaw will
46
1160731, 1160815
nonetheless not support that holding.  To the extent that the
trial court ordered the production of materials identified by
Gamper as relating to quality assurance and thus protected by
§ 22-21-8, the trial court exceeded its discretion.  Thus, we
direct those portions of its May 5, 2017, orders compelling
production to be vacated.13
II.  Case No. 1160815
In its second petition, MIMC seeks relief from the trial
court's May 5, 2017, discovery order denying MIMC's motions to
reconsider or for protective orders, which were filed in
response to the trial court's November 10, 2016, order
compelling MIMC to respond to certain discovery requests from
Connie's 
second 
interrogatories, 
third 
requests 
for
production, and fourth requests for production.14  
13To the extent MIMC notes that among the materials it was
compelled to produce were documents allegedly protected by the
attorney-client or work-product privileges, but not the
quality-assurance privilege, we see no sufficient request to
issue a writ directing the trial court to vacate its orders
compelling protection of those materials.
14We initially note that Connie appears to criticize MIMC
for failing to also submit, before filing a mandamus petition,
the withheld documentation made the subject of the petition in
case no. 1160815 for the trial court's in camera review;
however, Connie cites nothing indicating that submission of
the documents for inspection was a prerequisite to mandamus
review.  See, generally, Ex parte Fairfield Nursing, 22 So. 3d
47
1160731, 1160815
A.  The Discovery Requests and Objections Thereto
In his second interrogatories, Connie sought, among other
things, information regarding MIMC's "Joint Commission
Accreditation," 
including 
when 
MIMC 
became 
accredited, 
whether
it is currently accredited, and whether its accreditation
status had ever been withdrawn or MIMC placed on probation or
had been "otherwise at risk of losing accreditation,"
including the circumstances.  Connie's second interrogatories
also inquired as to MIMC's subscription to and, generally, its
receipt of, "The Joint Commission Sentinel Event Alert
publications" from the period "2012 to the present date." 
Connie also specifically sought information as to 
whether MIMC
had received "Sentinel Event Alert #49 titled 'Safe Use of
Opioids in Hospitals'" and, if so, requested that MIMC provide
details regarding its response/implementation of the concerns
highlighted in that alert.
at 454.  See also note 8, supra.  In any event, in its reply
brief, MIMC explains that the trial court's May 5, 2017, order
denying its motions to reconsider and/or for a protective
order failed to contain the language found in the trial
court's November 10, 2016, order requiring MIMC's response to
Connie's first requests for production but allowing MIMC to
separately submit any 
documents it objected to producing under
either § 6-5-551 or § 22-21-8 and an accompanying privilege
log for the trial court's in camera review.   
48
1160731, 1160815
In response to the foregoing interrogatories, MIMC
apparently disclosed its current accreditation status, which
was also allegedly available on the Joint Commission's Web
site, but objected to the interrogatories to the extent that
they allegedly sought "accreditation, quality assurance,
credentialing or similar functions" and argued that, because 
Connie's complaint and any amendment to that pleading
contained no allegations regarding MIMC's accreditation
status, 
the 
requested information was 
protected 
from 
discovery
under § 6-5-551.  As to Connie's queries regarding sentinel-
event alerts, MIMC disclosed only its awareness that Sentinel
Event Alert #49 had, on the referenced date, been posted to
the Joint Commission's Web site.  MIMC again objected to
responding to the remainder of Connie's request on the ground
that the requested information was allegedly exempt from
discovery under both § 6-5-551 and § 22-21-8.
Pursuant to his third requests for production of
documents, Connie sought MIMC's disclosure of "any and all
correspondence, emails, documents, memos, meeting agendas,
minutes of meetings, action plans and/or materials," if any,
undertaken by MIMC in response to Sentinel Event Alert #49. 
49
1160731, 1160815
MIMC again objected on the ground that the request allegedly
sought information exempt from discovery pursuant to 
§ 
6-5-551
and § 22-21-8.  MIMC also asserted that the documents were
protected from disclosure by the attorney-client privilege. 
As to Connie's related request seeking production of any
policies and procedures implemented or reviews by MIMC in
response or relation to Sentinel Event Alert #49, MIMC
objected to the request as seeking information protected from
discovery by § 6-5-551 but did produce a list of all policies
and procedures in place in December 2013.
Connie's fourth requests for production sought, "[f]or
the time period 2012 to the present," the following:
"[A]ny and all communications of any description
(correspondence, 
emails, 
memos, 
notifications,
alerts, 
warnings, 
etc., 
whether 
written 
or
electronic) between [MIMC] and its employees,
Infirmary Health System employees and/or any other
healthcare providers regarding:
"a. dispensing narcotics, opioids, Dilaudid
and/or Hydromorphone to patients;
"b. administering narcotics, opioids, Dilaudid
and/or Hydromorphone to patients;
"c. administering narcotics, opioids, Dilaudid
and/or Hydromorphone to obese patients and/or
patients known or expected to have sleep apnea;
50
1160731, 1160815
"d. administering narcotics, opioids, Dilaudid
and/or 
Hydromorphone 
in 
accordance 
with
range/PRN orders;
"e. 
monitoring 
patients 
who 
have 
been
administered 
narcotics, 
opioids, 
Dilaudid
and/or Hydromorphone.
"This request specifically includes but is not
limited to any and all HealthStream communications
(correspondence, 
emails, 
memos, 
notifications,
alerts, 
warnings, 
etc., 
whether 
written 
or
electronic)."
A second request asked for identical information within the
same time frame regarding "any and all educational/training
materials 
(tests, 
lessons, 
course 
outlines, 
reference
materials, 
study 
guides, 
PowerPoints 
[slide-show
presentations] and/or other learning materials, etc., whether
written or electronic)." 
In response MIMC produced documents that had been
provided to Barnes.  It objected, however, to producing
further documentation on various grounds, including that
Connie's request was allegedly "overbroad in time and scope"
and that it sought "information not relevant to the claims
asserted in this litigation" "about caregivers who were not
involved in [Rhonda's] care and treatment," and "about
facilities other than [MIMC]."  MIMC further objected on the
51
1160731, 1160815
grounds that the information sought predated Barnes's
employment with MIMC and postdated the period identified in
Connie's complaint in violation of the protection from
discovery provided by § 6-5-551 and that it further sought
information protected from discovery under § 22-21-8.
B.  Discussion
As explained above, included in the trial court's
November 10, 2016, discovery orders was its decision
compelling full responses to each of the above-described
discovery requests.  MIMC filed, as to each, a motion seeking
reconsideration of the trial court's order compelling its
response and for a protective order.  MIMC supported each
motion 
with 
authority 
and 
attachments, 
including 
the 
affidavit
testimony of Gamper. Specifically, in addition to the
incorporation of her initial March 24, 2016, affidavit, as
discussed above, MIMC also produced an additional affidavit by
Gamper, which was executed on December 21, 2016, and in which
Gamper attested, in pertinent part, as follows:
"I am familiar with the accreditation process
for 
[MIMC] 
and 
the 
information 
(including
documentation) 
generated, 
prepared, 
presented,
maintained and evaluated in connection with the
accreditation process and [MIMC] maintaining its
accredited status.  The disclosure of these
52
1160731, 1160815
materials would be prejudicial to [MIMC] because it
would 
discourage 
full 
candor 
during 
the
accreditation process.  This candor is necessary to
protect the public interest.
"I am also familiar with the process applicable
at [MIMC] for reviewing Sentinel Event Alerts from
The Joint Commission (including but not limited to
Sentinel Event Alert #49) and developing and
implementing any actions in response to such Alerts. 
The process of reviewing Sentinel Event Alerts from
The Joint Commission is initiated in the Hospital
Quality 
improvement 
Committee, 
which 
performs
quality assurance functions on behalf of [MIMC], and
all actions ultimately taken in response to a
Sentinel Event Alert are a result of the process
initiated by the Hospital Quality Improvement
Committee and are a part of the quality assurance
process. 
"Indeed, 
all 
review of 
Sentinel Event Alerts and
developing and implementing action plans is done as
part 
of 
[MIMC's] 
quality 
assurance 
process. 
Further, 
all 
documents 
generated, 
prepared,
maintained, created, produced or presented in
connection 
with 
[MIMC's] 
review, 
evaluation,
recommendations, findings, opinions, and actions
taken in response to any Sentinel Event Alert from
The Joint Commission are generated, prepared,
maintained, created, produced and presented as a
part of [MIMC's] quality assurance process. This
quality assurance process includes communications
with employees and other healthcare providers about
the recommendations, findings, opinions and actions
taken in response to any Sentinel Event Alert, as
well 
as 
the 
process 
of 
carrying 
out 
any
recommendations and action plans.
"The disclosure of these materials would be
prejudicial to [MIMC] because it would discourage
full candor during the quality assurance process. 
This candor is necessary to protect the public
53
1160731, 1160815
interest, 
to 
encourage 
openness 
during 
the
investigation and evaluation of Sentinel Event
Alerts, and to improve the quality of care provided
for all patients.
"To 
the 
extent 
there 
were 
communications 
between
... Barnes, any other [MIMC] employee, Infirmary
Health 
Systems 
employee, 
or 
other 
healthcare
provider and the Risk Management Department or any
other person or entity involved in the quality
assurance 
process 
related 
to 
the 
Dilaudid
administration 
made 
the 
basis 
of 
[Connie's]
Complaint, these communications relate directly to
the quality assurance process and were made as a
part of the quality assurance process.  The
disclosure of these materials would be prejudicial
to [MIMC] because it would discourage full candor
during the quality assurance process.  This candor
is necessary to protect the public interest.
"Moreover, to 
the 
extent there was 
any 
education
or training provided to ... Barnes, any [MIMC]
employee, any Infirmary Health Systems employee or
any other healthcare provider related to the
Dilaudid 
administration 
made 
the 
basis 
of
Plaintiff's Complaint, this education/training was
part of the quality assurance process.  The
disclosure of these materials would be prejudicial
to [MIMC] because it would discourage full candor
during the quality assurance process.  This candor
is necessary to protect the public interest."
As also mentioned above, after he deposed Gamper, Connie moved
to strike all of Gamper's affidavit testimony filed by MIMC in
the matter, which motion the trial court never ruled on.
In its May 5, 2017, order the trial court denied all of
MIMC's motions.  MIMC contends in the present petition that
54
1160731, 1160815
the trial court exceeded its discretion because it directed
MIMC to produce items that are exempt from discovery under §
22-21-8.
1.  Second Interrogatories/Third Requests for Production
MIMC contends that the questions included in the second
set of interrogatories, which seek disclosure of information
related to MIMC's accreditation and probation history and to
MIMC's receipt of sentinel-event alerts from the Joint
Commission, improperly request accreditation and/or quality-
assurance material protected from discovery by § 22-21-8 and
by § 6-5-551.  MIMC also contends that the questions included
in Connie's second set of interrogatories to MIMC, which seek
disclosure about Sentinel Event Alert #49 and MIMC's response
to and implementation of that alert, are likewise protected
from disclosure by § 22-21-8.  More specifically, MIMC notes
that Gamper's affidavit, which is set out in large part above, 
established that the entire process of reviewing and
implementing sentinel-event alerts "is initiated in the
Hospital 
Quality 
Improvement 
Committee, 
which 
performs 
quality
assurance functions on behalf of [MIMC]." 
55
1160731, 1160815
Similarly, MIMC maintains that, to the extent Connie's
third requests for production of documents sought the
production of materials that evidence MIMC's response to and
implementation of Sentinel Event Alert #49, those materials
were likewise generated pursuant to MIMC's quality-assurance
process.  As to Connie's request regarding MIMC's receipt of
and response to sentinel-event alerts, generally, MIMC argues
that no alert other than Sentinel Event Alert #49 is at issue. 
Based on the analysis detailed in Part I.B., above, and, more
particularly this Court's decision in Ex parte Fairfield
Nursing, supra, we agree.  Specifically, as we found in Ex
parte Fairfield Nursing and in Part I (case no. 1160731), MIMC
presented 
sufficient 
evidence 
demonstrating 
that 
the 
materials
it objected to producing were entitled to the privilege
provided in § 22–21–8; thus, we likewise find that the trial
court exceeded its discretion in ordering MIMC to respond to
the 
identified 
portions 
of 
both 
Connie's 
second
interrogatories and his third requests for production.  22 So.
3d at 454.
We further note, as discussed in Ex parte Anderson,
supra, that merely answering the question as to any
56
1160731, 1160815
accreditation probation would itself constitute impermissible
evidence of other acts or omissions.  We explained:
"Discovery 
of 
any 
incidents 
of 
malpractice 
other
than those specifically alleged in the complaint is
precluded. As previously stated in Part I of this
opinion, § 6–5–551 states in plain language that
'discovery with regard to any other act or omission'
or the introduction 'at trial [of] evidence of any
other act or omission' is prohibited.
"Despite her argument to the contrary, [the
plaintiff] is not even entitled to learn whether any
such 'complaints' exist.  The mere acknowledgment of
whether a complaint was ever filed concerning
alleged incidents of malpractice would indeed
constitute evidence of prior claims of medical
malpractice allegedly committed by [the defendant
doctor]; this is exactly the kind of information the
statute protects from discovery.  Therefore, even a
simple 'yes' or 'no' answer to the question whether
any complaints against [the defendant doctor] had
been 
filed 
regarding 
alleged 
incidents 
of
malpractice other than those that involved [the
plaintiff] would fall within the prohibition of the
statute."
789 So. 2d at 198.  Further, to the extent Connie sought
information regarding sentinel-event alerts other than those
at issue in Rhonda's case, our caselaw clearly establishes
that "[Connie] is entitled to discovery of information
involving the provision of care and/or services to [Rhonda],
but not to other persons."  Ex parte Coosa Valley Health Care,
789 So. 2d at 218.  Thus, to the extent the trial court also
57
1160731, 1160815
compelled MIMC to produce materials involving persons other
than Rhonda and/or the treatment of such other persons, the
trial court also exceeded its discretion.  See id.
2.  Fourth Requests for Production
Finally, MIMC contends that, with regard to Connie's
attempt to obtain, via his fourth requests for production of
documents, communications among MIMC personnel regarding the 
administration of Dilaudid and educational materials related
to its administration, any such communication occurred as 
part
of MIMC's quality-assurance process and that any resulting
education was also implemented "as part of the quality
assurance process." Therefore, according to MIMC, that
information is likewise exempted from discovery by § 22-21-8. 
MIMC further argues that both the subject requests and
Connie's related request for educational materials are
overbroad in violation of § 6-5-551, to the extent they are
not limited to either the particular treatment allegations or
the time frame in Connie's complaint, are not limited to the
MIMC employees responsible for Rhonda's treatment and care,
and are not limited to the facility where Rhonda was
hospitalized.  Again, for the reasons set forth in and the
58
1160731, 1160815
authority cited by this Court in both Parts I.A. and I.B.,
above, we agree.
Conclusion
In consideration of the foregoing, we hold that MIMC  has 
demonstrated that the trial court exceeded its discretion in
requiring MIMC to respond to the discovery requests at issue,
namely Connie's discovery requests seeking information
concerning any act or omission other than those specifically
alleged in Connie's complaint as amended and in requiring MIMC
to 
produce 
information specifically exempted 
from 
discovery 
by
the plain language of § 22-21-8; accordingly, MIMC has also
demonstrated a clear legal right to the relief sought. 
Therefore, in case no. 1160731, we grant MIMC's petition and
direct the trial court to vacate all portions of its May 5,
2017, discovery order requiring MIMC to produce documents that
MIMC had designated as privileged pursuant to either § 6-5-551
or § 22-21-8.  In case no. 1160815, we direct the trial court
to vacate the portions of its May 5, 2017, discovery order
requiring MIMC to respond to the above-described portions of
Connie's 
second 
interrogatories, 
third 
requests 
for
production, and fourth requests for production.
59
1160731, 1160815
1160731  --  PETITION GRANTED; WRIT ISSUED.
Bolin, Main, Wise, Bryan, Sellers, and Mendheim, JJ.,
concur.  
Parker, J., concurs in part and concurs in the result.
1160815  --  PETITION GRANTED; WRIT ISSUED.  
Bolin, Main, Wise, Bryan, Sellers, and Mendheim, JJ.,
concur.  
Parker, J., concurs in the result.
60
1160731, 1160815
PARKER, Justice (concurring in part and concurring in the
result in case no. 1160731).
I concur in the result as to Part I.B. of the opinion; I
concur fully in the remainder of the opinion addressing case
no. 1160731.
61