Case Name: John W. Ritter, Respondent, v. The Board of Commissioners of Adams County Public Hospital District No. 1, Appellant
Court: Washington Supreme Court
Jurisdiction: Washington
Decision Date: 1981-12-10
Citations: 96 Wash. 2d 503
Docket Number: No. 47431-1
Parties: John W. Ritter, Respondent, v. The Board of Commissioners of Adams County Public Hospital District No. 1, Appellant.
Judges: 
Reporter: Washington Reports
Volume: 96
Pages: 503–532

Head Matter:
[No. 47431-1.
En Banc.
December 10, 1981.]
John W. Ritter, Respondent, v. The Board of Commissioners of Adams County Public Hospital District No. 1, Appellant.
Halverson, Applegate & McDonald, Inc., P.S., by Dennis L. Fluegge and Bryan G. Evenson, for appellant.
Reed, Otterstrom & Giesa, P.S., by D. Roger Reed and Michael J. Casey, for respondent.

Opinion:
Brachtenbach, C.J.
Adams County Public Hospital District No. 1 (District) appeals from the Superior Court's reversal of the District Board of Commissioners' (Board) summary suspension of Dr. John Ritter's staff privileges at Ritzville Memorial Hospital (Hospital). Because the Board failed to follow its own rules in summarily dismissing Dr. Ritter, that act was improper. However, we hold that the review procedures followed after the summary action comported with due process and were otherwise sustainable. Therefore, the trial court erred in ordering Dr. Ritter's permanent reinstatement to the Hospital staff and the destruction of the hearing records.
The District is a state municipality which operates hospitals in Ritzville and Othello under authority of RCW 70.44. Its Board confers hospital "staff" or "courtesy staff" privileges upon selected physicians on an annual basis. Although no formal contract is entered, the Hospital maintains a "Medical Staff Appointment" sheet signed each year by a doctor's supervising medical and administrative personnel. Privileged physicians are entitled to admit patients and to perform medical procedures at district hospitals.
In 1970, Ritter moved to Ritzville from Seattle where he had practiced medicine for approximately 10 years. He was soon thereafter granted staff privileges at the Hospital, which were renewed in each of the next 7 years. During this period respondent enjoyed a good reputation with the public and a successful practice.
Friction began developing, however, between Ritter, the nursing staff, and the then Hospital Administrator. Complaints were submitted to the staff executive committee about Ritter's repeated performance of surgery without a qualified assistant in violation of Hospital rules. Nurses were also concerned with his prescription of the drug Pitocin in excess of the suggested, dosage. While committee members discussed these matters with Dr. Ritter, no formal action against him was taken.
On July 24, 1978, Ritter performed a tubal ligation under local anesthetic without a full surgical crew. Ritter decided that he did not need a full crew, although the Director of Nurses had informed him previously that the procedure was major surgery and required a qualified assistant. When the Director learned that Ritter was proceeding with only the assistance of his medex, she drove from Othello to Ritzville and assisted Ritter in the operation.
The Hospital Administrator learned of the tubal ligation incident the next day. He immediately ordered that no more operations be performed at the Hospital unless a full surgery crew was present. Ritter complied with this directive, performing six surgical procedures without any reported problems during the 3 weeks that followed.
The Administrator reported the tubal ligation incident to the Hospital Board by mail prior to their August 17 meeting. At the gathering he also informed the Board of other charges against Ritter including chart alterations, chart delinquencies, failure to cooperate with administration and staff, and violation of Hospital rules and regulations regarding the use of an unauthorized first assistant in surgery. The Board discussed its possible courses of action, then voted to summarily suspend Ritter's clinical privileges. The Board was authorized to do so by article 7, section 2 of the Medical Staff Bylaws, which reads, in part:
[T]he governing body shall have the authority, whenever action must be taken immediately in the best interest of patient care in the hospital, to summarily suspend all or any portion of the clinical privileges of a practitioner, and such summary suspension shall become effective immediately upon imposition.
Ritter was notified of the Board's action and decision by a notice of suspension dated August 22.
Ritter requested and was granted a hearing pursuant to the fair hearing plan which governed the procedure for suspending staff privileges. The hearing committee recommended that the tubal ligation surgery and one altered chart were grounds for immediate suspension. The Board accepted the recommendation and continued the suspension. Ritter then exercised his right of review before the Appellate Review Body (ARB). At the hearing before the ARB, Ritter challenged the participation of a Dr. Bunch on that panel because of his alleged pecuniary interest and because Bunch had been a witness before the hearing committee and therefore would be biased. The ARB, including Bunch, found that the suspension was justified. The Board then again voted to continue the suspension.
Ritter filed a writ of review, pursuant to RCW 7.16.120 before the Superior Court for Spokane County. After a week's trial, the court held, inter alia, that (1) Ritter had been deprived of his constitutionally protected liberty and property interests by not being accorded a presuspension hearing, (2) Ritter had been denied due process before the ARB by reason of a violation of the appearance of fairness doctrine stemming from Bunch's dual role as witness before the hearing committee and as a member of the ARB, (3) the summary suspension of Ritter was arbitrary and capricious, and (4) Ritter was ordered reinstated to all clinical privileges and offices at the Hospital.
I
It is well settled that an administrative body must follow its own rules and regulations when it conducts a proceeding which can deprive an individual of some benefit or entitlement. See In re Young, 95 Wn.2d 216, 229-32, 622 P.2d 373 (1980); Smith v. Greene, 86 Wn.2d 363, 373-74, 545 P.2d 550 (1976); Vitarelli v. Seaton, 359 U.S. 535, 3 L. Ed. 2d 1012, 79 S. Ct. 968 (1959). The District's bylaws provided for suspension of a physician's clinical appointment without a prior hearing only when "action must be taken immediately in the best interests of patient care". Art. 7, § 2, Medical Staff Bylaws. The trial court found that the Board initially solicited no medical staff advice as to whether Ritter's continued practice posed an imminent threat to patient care at the Hospital. Finding of fact No. 22. The court also found that none of the Board members concluded that there was an emergency meriting the immediate suspension of Dr. Ritter on August 17, 1978. Findings of fact Nos. 28, 29. The Board's stated rationale for the suspension was his "continued behavioral problems affecting risk management and for lack of cooperation with procedures" rather than for concerns that immediate suspension was in the best interest of patient care at Ritz-ville Hospital. Findings of fact Nos. 31, 32, 34, 35. Because the Board's suspension of Dr. Ritter prior to his hearing contravened the District's standards upon which all physicians were entitled to rely, its August 17 summary act was improper.
II
Dr. Ritter claims that the Board's summary and then continued suspension of his Hospital staff privileges has deprived him of due process of the law. However, "[t]he Due Process Clause of the Fourteenth Amendment is not a guarantee against incorrect or ill-advised personnel decisions." Bishop v. Wood, 426 U.S. 341, 350, 48 L. Ed. 2d 684, 96 S. Ct. 2074 (1976). The protections of the Clause adhere only if the asserted individual interests are encompassed within the Amendment's protection of "life, liberty or property." Paul v. Davis, 424 U.S. 693, 712, 47 L. Ed. 2d 405, 96 S. Ct. 1155 (1976). If protected interests are implicated, we then must decide if the procedures employed constituted "due process of law." Morrissey v. Brewer, 408 U.S. 471, 481, 33 L. Ed. 2d 484, 92 S. Ct. 2593 (1972). Following that analysis, we find that the Board's derogation of Dr. Ritter's reputation in the community affected a protected "liberty" interest, but that his postsuspension hear ing afforded him due process of law.
Dr. Ritter claims a property interest in continued staff privileges for the duration of his annual appointment. A due process property interest exists "if there are such rules or mutually explicit understandings that support [an individual's] claim of entitlement to the benefit and that he may invoke at a hearing." Perry v. Sindermann, 408 U.S. 593, 601, 33 L. Ed. 2d 570, 92 S. Ct. 2694 (1972); see Board of Regents v. Roth, 408 U.S. 564, 577-78, 33 L. Ed. 2d 548, 92 S. Ct. 2701 (1972); Perry, at 602 (no property interest unless there is a "legitimate claim of entitlement"). Respondent does not have a constitutional right to practice in a public hospital simply because he is a licensed physician. Hayman v. Galveston, 273 U.S. 414, 416-17, 71 L. Ed. 714, 47 S. Ct. 363 (1927); cf. Rao v. Board of County Comm'rs, 80 Wn.2d 695, 699, 497 P.2d 591, cert. denied, 409 U.S. 1017, 34 L. Ed. 2d 309, 93 S. Ct. 436 (1972). A property interest could rest on a contractual basis, however, either express or implied. See Lynch v. United States, 292 U.S. 571, 579, 78 L. Ed. 1434, 54 S. Ct. 840 (1934); Roth, at 577 ("clearly implied promise of continued employment" is a property interest). The trial court made a legal conclusion that respondent's 1-year staff appointment constituted an "implied contract," and thus a property interest. This legal conclusion is unsupported either by the trial court's findings of fact or any other part of the record. Neither has respondent shown that he received any representations of "tenure." He appears to have had no more than a subjective expectancy of continued Hospital privileges. See Kyles v. Eastern Neb. Human Servs. Agency, 632 F.2d 57, 60 (8th Cir. 1980) (no property interest where public employee did not show that any understandings of tenure were fostered by his employer); Smith v. Greene, supra at 367 ("subjective expectancy" of tenure not entitled to due process protection). Although Ritter could assume he would remain a member of the Hospital staff absent cause for dismissal, and he was protected by extensive procedural protections established by the medical staff bylaws, he did not have a property interest in staff privileges at Ritzville Memorial Hospital. Suckle v. Madison Gen. Hosp., 499 F.2d 1364, 1365-66 (7th Cir. 1974).
Dr. Ritter claims that his "liberty" interests were triggered by both (1) his preclusion from practice at the Ritzville Hospital and (2) the derogation of his good name and reputation in the community and among his peers. See generally Giles v. Department of Social & Health Servs., 90 Wn.2d 457, 461, 583 P.2d 1213 (1978) ("liberty" interest implicated for employment discharge if [1] government imposes a stigma and thereby forecloses the employee's freedom to obtain other employment or [2] dismisses an employee on grounds that call into question his integrity, honor, or good name in the community); Department of Health & Social Servs. v. State Personnel Bd., 84 Wis. 2d 675, 687, 267 N.W.2d 644 (1978).
In Giles we held that a constitutionally protected "liberty" interest based on foreclosure of employment opportunities was not implicated where a discharged state employee's license was not revoked and "he was not prohibited from working in his chosen field." Giles, at 461; see State ex rel. Swartout v. Civil Serv. Comm'n, 25 Wn. App. 174, 184, 605 P.2d 796, review denied, 93 Wn.2d 1021, cert. denied, 449 U.S. 992, 66 L. Ed. 2d 288, 101 S. Ct. 527 (1980) (state must take some affirmative action to foreclose employment opportunities). In the present case, Ritter's license was not revoked, nor was he otherwise "prohibited from working in his chosen field." It is undisputed that for a time Ritter continued to operate his clinic, albeit with substantially fewer patients, after his Hospital privileges were suspended. Ritter's employment opportunities were only diminished, not foreclosed, and under Giles' reasoning he was not deprived of a "liberty" interest.
However, the other prong of the "liberty" interest test was satisfied. Shortly after Ritter's summary suspension, the District issued a press release which implicitly questioned his diligence, and arguably his competence, as a physician. Several months later at a public Board meeting one of the Board members stated that reinstating Ritter pending the administrative appeal of his summary suspension would be tantamount to rehiring an embezzler at a bank. Clearly these charges "might seriously damage [Ritter's] standing and associations in his community." Roth, at 573. Had the District remained silent and not attempted to justify its actions, no liberty interest would have been implicated. Board of Curators v. Horowitz, 435 U.S. 78, 83, 55 L. Ed. 2d 124, 98 S. Ct. 948 (1978) (dismissal without publication of reasons therefore does not implicate liberty interest); Codd v. Velger, 429 U.S. 624, 628, 51 L. Ed. 2d 92, 97 S. Ct. 882 (1977) (per curiam); Bishop v. Wood, 426 U.S. 341, 348-49, 48 L. Ed. 2d 684, 96 S. Ct. 2074 (1976).
Although we conclude that Ritter's interest in preserving his reputation is protected by the Fourteenth Amendment, his due process rights were not violated by the timing of the suspension hearing. As the United States Supreme Court noted in Mathews v. Eldridge, 424 U.S. 319, 335, 47 L. Ed. 2d 18, 96 S. Ct. 893 (1976),
the specific dictates of due process generally requires consideration of three distinct factors: First, the private interest that will be affected by the official action; second, the risk of an erroneous deprivation of such interest through the procedures used, and the probable value, if any, of additional or substitute procedural safeguards; and finally, the Government's interest, including the function involved and the fiscal and administrative burdens that the additional or substitute procedural requirement would entail.
Requiring hospitals to provide immediate hearings before removing physicians from active practice could be unduly burdensome. The risk of unjustified suspension is small when the Board has worked closely with the doctor over a period of years as in this case. While Ritter's protected "liberty" interest is not a matter of life or death, the interest of the Board in insuring competent, careful medical attention at all times might well be. It is also recognized that hearings after reputational "liberty" interest deprivations "provide the person an opportunity to clear his name". Roth, at 573 n.12. Many cases indicate that a hearing for this purpose after an individual's suspension is all that is constitutionally required. E.g., Arnett v. Kennedy, 416 U.S. 134, 157-58, 40 L. Ed. 2d 15, 94 S. Ct. 1633 (1974) (Rehnquist, J., plurality opinion); Bishop, at 352 (Brennan, J., dissenting); cf. Christhilf v. Annapolis Emergency Hosp. Ass'n, 496 F.2d 174, 180 (4th Cir. 1974) ("due process does not always require a hearing before a doctor's [hospital] privileges are suspended"). In this context we agree.
Ritter's due process rights were not violated by the participation of a hearing committee witness, Dr. Bunch, on ARB.
We have recognized that there are at least three types of bias which call for disqualification in quasi-judicial proceedings. "These are [1] prejudgment concerning issues of fact about parties in a particular case; [2] partiality evidencing a personal bias or personal prejudice signifying an attitude for or against a party as distinguished from issues of law or policy; and, [3] . . . an interest whereby one stands to gain or lose by a decision either way." (Footnote omitted.) Buell v. Bremerton, 80 Wn.2d 518, 524, 495 P.2d 1358 (1972); See 3 K. Davis, Administrative Law § 19.1, at 371 (2d ed. 1980). The trial court concluded that Bunch's participation constituted the first type of bias. It is necessary to examine the facts surrounding Bunch's participation as a witness before the hearing committee to properly evaluate this holding.
Dr. Bunch was called as a witness before that committee by Ritter. On direct examination, Bunch testified that he had known Ritter for approximately 8 years and had a high regard for him both personally and professionally. Bunch also testified on direct examination that summary suspension would not be justified if a doctor was delinquent in maintaining his patients' charts, but that failure to cooperate with staff "may" call for summary suspension.
The ARB concluded that the tubal ligation incident and a chart alteration by Ritter justified suspension of staff privileges. Bunch was queried about these matters on cross-examination before the hearing committee. The Hospital's counsel asked Bunch a hypothetical question based on the Hospital's version of the facts relating to the chart alteration. Bunch knew that these allegations were unproven at that time. Assuming they were true, Bunch stated: "I think this is conduct unbecoming and unprofessional to a physician and it would have an effect on my feeling."
In response to hypothetical questions assuming the accuracy of the Hospital's version of the facts relating to the tubal ligation incident, Bunch stated: "I feel that this does expose a patient to risks that are not necessary. . . . My feeling is that the procedure should not be done, or should not be allowed, or should not be carried out without adequate assistance ." On redirect Bunch mitigated his comments, stating that it merely would have "been wise" if Ritter had used more assistants for the tubal ligation. Bunch's testimony further reveals that he talked with Ritter about his problems at the Hospital, and "felt very good at the time about his reaction."
In evaluating the claim that Bunch's participation on the ARB constituted unconstitutional prejudgment bias, it must be borne in mind that principles relating to disqualification are the same whether the proceeding is before a judge or an administrative body. See Hill v. Department of Labor & Indus., 90 Wn.2d 276, 279, 580 P.2d 636 (1978). A judge is not presumed to be biased, In re Borchert, 57 Wn.2d 719, 722, 359 P.2d 789 (1961), and one alleging bias bears the burden of making an "affirmative showing" to that effect. Williams & Mauseth Ins. Brokers, Inc. v. Chapple, 11 Wn. App. 623, 628, 524 P.2d 431 (1974). It is especially appropriate that plaintiff bear this burden in this case, as it may be very difficult in a hospital with only seven physicians on its active staff to ensure some review by peers which is free of all prior knowledge or "feelings."
Mere exposure to adjudicative facts is not a basis for disqualification. Withrow v. Larkin, 421 U.S. 35, 55, 43 L. Ed. 2d 712, 95 S. Ct. 1456 (1975). In Withrow, a doctor claimed that he was deprived of due process because the same board which investigated charges of misconduct and found sufficient evidence to justify a contested hearing later decided the case. However, the board's earlier determination of "probable cause" for suspension did not amount to a prejudgment on the ultimate issues. In addition, no specific foundation was presented for suspecting that the board had been prejudiced by its investigation or would have been disabled from hearing and deciding on the basis of the evidence presented at the contested hearing. Therefore, the state officials were presumed to be acting with integrity, making the proceeding constitutionally proper.
Similarly, Dr. Bunch did not express his opinion directly or implicitly on whether the tubal ligation or chart alteration justified suspension. Not only did he refrain from commenting on that ultimate question, he never committed himself to any intermediate position such as by voting that probable cause for a suspension existed. As in Withrow, no specific grounds were shown for suspecting that Ritter's own witness had actually prejudged the propriety of suspension. A fortiori, there was no deprivation of due process. See also Duffield v. Charleston Area Medical Center, Inc., 503 F.2d 512 (4th Cir. 1974) (where five members of the board suspending a physician's hospital privileges were also members of the tribunal which heard his appeal, due process was satisfied because the earlier decision was only tentative and the five obtained their exposure to the case only through the same proceeding); Wilson v. Lincoln Redevelopment Corp., 488 F.2d 339, 343 (8th Cir. 1973) (committee member who voted to evict plaintiff from public housing at earlier proceeding not thereby disqualified where he had to assess new evidence and make a final decision); Simard v. Board of Educ., 473 F.2d 988, 993 (2d Cir. 1973); 3 K. Davis, supra at 383, 385 (only when knowledge of the applicable adjudicative acts is coupled with an expressed definite opinion is disqualification required). While placing Dr. Bunch on the ARB may have not been the most prudent course, it was not basically unfair, cf. United States ex rel. Goldbaum v. Curran, 298 F. 118, 120 (S.D.N.Y. 1924) (L. Hand, J.), and it accordingly was not violative of due process.
Finally, while we agree that Ritter was improperly summarily suspended because the medical staff bylaws require a hearing before suspension unless such an "action must be taken immediately in the best interests of patient care" (which was absent here), we do not agree with the trial court's conclusion of law that the Hospital commissioners' final decision (reached after reviewing the ARB report) to continue Ritter's suspension was arbitrary and capricious.
We will overturn a public hospital's decision denying an initial grant of hospital privileges only if the hospital's action is arbitrary, capricious, or discriminatory. Group Health Coop. v. King County Medical Soc'y, 39 Wn.2d 586, 669, 237 P.2d 737 (1951); see Rao v. Board of County Comm'rs, 80 Wn.2d 695, 698, 497 P.2d 591 (dictum), cert. denied, 409 U.S. 1017, 34 L. Ed. 2d 309, 93 S. Ct. 436 (1972). An identical rule should apply when privileges are withdrawn. No claim is made that the District acted in a discriminatory fashion. Its final decision therefore is invalid only if it was arbitrary or capricious.
Administrative action is not arbitrary or capricious if there are grounds for two or more reasonable opinions and the agency reached its decision honestly and with due consideration of the relevant circumstances. Such action is not arbitrary or capricious merely because an appellate court believes it would have reached a different decision on the same facts. See, e.g., Barrie v. Kitsap County, 93 Wn.2d 843, 850, 613 P.2d 1148 (1980). Our scope of review should be especially unobtrusive in this context given the gravity of interests at stake, the inherent difficulty of precisely defining fitness to be a member of a hospital staff, and the judiciary's limited capacity to question competently a hospital administration's discretion in such matters. See Sosa v. Board of Managers, 437 F.2d 173, 176-77 (5th Cir. 1971); Shulman v. Washington Hosp. Center, 222 F. Supp. 59, 64 (D.D.C. 1963); Khan v. Suburban Community Hosp., 45 Ohio St. 2d 39, 44, 340 N.E.2d 398 (1976). "[S]o long as [initial] staff selections are administered with fairness, geared by a rationale compatible with hospital responsibility, and unencumbered with irrelevant considerations, a court should not interfere." Sosa, at 177. There is no reason why judicial review should not be similarly limited when staff privileges are withdrawn.
The ARB found that Ritter's serious alteration of a patient's Hospital chart was grounds for suspension because such a practice (1) could put the accuracy of all Hospital records in question and (2) evidenced noncooperation with nursing and record-keeping staff. Such alterations are expressly prohibited by medical staff rules and regulations. This proscription is clearly reasonable, as other medical personnel often must make decisions based on such records. The medical staff bylaws also require an ability to cooperate and satisfactorily relate with others as a condition of continuing membership. This requirement is also rationally related to the effective functioning of a hospital. See Rao v. Auburn Gen. Hosp., 19 Wn. App. 124, 127, 573 P.2d 834, review denied, 90 Wn.2d 1015 (1978); Rao v. Auburn Gen. Hosp., 10 Wn. App. 361, 366, 517 P.2d 240 (1973). Applying the appropriately narrow standard of review, we are similarly unable to conclude that the District abused its discretion by finding that Ritter's questionable tubal ligation procedure justified suspension.
In conclusion, we hold that the District's violation of its own regulations invalidated Ritter's summary suspension, but that the District did not improperly permanently suspend Ritter's staff privileges after the administrative hearing and an appeal therefrom. We therefore reverse the trial court's judgment that Ritter "be reinstated to all clinical privileges and offices at Ritzville Memorial Hospital," and that all "documents and records" relating to the suspension proceeding be expunged.
Stafford, Utter, Dolliver, Williams, and Dimmick, JJ., concur.