Opinion ID: 585038
Heading Depth: 4
Heading Rank: 1

Heading: Audit Subcommittee Review

Text: 50 Marrese next maintains that the course of the audit subcommittee's review showed malice. First, Marrese contends that audits were regularly conducted through the standing Medical Audit Committee and that the formation of the special audit subcommittee indicated something amiss. The By-Laws of the Medical and Dental Staff of Deaconess Hospital (By-Laws) expressly permit the MSEC to form special committees as may be required. The February 8, 1978 minutes of the MSEC meetings reveal that the MSEC decided that an audit of back surgeries would be conducted through the Surgery Department. Even if this were the first time the MSEC had ever formed a special audit subcommittee pursuant to its powers under the By-Laws, Marrese can do no more than speculate that the defendants formed the special audit subcommittee for malicious reasons. 51 Second, Marrese maintains that his spinal fusions met the criteria in the initial fusion audit and that further review of spinal fusion cases evidenced an intent to focus on him since he was the only surgeon specializing in spinal reconstructive surgery. Regardless of whether or not Marrese's spinal fusions met the criteria in the initial fusion audit, uncontradicted evidence in the record establishes that the results of a screening audit are not conclusive as to whether the appropriate standard of care has been met. Therefore, because the audit subcommittee inquired beyond the established criteria for the spinal fusion audit to determine whether Marrese's care fell below appropriate standards, it does not follow that the audit subcommittee acted out of malice. Furthermore, Marrese's indisputable dominance in the spinal fusion market is precisely one of the factors that led the audit subcommittee to further study his spinal fusions. As defendant Evans stated at the Fair Hearing, [i]t seemed remarkable that one surgeon should be able to find all the necessary indications for a spinal fusion in such a large number of people. When all the other orthopedic surgeons practicing at this hospital during that same length of time had only found eight people to operate on, Dr. Marrese had been able to glean up thirty-two. (Defendants' Motion for Summary Judgment, Johnson Affidavit, Fair Hearing Tr. at 218). 52 Marrese attempts to derive malice from the audit subcommittee's failure to further study lumbar laminectomies included in the lumbar laminectomy audit that the audit subcommittee conducted at the same time as the spinal fusion audit. Contrary to Marrese's contentions, the summary report from the lumbar laminectomy audit does not reveal that the results of the audit generated any further need for studying the lumbar laminectomies. Although there seems to be some debate regarding how many lumbar laminectomies satisfied the audit criteria as compared to how many spinal fusions passed the audit, this dispute does not help Marrese. Even if a lower percentage of lumbar laminectomies than spinal fusions met the criteria of their respective audits, the decision of the audit subcommittee to further study only spinal fusions would not tend to establish that the audit subcommittee was motivated by something other than patient welfare. As the defendants explained, and Marrese has not disputed, the audit criteria are not the sole criteria by which the appropriateness of patient care is measured. While the audit subcommittee noted after the lumbar laminectomy audit that certain documentation needed improvement, it did not find any indications for further study of the care provided by the physicians who conducted the lumbar laminectomies. By contrast, the spinal fusion audit summary did indicate that some areas needed further study. Nothing in these audit summaries and the audit subcommittee's subsequent course of action raises a genuine issue of material fact regarding malice. 53 The audit subcommittee met only once with Marrese and managed to discuss only one of the 32 cases from 1977-78 that had been audited. Marrese claims that this contravened the collegiality and counseling components of peer review properly conceived, and impl[ies] a motive other than patient welfare. (Appellant's Brief at 43). A brief review of the transcript of the meeting between Marrese and the audit subcommittee reveals that Marrese personally attacked committee members and insisted on haggling over why the committee members had not come to him without going to the MSEC. Since Marrese effectively precluded any discussion about the cases under study, it is no wonder that the audit subcommittee did not come back for more. A reasonable trier of fact would be hard pressed to conclude that the audit subcommittee's failure to subject itself to another futile round of talks with Marrese indicated malice on the part of the audit subcommittee. If anything, the transcript evidences the audit subcommittee's efforts to be fair to Marrese. For example, near the end of the meeting, Marrese suggested that an outside audit be conducted and that Bryant A. Bloss, M.D., be added to the audit subcommittee. When Rabin left town, the Surgical Control Committee appointed Bloss and Pedro Dominguez, M.D., to the audit subcommittee.