Opinion ID: 2604297
Heading Depth: 3
Heading Rank: 2

Heading: Denial of privileges based on a subjective process.

Text: Kiester challenges virtually every step of the process through which Humana evaluated his application for privileges. [3] Kiester contends that he was never given notice of the charges against him so he could prepare for the hearing before the Ad Hoc Committee. He also argues that the Ad Hoc Committee did not conduct its hearing according to the bylaws and that the committee instead subjected him to an unprecedented prolonged oral examination. Kiester contends that the bylaws do not provide for oral examinations and that such examinations are unsound because of their subjective nature. He claims that Humana had no criteria regarding questions that would be asked in the examination and also had no criteria regarding the answers. Finally, he claims that he was denied due process of law and was arbitrarily denied privileges because Humana did not consider evidence Kiester assembled which, in his opinion, demonstrated that he correctly answered the questions and passed the examination. Humana's bylaws provide for a hearing and appellate review of a decision to deny an application for clinical privileges. Medical Staff Bylaws Article VIII. Regarding notice of the hearing, the bylaws provide as follows: The notice of hearing shall state in concise language the acts or omissions with which the practitioner is charged, a list of specific or representative charts being questioned, and/or the other reasons or subject matter considered in making the adverse recommendation or decision. Medical Staff Bylaws Article VIII, Section 3(b). On December 27, 1985, Humana's Executive Director sent a letter to Kiester which stated in part: As per our bylaws, page 4, section 2a. only physicians and dentists currently licensed to practice in the State of Alaska who can document their background, experience, training and demonstrated competence shall be qualified for membership on the medical staff. I would like to further add that there are no particular charges against you, as per your request of the same. This language gave Kiester notice that the rejection of his application was not based on charges of misconduct or malpractice. [4] Moreover, the letter put Kiester on notice that he had not satisfied his burden of producing adequate information and resolving doubts about his qualifications for surgical privileges. [5] However, in a more fundamental sense, Humana did not give Kiester notice of the reason his application was denied. There is nothing in that letter, or other prior letters, memoranda or transcripts, which identifies the bases for the implicit conclusion that Kiester's background, experience, training and demonstrated competence were lacking. Although the focus of the denial apparently was on Dr. Kiester's training and education, and presumably also demonstrated competence, no specific deficiencies in training or education were noted by Humana. Further, despite the admittedly examination-like nature of interviews with individual doctors and the Ad Hoc Committee, Humana did not provide Kiester with notice of how he had failed to carry his burden of demonstrating competence. Yet the record does demonstrate that it was answers to these questions which were unsatisfactory for some unidentified reason or reasons. We recognize that the governing body of a hospital must be given great latitude in establishing standards which an applicant must meet before privileges will be granted. See Sosa, 437 F.2d at 176. We also recognize that it may be difficult for a hospital to establish criteria which may be applied objectively in evaluating whether an applicant has met the standards for every conceivable medical or surgical privilege. See Ritter v. Bd. of Comm'rs of Adams County Public Hosp. Dist. No. 1, 96 Wash.2d 503, 637 P.2d 940, 947-48 (1981); Sosa, 437 F.2d at 176. However, basic principles of due process of law require that criteria established for granting or denying privileges not be vague and ambiguous, and that as established, they be applied objectively. See Williams v. Kleaveland, 534 F. Supp. 912, 917 (W.D.Mich. 1981) (holding that rules established by hospitals to regulate the conduct of doctors must be capable of objective application); Miller v. Eisenhower Medical Ctr., 27 Cal.3d 614, 166 Cal. Rptr. 826, 833, 614 P.2d 258, 265 (1980) (finding that rules governing the admission of physicians cannot stand if the standard is unreasonably susceptible of arbitrary or discriminatory application); Martino v. Concord Community Hosp. Dist., 233 Cal. App.2d 51, 43 Cal. Rptr. 255, 260 (1965) (stating a hospital must set up standards which are clear, not vague, ambiguous or uncertain); Wyatt v. Tahoe Forest Hosp., 174 Cal. App.2d 709, 345 P.2d 93, 97 (1959) (noting that the standard set up was so vague and uncertain that admission to the staff can depend on the whim and caprice of the directors). Furthermore, basic principles of due process of law require that when a hospital denies an application for privileges, it notifies the applicant of the specific criteria which were determinative in the denial and how the applicant failed to meet the hospital's expectations with regard to the criteria. Fundamental fairness dictates that the hospital apprise the physician of the specific charges and that the applicant be afforded the opportunity to appear and present witnesses and material in support of his position and to contradict or explain the bases asserted for the proposed denial. Such hearings in addition to affording the doctor an opportunity to respond to charges enable a hospital to make an intelligent and reasonable judgment in good faith upon all the facts presented. Garrow v. Elizabeth General Hosp. & Dispensary, 79 N.J. 549, 401 A.2d 533, 541 (1979) (citations omitted) (quoting Sussman v. Overlook Hosp. Ass'n, 95 N.J. Super. 418, 231 A.2d 389, 393 (App.Div. 1967)). Based on our review of the record, we conclude that Humana has not satisfied these basic requirements of due process of law. Humana based its decision in large part on the adverse letters of Doctors Gower and Marbarger and on the adverse recommendation of the Ad Hoc Committee. These negative evaluations were based in turn on oral evaluations of Kiester's medical competence. These evaluations concluded in general terms that Kiester lacked sufficient medical knowledge to be granted surgical privileges. While the evaluations articulate conclusions that Kiester lacked sufficient knowledge, none of the evaluations establish the level of knowledge which would be of sufficient adequacy [6] or the criteria used to evaluate sufficiency. There are references to instances where the evaluator felt Kiester's approach to a specific medical problem was not in accordance with unspecified current medical literature. However, the notice to Kiester does not indicate which questions Kiester answered correctly and which he answered inadequately or incorrectly, nor does it attempt to quantify in any way the extent to which an applicant must answer in a satisfactory manner in order to meet standards of training and education or demonstrated competence. Absent such notice, it is impossible for any reviewing body to objectively and independently determine if an applicant has established competence. Further, there is little record of the questions and answers exchanged between Kiester and Dr. Marbarger. In the absence of such a record, it would seem impossible for an appellate panel of medical experts to make an independent evaluation of Kiester's responses to those questions. It is possible that the evaluators had in mind criteria for measurement of an applicant's qualification which would satisfy the requirements of due process. However, we cannot find an articulation of such criteria in the record. In the absence of specific charges indicating in what respect Kiester's information was not adequate, there is no evidence of criteria for evaluation of medical qualifications. We conclude that Humana did not afford Kiester the consideration required by basic principles of due process of law. We do not mean to imply that a hospital may not utilize an oral inquiry into the qualifications of an applicant for medical or surgical privileges. The bylaws provide that by applying for appointment to the medical staff, each applicant thereby signifies his/her willingness to appear for interviews in regard to his/her application. Medical Staff Bylaws Article V, Section 1(b). Moreover, the bylaws authorize the Ad Hoc Committee to consider [a]ny relevant matter upon which responsible persons customarily rely in the conduct of serious affairs. Article VIII, Section 5(g). Therefore, we do not say that an oral examination may not be administered. However, if the results of an oral examination provide the basis for a denial of an application for privileges, the hospital must establish criteria for determining whether an applicant has passed the examination and must establish a process whereby the applicant may challenge the conduct of the examination and the hospital's evaluation of the answers given. It follows from our discussion that we must conclude that Kiester was also denied due process of law when Humana's second ARC declined to review Kiester's evidence, which he claimed would show that he correctly answered most of the questions asked by the Ad Hoc Committee. When Kiester attempted to introduce this evidence, the committee chair refused it saying: I think the appropriate [matter for consideration] is whether the quiz, the interview, the whole process was correct, not what the questions were and what the answers were. The answers to the questions have to be viewed by the medical staff. I think whether the process was correct is what we should be looking at. In our view, Humana had an obligation at some point in the process to review Kiester's claim and the evidence he offered to prove that he had correctly answered the questions given during the Ad Hoc Committee's oral examination. [7] Due process requires that a physician must be provided every reasonable means and opportunity to show that the grounds specified for the denial of the application are either inadequate or baseless, or to refute the charges upon which revocation or denial of [privileges] is based. Silver v. Queen's Hosp., 63 Haw. 430, 629 P.2d 1116, 1124 (1981); Sosa, 437 F.2d at 177 ([P]rocedural due process must be afforded the applicant so that he may explain or show to be untrue those matters which might lead the board to reject his application.).