Court Opinion

ID: 9839258
Source: CourtListenerOpinion
Date Created: 2023-09-12 17:09:06.417898+00
Date Added: 2024-06-11T09:12:53.965337
License: Public Domain

J-A03020-23

                                  2023 PA Super 163

  WAKEEM FORD-BEY,                  :           IN THE SUPERIOR COURT OF
  ADMINISTRATOR OF THE ESTATE OF    :                PENNSYLVANIA
  WANETTA FORD-BEY                  :
                                    :
                                    :
            v.                      :
                                    :
                                    :
  PROFESSIONAL ANETHESIA            :           No. 162 EDA 2022
  SERVICES, JOEL D. SOKOLOFF, M.D., :
  THOMAS MADDALONI, CRNA, SCOTT :
  WILSON, CRNA, AND PHYSICIAN'S     :
  CARE SURGICAL HOSPITAL, LP        :
                                    :
                                    :
  APPEAL OF: PHYSICIAN'S CARE       :
  SURGICAL HOSPITAL, LP             :

               Appeal from the Order Entered December 7, 2021
             In the Court of Common Pleas of Montgomery County
                      Civil Division at No(s): 2017-02996

BEFORE:      KING, J., SULLIVAN, J., and STEVENS, P.J.E.*

OPINION BY SULLIVAN, J.:                        FILED SEPTEMBER 12, 2023

       Physician’s Care Surgical Hospital (“Hospital”) appeals from the

discovery order requiring Hospital to produce documents to Wakeem Ford-Bey

(“Appellee”), administrator of the estate of Wanetta Ford-Bey (“Ms. Ford-

Bey”). Hospital has also filed a petition for permission to appeal from the

amended discovery order denying its request for a certification of immediate

appealability.    See Pa.R.A.P. 1311(a)(1).     We affirm and deny Hospital’s

petition for allowance of appeal as moot.

____________________________________________

* Former Justice specially assigned to the Superior Court.
J-A03020-23

       Ms. Ford-Bey underwent wrist surgery at Hospital.         See Complaint,

2/13/17, at ¶ 25. Shortly after the surgery, Ms. Ford-Bey suffered cardiac

and respiratory failures that required her transfer to another facility for further

care. See id. at ¶¶ 27-28. A nurse internally reported the incident pursuant

to Hospital’s “Sentinel Event Policy” (or “Policy”).1 See Hospital’s Responses

to Appellee’s Supplemental Request for Production of Documents (Set X),

4/3/19, at ¶ 1. Lisa Gill (“Gill”), who holds several titles at Hospital, conducted

a “root cause analysis” to determine the cause of Ms. Ford-Bey’s decline. See

Hospital’s Response and Opposition to Appellee’s Motion to Strike Objections

and Compel Hospital’s Responses, 8/2/19, at ¶ 24; Hospital’s Sur-Reply to

Appellee’s Motion to Strike Objections and Compel Hospital’s Responses,

10/23/19, at 5.

       On June 17, 2015, Gill interviewed Hospital staff members involved in

Ms. Ford-Bey’s surgery and care. See Hospital’s Response and Opposition to

Appellee’s Motion to Strike Objections and Compel Hospital’s Responses,

8/2/19, at ¶ 24. Gill took notes on a three-page form containing standard

questions. The parties agree that Gill authored at least one report that she

sent to the Pennsylvania Patient Safety Authority (“PPSA”), an independent

agency established under the Medical Care and Reduction of Error Act

____________________________________________

1 Hospital was formed and funded by Nueterra Holding’s LLC (“Nueterra”), a

Kansas company. Nueterra, through its related entities, provides Hospital
with its management, staff, and internal policies, including the Policy.

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(“MCARE”), 40 P.S. §§ 1303.101-1303.910.2 See N.T., 9/17/21, at 26-27.

Ms. Ford-Bey remained in a vegetative state after the surgery and died in July

2015.

        Appellee commenced the underlying medical malpractice action against

Hospital and several other defendants. During discovery, Appellee requested

from Hospital all data and documents from the root cause analysis.            See

Hospital’s Response to Appellee’s Supplemental Request for Production of

Documents (Set IV), 8/1/17, at ¶ 15. Hospital objected based on privilege,

and Appellee moved to strike the objections. See id.

        Hospital responded to Appellee’s motion to strike and asserted that

materials from the root cause analysis arose out of Hospital’s performance of

its MCARE obligations and that section 311(a) of MCARE protected such

materials from disclosure in a civil proceeding. See Hospital’s Response and

Opposition to Appellee’s Motion to Strike Objections and Compel Hospital’s

Responses, 8/2/19, at ¶ 24; see also 40 P.S. § 1303.311(a). In support of

its claim of confidentiality, Hospital provided the trial court with a copy of its

Sentinel Event Policy.

        The Policy, upon which Hospital relied, establishes the procedures for

reporting a “sentinel event”3 and provides that Hospital will conduct a “root
____________________________________________

2 See 40 P.S. §§ 1303.303 (establishing the PPSA); 1303.304 (stating the
duties of the PPSA); 1303.313 (imposing a duty on medical facilities to report
to the PPSA and the Pennsylvania Department of Health).

3 A “sentinel event” under the Sentinel Event Policy means an “[u]nexpected

adverse occurrence involving death . . . or the risk thereof.” Policy at 1.

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cause analysis . . . to determine the basic, causative factor(s) that led to the

event.” Policy at 1. An “administrative team” and the Hospital’s director of

performance improvement also review the notification of a sentinel event. Id.

at 1. They determine whether an “intensive assessment resulting in a root

cause analysis” is required, and, if necessary, form a team to conduct a root

cause analysis. Id. at 1-2. The root cause analysis may result in an action

or improvement plan, which the team will report to an “organizational

administrative team,” a “performance improvement committee,” and the

Hospital’s “governing body,” and, at the direction of the “administrative team,”

to other Hospital committees. Id. at 2 (some capitalization omitted). The

root cause analysis may also result in corrective actions managed through

“the medical staff committee” process, a “department manager,” or through

“the organizational performance improvement model,” depending upon the

cause of or factors related to the event. Id. The Policy states that Hospital’s

“Administrator/CEO” has the sole discretion to communicate the event or

corrective action to “other organizations or individuals.” Id.

      Additionally, Hospital referred to Appellee’s deposition of Christopher

Doyle (“Doyle”), the Chief Executive Officer and corporate designee of

Hospital.   See Hospital’s Sur-Reply in Further Support of Response and

Opposition, 10/23/19, at 7-9.    Of relevance to this appeal, Doyle testified

about Hospital’s boards and committees, its policies, and the specific root

cause analysis that Gill conducted after Ms. Ford-Bey’s respiratory failure

following her surgery. Specifically, Doyle noted that Hospital did not have a

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committee specifically designated a “patient safety committee,” as is required

by MCARE, but later testified that Hospital’s Committee on Quality Initiatives

(“CQI”) is the “primary safety committee” that will “review safety” during its

meetings and receives reports of all incidents at Hospital.                See Doyle

Deposition, 10/1/19, at 40-41.4          Doyle described how the nurse’s internal

incident report regarding Ms. Ford-Bey’s cardiac and respiratory failures went

to Hospital’s risk manager and the director of nursing, then to Gill. See id. at

44-45. Doyle testified that the incident report triggered the Policy, which, in

turn, caused Gill to conduct the root cause analysis. See id. at 80, 105, 115.

Doyle described Gill’s corporate titles as “possibly” Hospital’s patient safety

officer,   and   as   Hospital’s    director   of   quality   and   accreditation,   the

“performance improvement department,” and a senior clinical nurse. See id.

at 44-45, 81. He could not recall if Gill submitted a report concerning Ms.

Ford-Bey to the CQI, but recalled discussions of the event. See id. at 119.

       Following oral arguments, the trial court struck Hospital’s objections and

on December 7, 2021, ordered Hospital to produce “any notes of Lisa Gill

pertaining to the root cause analysis she conducted on June 17, 2015.” Order,

____________________________________________

4 Doyle also later referred to a “patient safety committee” as a subcommittee

of the CQI. See id. at 41-43. Doyle was not able to recall the CQI’s or the
patient safety committee’s members. Hospital, in later discovery responses,
identified the membership of the CQI and a patient safety subcommittee.

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12/7/21.5     Hospital timely appealed, and both Hospital and the trial court

complied with Pa.R.A.P. 1925.

       Hospital raises the following issues for our review:

       1. Whether this appeal, which arises from the trial court’s [o]rder
          compelling disclosure of material that is privileged under
          [s]ection 1303.311(a) of [MCARE] falls within th[is] Court’s
          appellate jurisdiction to review collateral orders.

       2. Whether information gathered in accordance with an internal
          hospital policy “arise[s] out of” the hospital’s duties under
          MCARE, such that the information is privileged pursuant to
          [s]ection 1303.311(a) . . ..

Hospital’s Amended Brief at 4.

       In its first issue, Hospital invokes the collateral order doctrine. See id.

at 17-24. This issue implicates this Court’s jurisdiction and involves a question

of law, over which our standard of review is de novo, and our scope of review

is plenary. See Calabretta v. Guidi Homes, Inc., 241 A.3d 436, 441 (Pa.

Super. 2020).

       Pennsylvania Rule of Appellate Procedure 313 permits an immediate

appeal as of right from an otherwise interlocutory order where the appellant
____________________________________________

5 Hospital timely filed a motion for reconsideration and a petition to certify the

December 7, 2021 order for an immediate appeal pursuant to 42 Pa.C.S.A.
§ 702(b).      On December 27, 2021, the trial court granted Hospital
reconsideration, in part, and amended its order to permit Hospital to withhold
the report that Gill submitted to the PPSA. See Amended Order, 12/27/21,
at 1 (stating that “the subsequent report authored and submitted by . . . Gill
to the [PPSA] does not have to be produced as per agreement of the parties
and counsel”).      The amended order also denied Hospital’s request for
certification for immediate appeal. Hospital, as noted above, has filed in this
Court a Rule 1311 petition for permission to appeal in conjunction with its
timely notice of appeal.

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demonstrates that the order appealed from meets the following elements: (1)

it is separable from and collateral to the main cause of action; (2) the right

involved is too important to be denied review; and (3) the question presented

is such that if review is postponed until final judgment in the case, the claim

will be irreparably lost. See Pa.R.A.P. 313(b); see also Witt v. LaLonde,

762 A.2d 1109, 1110 (Pa. Super. 2000). To establish a collateral order, each

of the three requirements must be clearly present. See J.S. v. Whetzel, 860

A.2d 1112, 1117 (Pa. Super. 2004).

       Before addressing Hospital’s arguments, it is helpful to outline the

framework of MCARE’s reporting requirements. Chapter 3 of MCARE, entitled

“Patient Safety” (“Chapter 3”), “relates to the reduction of medical errors for

the purpose of ensuring patient safety.” 40 P.S. § 1303.301. Chapter 3 calls

for the creation of public and private offices for reporting events that result in

a patient’s death, which MCARE defines as a “serious event.” 6         Chapter 3

establishes the PPSA as an independent agency, and section 304 authorizes

the PPSA to contract with third-party entities to collect and analyze reports of

serious events, relay recommendations to medical facilities, and advise

medical facilities of immediate changes to reduce serious events.        See id.

§ 1303.304(a)(5).7
____________________________________________

6 40 P.S. § 1303.302 (defining a “[s]erious event” as “an event, occurrence

or situation involving the clinical care of a patient in a medical facility that
results in death . . .”).

7 The PPSA may also receive anonymous reports from health care workers
concerning serious events. See id. § 1303.304(b).

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      Chapter 3 mandates that a medical facility, such as Hospital, develop

and implement a “patient safety plan” that designates a facility’s “patient

safety officer,” establishes a “patient safety committee,” and identifies internal

systems for employees to report serious events. Id. § 1303.307(b)(1)-(3).

A medical facility must submit its patient safety plan to the Pennsylvania

Department of Health for approval.       See id. § 1303.307(c).      Health care

workers must report serious events pursuant to this plan.                See id.

§ 1303.308(a). The medical facility, in turn, must report serious events to

the Pennsylvania Department of Health and the PPSA. See id. § 1303.313.

      Chapter 3 also sets requirements for the membership on a medical

facility’s patient safety committee. See id. § 1303.310(a)(2) (requiring, for

example, that a patient safety committee include at least one resident of the

community that a facility serves). Chapter 3 requires that the patient safety

officer be a member of the patient safety committee, and section 309(4)

requires the patient safety officer to report to the patient safety committee

any action she takes to promote patient safety based on investigations that

she commences pursuant her statutory duties. See id. § 1303.309(4).

      Section 310(b) further mandates that a patient safety committee:

      (1) Receive reports from the patient safety officer pursuant to
      section 309.

      (2) Evaluate investigations and actions of the patient safety officer
      on all reports.

      (3) Review and evaluate the quality of patient safety measures
      utilized by the medical facility.  A review shall include the

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      consideration of reports made under sections 304(a)(5) and (b),
      307(b)(3) and 308(a).

      (4) Make recommendations to eliminate future serious events and
      incidents.

      (5) Report to the administrative officer and governing body of the
      medical facility on a quarterly basis regarding the number of
      serious events and incidents and its recommendations to eliminate
      future serious events and incidents.

Id. § 1303.310(b) (footnotes omitted).

      Section 311 of MCARE sets forth the following confidentiality provision:

      (a) Prepared materials.--Any documents, materials or
      information solely prepared or created for the purpose of
      compliance with section 310(b) or of reporting under section
      304(a)(5) or (b), 306(a)(2) or (3), 307(b)(3), 308(a), 309(4),
      310(b)(5) or 313 which arise out of matters reviewed by the
      patient safety committee pursuant to section 310(b) or the
      governing board of a medical facility pursuant to section
      310(b) are confidential and shall not be discoverable or
      admissible as evidence in any civil or administrative action
      or proceeding. . . .

                                     ****

      (c) Applicability.--The confidentiality protections set forth in
      subsection[] (a) . . . shall only apply to the documents,
      materials or information prepared or created pursuant to
      the responsibilities of the patient safety committee or
      governing board of a medical facility set forth in section
      310(b).

See id. § 1303.311(a)-(c) (footnote omitted) (emphases added).             The

confidentiality provision of section 311(a) thus strikes a balance between the

MCARE requirements to report and respond to serious events with assurances

that documents, material, and information prepared or created to comply with

MCARE will not be used against a facility in civil litigation.

                                       -9-
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       Following our review, we conclude that the question of confidentiality

under section 311(a) of MCARE is separable from and collateral to Appellee’s

cause of action. Further, MCARE’s confidentiality provisions involve important

rights concerning the collection and processing of information related to

patient safety, as well as the sharing of such information with governmental

agencies pursuant to Pennsylvania law.             See 40 P.S. §§ 1303.310(b),

1303.311(a).      Lastly, postponement of review until a final determination

would result in an irreparable loss of the rights established under MCARE.

Therefore, we conclude that we have jurisdiction pursuant to Pa.R.A.P. 313

and will address the merits of Hospital’s claims that Appellee sought

documents or information protected by section 311(a) of MCARE.                 See

Ungurian v. Beyzman, 232 A.3d 786, 793 & n.10 (Pa. Super. 2020).8

       Hospital, in its second issue, claims that the trial court erred in its

interpretation and application of Chapter 3 of MCARE. Our standard of review

is as follows:

       In reviewing the propriety of a discovery order, our standard of
       review is whether the trial court committed an abuse of discretion.
       Abuse of discretion occurs if the trial court renders a judgment
       that is manifestly unreasonable, arbitrary or capricious; that fails
       to apply the law; or that is motivated by partiality, prejudice, bias
       or ill-will.

Carlino E. Brandywine, L.P. v. Brandywine Village Associates, 260 A.3d

179, 195-96 (Pa. Super. 2021) (internal citations, quotations, and brackets

____________________________________________

8 Because the collateral order doctrine applies, we deny Hospital’s petition for

permission to appeal pursuant to Rule 1311 as moot.

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omitted) (“Carlino”). When the claim of privilege requires consideration of a

question of law, such as the interpretation of a statute, our standard of review

is de novo, and the scope of our review is plenary. See Ungurian, 232 A.3d

at 794.

      Pennsylvania law imposes a shifting burden of proof in disputes when

deciding whether to compel disclosure of materials over a claim of any

privilege.   The party asserting a privilege must initially produce facts to

properly invoke the privilege; once properly invoked, the party seeking

disclosure bears the burden of showing that disclosure should be compelled

either because the privilege has been waived or because an exception to the

privilege applies. See Carlino, 260 A.3d at 197. If the party asserting the

privilege produces insufficient facts to invoke the privilege, then the burden

will not shift to the party seeking disclosure. See id.

      Hospital claims that the trial court erred in compelling disclosure

because the evidence from its Policy and Doyle’s deposition established that

MCARE protected Gill’s notes from her root cause analysis of Ms. Ford-Bey’s

cardiac and respiratory failures. See Hospital’s Amended Brief at 16-17, 34-

36.   Hospital argues that section 311(a)’s confidentiality provision only

requires that documents, materials, or information created or prepared by Gill

“arise out of a” patient safety committee’s or governing board’s duties to

review matters under section 310(b).          Id. at 15-16 (quoting 40 P.S.

§ 1303.311(a)). Hospital engages in a statutory interpretation analysis and

maintains that section 311(a)’s confidentiality provision does not require that

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a board of directors or a patient safety committee actually examine or review

a root cause analysis. See id. at 31, 33. Hospital further claims that the

Policy and Hospital’s implementation of its board and committees ensured that

Hospital complied with its MCARE requirements and are therefore “rationally

related” to MCARE. See id. at 32, 40-41. Hospital concludes that Gill’s notes

“are the manifestation of information that is solely prepared or created for

the purpose of compliance” with MCARE.             Id. at 42 (internal citations and

quotations omitted) (emphasis in original).

       The trial court rejected Hospital’s claim of privilege under MCARE. The

trial court observed that there are no published appellate cases analyzing

MCARE, section 311(a), but relied on a court of common pleas decision in

Venosh v. Henzes, 31 Pa. D. & C. 5th 411, 2013 WL 9593953 (Lackawanna

Cty.   2013),    aff’d,   105    A.3d    788   (Pa.   Super.   2014)   (unpublished

memorandum).9 Applying Venosh, the trial court determined that section

____________________________________________

9 In Venosh, the court of common pleas discerned three elements to a claim

of privilege under section 311(a): (1) the document was “solely prepared or
created for the purpose of compliance with” MCARE; (2) the document
“arise[s] out of matters reviewed by the patient safety committee . . . or the
governing board” pursuant to section 310(b); and (3) the document is not
otherwise available “from original sources.” Venosh, 2013 WL 9593953, at
*10. The court further reasoned that section 311(a) did not apply “if the
investigation of an incident by the defendant hospital was not commenced at
the request of or by the defendant’s Patient Safety Committee” or if a patient
safety committee, or the hospital’s governing board, did not review a
document. Id. (internal citations and quotations omitted). It is well settled
that the decision of a court of common pleas does not bind this Court, but we
may consider the reasoning as persuasive. See Darrow v. PPL Elec.
Utilities Corp., 266 A.3d 1105, 1112 n.6 (Pa. Super. 2021).

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311(a) did not protect Gill’s notes because the Policy was “clearly not an

implementation of the investigation or reporting requirements” of MCARE.

See Trial Court Opinion, 3/23/22, at 16. The trial court reasoned that the

Policy did not expressly refer to MCARE, did not require the Hospital’s patient

safety committee to receive reports from an investigation, and only called for

the Hospital’s governing board’s involvement in limited circumstances. See

id.

      The trial court further emphasized that Hospital did not establish its

patient safety committee or governing board “in fact” reviewed Gill’s notes

from the root cause analysis. See id. at 16-17. The trial court, again citing

Venosh, concluded that absent proof that a patient safety committee or a

governing board reviewed Gill’s notes, the confidentiality provision of section

311(a) did not apply. See id. at 17.

      Following our review, we concur in the trial court’s conclusion that

section 311(a) did not protect Gill’s notes. We begin with a review of MCARE’s

requirements and privileges mindful that, “[a]s with all questions of statutory

interpretation, our object is to ascertain and effectuate the intention of the

General Assembly, giving effect, if possible, to all provisions of the statutory

provisions under review” and that “[t]he best indication of legislative intent is

the statute’s plain language.” Reginelli v. Boggs, 181 A.3d 293, 300 (Pa.

2018) (citing 1 Pa.C.S.A. §§ 1921(a)-(b)).

      As noted above, MCARE requires Hospital to have in place a patient

safety plan that designates a facility’s “patient safety officer,” establishes a

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“patient safety committee,” and identifies internal systems for employees to

report serious events. Id. § 1303.307(b)(1)-(3). MCARE further requires that

Hospital’s patient safety committee: (1) receives reports from the patient

safety officer; (2) evaluates investigations and actions of the patient safety

officer on all reports; (3) reviews and evaluates the quality of the facility’s

patient safety measures; (4) makes recommendations to eliminate future

serious events; and (5) reports the number of serious events and its

recommendations to an administrative officer or governing body of the facility

on a quarterly basis. See id. § 1303.310(b). In exchange for these policies

and procedures, MCARE protects “[a]ny documents, materials or information

solely prepared or created for the purpose of compliance with section 310(b)

. . . which arise out of matters reviewed by the patient safety committee

pursuant to section 310(b) or the governing board of a medical facility

pursuant to section 310(b) . . ..” Id. § 1303.311(a).

      While Hospital focuses on the phrase “which arise out of matters

reviewed,” the critical term, here, is “solely.”     That is, section 311(a)

confidentiality attaches to “documents, materials or information solely

prepared or created for the purpose of compliance” with the relevant MCARE

requirements. Id. (emphasis added). “Solely” means “without another or

others,” or “only, exclusively, merely, or altogether.”   Webster New World

College Dictionary (4th Ed.) at 1364 (2002). Thus, for Hospital to assert a

privilege under section 311(a), it bore a burden of demonstrating that Gill’s

notes were exclusively prepared or created to comply with MCARE.

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       Here, aside from Gill’s filing with the PPSA a report, which the trial court

held remained confidential, Hospital failed to produce evidence demonstrating

Gill solely prepared or created her notes for the purpose of complying with

MCARE. To the extent Hospital relied on its Sentinel Events Policy, the Policy

emanated from a Kansas corporation, and Hospital adduced no clear evidence

that the Policy implemented the special requirement of an MCARE-required

safety plan.     See 40 P.S. § 1303.307(b).10           The Policy did not identify

Hospital’s MCARE-required patient safety officer or patient safety committee

or establish their duties with respect to “serious events.”          Compare id.

§§ 1303.307(b)(1)-(2), 1303.308(4), 1303.310(1) with Policy at 1-2

(discussing generally that “administrative team” and Hospital’s director of

performance improvement received notifications of events and determine if a

root cause analysis is required).              Doyle, Hospital’s CEO and corporate

designee, offered only equivocal testimony that Gill held several corporate

titles, and was “possibly” Hospital’s designated MCARE patient safety officer.

See Doyle Deposition, 10/1/19, at 40-45, 81. Doyle’s testimony that Hospital

CQI acted as its MCARE patient safety committee is, at best, muddled and

confusing. See id. at 40-43. Hospital presented no further evidence that its

____________________________________________

10 Hospital did not present evidence that the Department of Health approved

the Sentinel Event Policy as an MCARE-required patient safety plan. See 40
P.S. § 1303.307(c).

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CQI or any other subcommittee met the requirements of, or discharged the

duties, of an MCARE patient safety committee. See 40 P.S. § 1303.310.11

        In sum, we discern no error of law or abuse of discretion in the trial

court’s ruling that Hospital’s Sentinel Event Policy was “clearly not an

implementation of the investigation or reporting requirements” of MCARE.

See Trial Court Opinion, 3/23/22, at 16.            Absent any clear evidence of

Hospital’s   compliance      with   maintaining    the   offices,   committees,   and

procedures required Chapter 3 of MCARE, Hospital cannot demonstrate that

Gill solely prepared or created her notes during the root cause analysis to

comply with MCARE. Thus, Hospital did not meet their burden of invoking the

privilege set forth in section 311 of MCARE, and the burden did not shift to

Appellee to demonstrate waiver or an exception to the statute.             For these

reasons, we agree with the trial court that the MCARE privilege did not apply,

and we affirm its order compelling disclosure of Gill’s notes.

        Order affirmed. Hospital’s petition for allowance of appeal denied as

moot.

____________________________________________

11 Even if Gill acted as an MCARE patient safety officer—as opposed to a
director of quality and accreditation or some other corporate responsibility—
Hospital’s evidence did not establish she met her MCARE duties to report to
the patient safety committee the actions she took to promote patient safety
based on investigations she commenced for a serious event. See 40 P.S.
§§ 1303.309(4), 1303.310(b)(1).

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Judgment Entered.

Joseph D. Seletyn, Esq.
Prothonotary

Date: 9/12/2023

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