Court Opinion

ID: 8377516
Source: CourtListenerOpinion
Date Created: 2022-10-24 18:01:37.84696+00
Date Added: 2024-06-11T16:46:36.445682
License: Public Domain

Filed 10/24/22 Nashed v. Los Robles Regional Medical Center CA2/6
     NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions
not certified for publication or ordered published, except as specified by rule 8.1115(b). This opinion
has not been certified for publication or ordered published for purposes of rule 8.1115.

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                         SECOND APPELLATE DISTRICT

                                         DIVISION SIX

ASHRAF NASHED,                                                 2d Civ. No. B313131
                                                             (Super. Ct. No. 56-2019-
     Plaintiff and Appellant,                                00529474-CU-WM-VTA)
                                                                (Ventura County)
v.

LOS ROBLES REGIONAL
MEDICAL CENTER et al.,

  Defendants and
Respondents.

       Ashraf Nashed, M.D. appeals a judgment denying his
petition for writ of administrative mandamus to challenge the
decision of respondents Los Robles Regional Medical Center and
Los Robles Hospital Medical Staff, Inc. (collectively the Hospital)
to deny his request for category III cardiology privileges. We
conclude, among other things, that: 1) the admission of
unfavorable evidence at the administrative hearing did not deny
Nashed a fair administrative proceeding; 2) an administrative
hearing judge and an appeal board member were not biased

                                                    1
against Nashed; and 3) substantial evidence supports the
judgment. We affirm.
                               FACTS
       Nashed is an interventional cardiologist. He practiced
medicine at the Hospital with “staff and surgical privileges.” The
Hospital’s medical executive committee (MEC) makes
“recommendations regarding the Medical Staff[’s]” performance.
       The Hospital’s medical staff granted Nashed’s application
for reappointment to the medical staff and certain cardiology
privileges. But they denied his request for full “[c]ategory III
interventional cardiology privileges” because he “lacked the
professional ability and clinical judgment qualifications for
[those] privileges.”
       Nashed requested a hearing under the Hospital’s review
procedures, which include a hearing before an administrative
hearing judge, referred to as an “arbitrator,” and a review by an
appeal board.
       The arbitrator conducted a hearing where medical experts
testified in favor of and against Nashed. The arbitrator upheld
the recommendation to deny full category III privileges. Nashed
appealed to the board of trustees. His appeal was decided by a
three-member appeal board appointed by the trustees.
       The appeal board affirmed the arbitrator’s decision. In
2019, the board of trustees issued the final decision affirming the
arbitrator’s decision.
       Nashed filed a petition for writ of administrative
mandamus. (Code Civ. Proc., § 1094.5.) He claimed he was
denied a fair administrative proceeding; inadmissible evidence
was admitted; the arbitrator was biased; Doctor Paul David, a

                                2.
member of the appeal board, was biased; and there was no
substantial evidence to support the decision.
       The Hospital claimed the medical evidence in the record
showed problems with Nashed’s medical judgment. Nashed
treated an 84-year-old patient and anticipated performing an
angioplasty, but he had “difficulty with passing the balloon.”
Another cardiologist had to perform the procedure. Nashed
“failed to adequately plan” for the procedure, “was incapable of
completing [it],” and 3) “lacked appropriate clinical judgment.”
       The superior court independently reviewed the
administrative record. It found Nashed received a fair
administrative hearing. Nashed did not show that the arbitrator
and David were biased, and the evidence supported the decision
to deny the category III privileges.
                             DISCUSSION
                    A Fair Administrative Hearing
       Nashed contends he was denied a fair administrative
hearing. We disagree.
       “A hospital may not deprive a physician of staff privileges
without granting him minimal due process of law protection.”
(Rhee v. El Camino Hospital Dist. (1988) 201 Cal.App.3d 477,
488.) “This does not, however, compel adherence to formal
proceedings or to any single mode of process.” (Id. at p. 489.) “A
physician’s right to pursue his livelihood . . . must be balanced
against . . . the interest of members of the public in receiving
quality medical care . . . .” (Ibid.) When the issue is a fair
procedure, “the court will treat the issue as one of law, subject to
independent review based on the administrative record.” (Ellison
v. Sequoia Health Services (2010) 183 Cal.App.4th 1486, 1496.)

                                 3.
                          The Purmer Letter
      Nashed contends a letter by Doctor Purmer should have
been excluded at the administrative hearing. In that letter
Purmer evaluated Nashed’s deployment of a “stent.” He said,
“The stent was deployed at suboptimal pressure and this greatly
increases the risk for stent thrombosis.” Nashed claims this was
not Purmer’s actual letter and the arbitrator erred by not having
an expert examine it to make sure it was not a forged copy. We
disagree.
      Purmer authenticated the letter by testifying he wrote it.
The arbitrator examined it and found it was the original
document. The letter was properly admitted (Evid. Code, § 1413;
People v. Charles (2015) 61 Cal.4th 308, 322), and Nashed has not
shown prejudice because the arbitrator did not rely on it in
making his findings. (D.Z. v. Los Angeles Unified School Dist.
(2019) 35 Cal.App.5th 210, 231.)
                      The November 11th Letter
      Nashed contends the arbitrator improperly admitted a
November 11, 2014, letter where Nashed said he was
relinquishing his interventional cardiology privileges. He claims
it was admitted without proper authentication.
      But “ ‘strict rules of evidence’ ” do not apply in
administrative hearings. (Mohilef v. Janovici (1996) 51
Cal.App.4th 267, 291-292; Rhee v. El Camino Hospital Dist.,
supra, 201 Cal.App.3d at p. 489.) The letter was not signed. But
the arbitrator could consider the timing of the letter, its content,
and the surrounding circumstances to find Nashed wrote it.
(Evid. Code, §§ 1412, 1417, 1421.) Nashed has not shown
prejudice. We note the arbitrator did not mention or rely on it in
making his decision.

                                 4.
                    The Arbitrator’s Alleged Bias
       Nashed contends arbitrator John Harwell was biased
because he requested Harwell to be his counsel in these
proceedings, but Nashed ultimately “declined to retain him.”
Nashed argues Harwell “may have harbored ill will toward [him]
given that he declined Mr. Harwell’s services.”
       The trial court found Nashed knew the relevant facts before
the hearing, but he “only raised this concern after the Arbitrator
ruled against him.” Disqualification for bias “must be raised at
the earliest reasonable opportunity after the party becomes aware
of the disqualifying facts.” (North Beverly Park Homeowners
Assn. v. Bisno (2007) 147 Cal.App.4th 762, 769, italics added;
People v. Tappan (1968) 266 Cal.App.2d 812, 817.) Nashed
forfeited this issue because he knew the facts before the hearing,
but he only raised the bias issue after he received an unfavorable
decision. (Goodwin v. Comerica Bank, N.A. (2021) 72
Cal.App.5th 858, 867.)
       Bias is not “presume[d].” (Natarajan v. Dignity Health
(2021) 11 Cal.5th 1095, 1115; id. at p. 1113 [there must be
evidence showing “an intolerable risk of actual bias”]; El-Atttar v.
Hollywood Presbyterian Medical Center (2013) 56 Cal.4th 976,
995; Weinberg v. Cedars-Sinai Medical Center (2004) 119
Cal.App.4th 1098, 1115.) Bias is not shown because the
arbitrator ruled against Nashed on two evidentiary issues.
(Andrews v. Agricultural Labor Relations Board (1981) 28 Cal.3d
781, 795.) Nashed has not shown the arbitrator’s rulings or
hearing conduct showed bias. The “mere suggestion of bias” is
not sufficient “to overcome the presumption of integrity and
honesty” of the decision-maker. (BreakZone Billiards v. City of
Torrance (2000) 81 Cal.App.4th 1205, 1236.) Nashed only makes

                                 5.
the speculative claim that Harwell “may have harbored some ill
will” against him. (Italics added.) But he has not cited to
evidence.
       Moreover, Nashed had the opportunity to present evidence
of bias at the mandamus hearing (Code Civ. Proc., § 1094.5, subd.
(e); Pomona Valley Hospital Medical Center v. Superior Court
(1997) 55 Cal.App.4th 93, 101), but did not do so. Based on its
independent judgment, the trial court found no evidence of bias.
(Levingston v. Retirement Board (1995) 38 Cal.App.4th 996, 1000;
Val Strough Chevrolet Co. v. Bright (1969) 269 Cal.App.2d 855,
860.) Nashed has not shown the court erred.
                  Bias of An Appeal Board Member
       Nashed contends Doctor David, a member of the appeal
board, was biased. He “is informed that Dr. David may have a
financial interest due to his practice group’s exclusive contract to
staff the Emergency Department with physicians at Los Robles.”
(Italics added.) He argues he should have been given a chance to
“voir dire” him.
       But the trial court correctly found Nashed forfeited this
claim because: 1) Nashed only raised it “after the Appeal Board”
decision; 2) he knew the identity of the board members “14
months prior to” his first objection; and 3) he did not make a “voir
dire” request to the appeal board or conduct a timely
investigation.
       But even on the merits, the result does not change. Nashed
claims a letter by his attorney is evidence of David’s economic
bias. But the trial court correctly found it was not evidence. It
was a letter by Nashed’s counsel to another attorney requesting
information about David. Moreover, Nashed did not present
evidence of bias at the mandamus hearing (Code Civ. Proc.,

                                 6.
§ 1094.5, subd. (e); Pomona Valley Hospital Medical Center v.
Superior Court, supra, 55 Cal.App.4th at pp. 101-102), and that
undermines this claim. Merely speculating “that Dr. David may
have a financial interest” does not suffice. (El-Attar v. Hollywood
Presbyterian Medical Center, supra, 56 Cal.4th at pp. 995-997;
Weinberg v. Cedars-Sinai Medical Center, supra, 119 Cal.App.4th
at p. 1115.)
       Moreover, the trial court independently found no evidence
of bias. (Levingston v. Retirement Board, supra, 38 Cal.App.4th
at p. 1000; Val Strough Chevrolet Co. v. Bright, supra, 269
Cal.App.2d at p. 860.) Nashed has not shown error.
                        Substantial Evidence
       Nashed contends there is no substantial evidence to
support the decision to deny him the privileges. We disagree.
       A hospital may deny privileges to a doctor where he or she
“exhibited a pattern of substandard surgical techniques and poor
medical judgment.” (Gill v. Mercy Hospital (1998) 199
Cal.App.3d 889, 900.) They may be denied where the doctor did
not perform required tests, misunderstood medications, or made
improper medical assessments. (Bonner v. Sisters of Providence
Corp. (1987) 194 Cal.App.3d 437, 447.)
       In deciding substantial evidence, we do not “resolve
differences of medical judgment.” (Cipriotti v. Board of Directors
(1983) 147 Cal.App.3d 144, 154.) We determine whether the
decision is supported “in the light of the whole record,” and we
draw all reasonable inferences in support of the findings. (Ibid.)
       The arbitrator found Nashed was not eligible for category
III privileges because of: 1) “a historic problem with Dr. Nashed’s
clinical judgment and technical skills,” and 2) his “lack of

                                7.
understanding” of his responsibilities “to assure that patients are
prepared for interventional procedures.”
       Nashed challenges these findings by citing to his own
testimony. But the issue is not whether some evidence supports
appellant, it is whether substantial evidence supports the
judgment. The arbitrator did not find Nashed to be credible.
Nashed notes assessments by Doctor Mahmud and Doctor
Norcross were “laudatory.” But the arbitrator gave greater
weight to other doctors who testified against Nashed. We do not
resolve “differences of medical judgment.” (Cipriotti v. Board of
Directors, supra, 147 Cal.App.3d at p. 154.) Nashed claims a
quality care committee (QCC) determined that “no restriction on
his privileges was necessary.” But it found that Nashed had to
“be limited to diagnostic cardiology and forego interventional
(invasive) cardiology” until further review. Nashed claims an ad
hoc committee (AHC) decided not to terminate his current
privileges. But the issue is entitlement to higher privileges.
       Moreover, Nashed must show the trial court erred. The
court made its own independent findings from the record.
(Levingston v. Retirement Board, supra, 38 Cal.App.4th at
p. 1000.) It found Nashed did not have “the professional ability
and clinical judgment qualifications for those privileges” as
shown by the testimony and reports by “[Doctors] Dohad, Green,
and Papanicolaou.” Nashed has not shown error.
       Nashed attempted an angioplasty procedure for an 84-year-
old patient that he was unable to complete. Another doctor had
to finish the operation for him. The treatment of this patient
showed problems with Nashed’s medical abilities. Doctor
Papanicolaou said this incident showed “questionable judgment
calls” by Nashed. Nashed attempted “a quite challenging vessel

                                8.
on the second day with no clear advance in strategy.” Doctor
Reidy said “by having a physician caring for a patient that we
have concerns over to where we have to provide a backup . . .
every time he lays hands on that patient” is a problem. (Italics
added.) “We did not feel that was safe for the community and a
reasonable thing for the medical staff to be burdened with doing.”
(Italics added.)
       Doctor Suhail Dohad testified Nashed performed a renal
artery stent operation on a patient without documentation to
support it and without a medical necessity for it. Nashed did not
meet the standard of care. He performed an abdominal
aortography without a medical necessity for it. He had
unnecessarily exposed a patient to “multiple potential dramatic
complications.” He had created the risk for stent thrombosis.
Doctor Nathan Green said Nashed had “inadequate
documentation” of a “final angiographic result” and he performed
a “renal arteography” that “was medically unnecessary in a
patient with recent renal insufficiency.” The arbitrator found
Green’s testimony showed Nashed had “substandard technical
skills” that resulted in a “coronary dissection, unrecognized
perforation,” and it showed his “misinterpretation of clinical
results.” The trial court could reasonably make the same
findings. Dohad concluded that Nashed failed “to adequately
manage medications,” which was “the etiology of the cascade of
events” leading to a “patient’s demise.”
       The MEC reviewed Nashed’s performance and noted his
privileges were summarily suspended in 2008. Nashed had
inserted a stent in a “wrong vessel.” Dohad said Nashed had
“multiple opportunities” to prevent this mistake. Nashed had
performed an abdominal aortography without a patient’s consent.

                                9.
MEC said Nashed “did not provide competent interventional
cardiology care to elective and emergency patients consistently.”
(Italics added.)
                           DISPOSITION
       The judgment is affirmed. Costs on appeal are awarded in
favor of the respondents.
       NOT TO BE PUBLISHED.

                                     GILBERT, P. J.
We concur:

             YEGAN, J.

             PERREN, J.*

*Retired Associate Justice of the Court of Appeal, Second
Appellate District, assigned by the Chief Justice pursuant to
article VI, section 6 of the California Constitution.

                               10.
                   Ronda J. McKaig, Judge

               Superior Court County of Ventura
               ________________________________

     Fenton Law Group and Nicholas D. Jurkowitz for Plaintiff
and Appellant.
     Theodora Oringher, Todd C. Theodora, Anthony F.
Witteman and Adam G. Wentland for Defendants and
Respondents.

                             11.