Court Opinion

ID: 8484731
Source: CourtListenerOpinion
Date Created: 2022-11-17 21:02:03.636507+00
Date Added: 2024-06-11T16:49:56.464984
License: Public Domain

Filed 11/17/22 Medical Staff of St. Mary etc. v. St. Mary Medical Center CA2/7
   NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS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
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IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                         SECOND APPELLATE DISTRICT

                                      DIVISION SEVEN

MEDICAL STAFF OF ST. MARY                                           B316601
MEDICAL CENTER,
                                                                    (Los Angeles County
         Plaintiff and Appellant,                                   Super. Ct. No.
                                                                    20STCP01915)
         v.

ST. MARY MEDICAL CENTER,

         Defendant and Respondent.

      APPEAL from a judgment of the Superior Court of
Los Angeles County, Mitchell L. Beckloff. Affirmed.
      Theodora Oringher, Anthony F. Witteman, Adam G.
Wentland, and Michelle Monroe for Plaintiff and Appellant.
      Jamie Ostroff and Charlotte M. Tsui for California Medical
Association as Amicus Curiae on behalf of Plaintiff and
Appellant.
      Manatt, Phelps & Phillips, Barry S. Landsberg, Doreen W.
Shenfeld, Joanna S. McCallum, and Craig S. Rutenberg for
Respondent.
     ArentFox Schiff, Lowell C. Brown, Annie Chang Lee, and
Man Him Joshua Chiu for California Hospital Association as
Amicus Curiae on behalf of Defendant and Respondent.

                   ___________________________

                        INTRODUCTION

       “Hospitals in this state have a dual structure, consisting of
an administrative governing body, which oversees the operations
of the hospital, and a medical staff, which provides medical
services and is generally responsible for ensuring that its
members provide adequate medical care to patients at the
hospital.” (El-Attar v. Hollywood Presbyterian Medical
Center (2013) 56 Cal.4th 976, 983.) This appeal arises from a
dispute between these two structural elements of St. Mary
Medical Center (the Hospital) and the scope of each element’s
respective authority.
       After new leadership at the Hospital declined to make
changes to the peer review process and solicited proposals for
new exclusive contracts for several departments, the Hospital’s
medical staff (the Medical Staff) filed a petition for writ of
mandate to prevent the Hospital from allegedly violating the
independence and bylaws of the Medical Staff. The trial court
ruled the Medical Staff failed to exhaust its administrative
remedies for certain aspects of the dispute and failed to identify a
ministerial duty to support the relief sought.
       The Medical Staff does not effectively challenge the trial
court’s finding it failed to exhaust its administrative remedies,
which proves fatal to all but one of the Medical Staff’s arguments

                                 2
on appeal. Because the Medical Staff also failed to identify a
ministerial duty to support its remaining challenge to the trial
court’s ruling, we affirm.

      FACTUAL AND PROCEDURAL BACKGROUND

      A.     A Dual Management Structure Governs St. Mary
             Medical Center
       Dignity Health owns and operates the Hospital. The
Dignity Health Board is the governing board of the Hospital and
has final authority over, and responsibility for, the operations of
the Hospital. (See Cal. Code Regs., tit. 22, § 70035.) The Dignity
Health Board created a Hospital Community Board (HCB) with
“final authority to approve all hospital policies and procedures for
hospital services . . . where such approval is required of a
governing body by law, regulation or accrediting body.” The
HCB’s authority, however, is actually not so “final.” The Dignity
Health Board may exercise the HCB’s approval rights by giving
notice to the HCB, and “in such case, the referenced policies and
procedures shall be deemed approved by the [HCB].”1
       The bylaws of the HCB make the HCB responsible for
matters concerning the Medical Staff to the extent the Dignity
Health Board delegates such authority to the HCB. The HCB
bylaws provide the Medical Staff “shall develop and adopt
Medical Staff Bylaws and review its Medical Staff Bylaws

1     The Medical Staff argued in the trial court that the
Hospital’s “governing body” was the HCB. The trial court
disagreed and found the Dignity Health Board was the Hospital’s
governing body. The Medical Staff does not challenge that
finding.

                                 3
periodically. The Medical Staff shall submit its approved Medical
Staff Bylaws and any needed and approved revisions to the
[HCB] (or the body otherwise designated by the Dignity Health
Board for approval), which approval shall not be unreasonably
withheld . . . . The Dignity Health Board may, by notice to the
[HCB], elect to exercise the approval rights of the [HCB] under
this Section.”
       The medical staff of a hospital “is a separate legal entity
from the hospital” (Natarajan v. Dignity Health (2021) 11 Cal.5th
1095, 1114) and is “responsible for the adequacy and quality of
the medical care rendered to patients in the hospital”
(Mileikowsky v. West Hills Hosp. (2009) 45 Cal.4th 1259, 1267).
Business & Professions Code section 2282.5 (section 2282.5),
subdivision (a), provides the medical staff’s “right of self-
governance” includes establishing standards for medical staff
membership and privileges; establishing standards to oversee
and manage quality assurance; and initiating, developing, and
adopting medical staff bylaws, rules, regulations, and
amendments, “subject to the approval of the hospital governing
board, which approval shall not be unreasonably withheld.” (See
Cal. Code Regs., tit. 22, § 70703, subd. (b).) California law
further requires medical staff bylaws to “provide formal
procedures for the evaluation of staff applications and
credentials, appointments, reappointments, assignment of
clinical privileges, appeals mechanisms and such other subjects
or conditions which the medical staff and governing body deem
appropriate.” (Mileikowsky, at p. 1267; see Cal. Code Regs.,
tit. 22, §§ 70701, 70703.)
       The bylaws the Medical Staff adopted permit only members
of the Medical Staff (or practitioners granted a temporary

                                4
appointment) to provide medical services to patients at the
Hospital. In general, the Hospital enters into exclusive contracts
with physician groups for services that require around-the-clock
physician availability. The contracts are exclusive in the sense
that only physicians affiliated with the contracted group may
provide services to patients as members of the Medical Staff.
Section 4.8.4 of the Medical Staff’s bylaws provides that the
expiration or termination of an exclusive contract “will result in
the automatic termination of [an affiliated practitioner’s]
membership and privileges,” unless otherwise stated in the
contract. The bylaws give the Medical Staff authority to “review
and make recommendations to the [HCB] regarding quality of
care issues related to medical service arrangements for physician
and/or professional services, prior to any decision being made” to
execute, renew, modify, or terminate a medical service contract in
a particular department. The Medical Executive Committee,
which is comprised of members of the Medical Staff, represents
the Medical Staff in dealings with the HCB.
       Section 10.4 of the Medical Staff’s bylaws creates a dispute
resolution mechanism for “[a]ll disputes between the Governing
Board/Administration and the Medical Staff . . . relating to the
Medical Staff’s rights of self-governance as set forth in [section]
2282.5.” Under section 10.4 the parties must resolve disputes
through an ad hoc dispute resolution committee, and neither
party may initiate any legal action related to the dispute until
the committee completes its efforts to resolve the dispute.

                                5
      B.     The Hospital’s Chief Executive Officer Creates a
             Physician Advisory Council and Invites Proposals for
             New Contracts in the Anesthesiology, Radiology, and
             Emergency Departments
       Carolyn Caldwell became the chief executive officer of the
Hospital in June 2017. In December 2018 leaders of the Medical
Staff, including Chief of Staff Dr. Douglas McFarland and Vice
Chairperson Dr. Laura Russell, met with Caldwell to discuss
changes to the Hospital’s peer review process. According to Dr.
McFarland, Caldwell refused to make the requested changes, and
two weeks later, Caldwell created a new entity, the Physician
Advisory Council, to advise the Hospital on matters such as
“physician engagement, quality measures, performance
expectations, and strategic goals to address the growing health
care needs in the community.” Caldwell characterized the
Physician Advisory Council as “an administrative, not Medical
Staff, committee.” The Medical Staff asserted, however, that its
bylaws gave the Medical Executive Committee exclusive
authority to represent the Medical Staff on such matters and that
the Physician Advisory Council “was not an authorized
committee of the Medical Staff.”
       According to Caldwell, she is authorized on behalf of the
Hospital to approve exclusive contracts with groups of physicians.
Exclusive contracts in the anesthesiology, radiology, and
emergency departments were scheduled to expire in 2019 and
2020. Because the Hospital had not considered alternative
providers of anesthesiology services since 2011, Caldwell
informed the existing anesthesiology group and Dr. McFarland
that the Hospital would issue a request for proposal (RFP) and
consider proposals from the existing group and any other

                                6
anesthesiology practice. Ending the Hospital’s relationship with
the existing anesthesiology group would effectively terminate the
privileges of that group’s members, including Dr. Russell, under
the terms of section 4.8.4 of the Medical Staff bylaws.
       On February 5, 2019 Caldwell informed the Medical
Executive Committee of the RFP for anesthesiology services and
invited members of the Medical Executive Committee to attend a
presentation from five contenders for the contract. The same
day, Dr. McFarland sent a letter to the HCB on behalf of the
Medical Executive Committee asking for a dispute resolution
committee to address: (1) the administration’s refusal to discuss
the Hospital’s “sources of clinical services”; (2) the
administration’s retaliation against Medical Staff leaders’
“advocacy for improved patient protection and peer review
policies”; and (3) the administration’s interference with the
Medical Staff’s right to select its leadership by terminating
existing contracts. The Medical Executive Committee asked the
Hospital to renew the existing contracts until the parties could
resolve the dispute, and Dr. McFarland informed the HCB that
the Medical Executive Committee had voted to suspend
enforcement of section 4.8.4 of the Medical Staff bylaws. The
HCB denied the request for a dispute resolution committee
because, according to the HCB, the dispute concerned “group
physician contracts,” not the Medical Staff’s rights to self-
governance under section 2282.5. The HCB, however, invoked a
meet-and-confer process established by the organization that
accredited the Hospital.
       An interdisciplinary panel considered presentations from
five anesthesiology groups at a meeting attended by a Medical
Executive Committee officer. On February 21, 2019 the Medical

                                7
Executive Committee recommended to the HCB that the Hospital
continue the existing contracts with the anesthesiology,
radiology, and emergency services groups. Several days later the
Medical Executive Committee met with the HCB and
representatives from the administration to attempt to resolve the
dispute concerning the contracts.
      According to Caldwell, the Hospital considered the Medical
Executive Committee’s recommendation to maintain the existing
providers, but a consensus of the interdisciplinary panel decided
to award the anesthesiology contract to a new group that “could
meet the Hospital’s needs better than the existing group.”
Although the expiration of the previous group’s contract initially
ended Dr. Russell’s privileges at the Hospital, the new
anesthesiology group offered positions to all physicians affiliated
with the prior anesthesiology group, including Dr. Russell, and
she eventually rejoined the Hospital as an anesthesiologist with
the new group.
      The Hospital had not conducted an RFP for the radiology
services contract for over 65 years, and the existing contract was
scheduled to expire in October 2019. In July 2019 Caldwell
informed the Medical Staff that she intended to issue an RFP for
radiology, and in August 2019 a panel including a representative
from the Medical Executive Committee reviewed proposals from
three radiology groups. Caldwell asked the Medical Executive
Committee for its recommendation by the middle of August, but
because the Medical Executive Committee was “dark” in August
and could not vote on a recommendation, the Medical Executive
Committee referred Caldwell to its February 2019
recommendation to retain the existing provider. The panel
selected a new group, and all but one of the physicians affiliated

                                 8
with the previous contractor became affiliated with the new
contractor and retained their clinical privileges.
      The Hospital’s emergency services contract was scheduled
to expire in June 2020, and the Hospital had not conducted an
RFP proposal for that contract since 2009. In February 2020
Caldwell informed the head of the existing group that she
intended to initiate an RFP. In March 2020 three groups,
including the existing emergency services group, made
presentations to a panel that included members of the Medical
Executive Committee. Based on feedback from the panelists, the
Hospital awarded the emergency services contract to a new
group. Dr. McFarland, who had been affiliated with the former
emergency services provider, did not join the new group, but 21 of
the former provider’s 27 physicians did.

      C.    The Medical Staff Proposes Amendments to Its
            Bylaws
       In April 2019, after the Hospital awarded the
anesthesiology contract to a new group, the Medical Executive
Committee proposed 22 amendments to the Medical Staff bylaws.
Two of the amendments would have changed section 4.8.4 dealing
with exclusive contracts to allow practitioners whose group
contract expired or was terminated to apply for Hospital
privileges and to allow officers of the Medical Staff to serve in an
administrative capacity for up to one year if the contract for the
group to which they belonged expired or was terminated.
Caldwell concluded many of the proposed amendments were
“vague or unclear,” and the Hospital and the Medical Executive
Committee agreed to form a committee to resolve their
differences. According to Caldwell, counsel for the Hospital and

                                 9
the Medical Executive Committee met and conferred and
resolved disputes regarding 10 of the 22 amendments, but Dr.
McFarland nevertheless submitted all 22 of the original proposed
amendments to the Medical Staff, which apparently approved
them.
       On July 25, 2019 the Medical Staff submitted the
22 proposed amendments to the HCB for approval. As stated, the
Medical Staff bylaws provide that amendments submitted to the
HCB are “deemed approved” if the HCB does not act on them
within 60 days and that the HCB may not unreasonably withhold
its approval. Also on July 25, 2019 the Dignity Health Board
notified the Medical Executive Committee that it had rescinded
the authority of the HCB to approve the proposed amendments
and had appointed a subcommittee that included two HCB
members to consider them. On September 19, 2019 the Dignity
Health Board sent a letter to the Medical Executive Committee
stating the Board had approved five of the proposed
amendments, sent seven of them back for clarification or
additional information, and rejected 10 of them. The letter
explained why the Board did not approve the 10 rejected
proposals. According to the chief executive officer of Dignity
Health, each of the rejected amendments “in one way or another
compromised the authority and responsibility vested in the
Dignity Health Board as the governing body, licensee, owner and
operator of the Hospital.”
       In December 2019 the Medical Staff requested an ad hoc
dispute resolution committee pursuant to section 10.4 of the
Medical Staff bylaws to resolve issues involving 19 of the
proposed amendments. The committee met on June 16, 2020 and
agreed on a process to review each disputed amendment. At the

                              10
end of the meeting the committee agreed to reconvene shortly,
but that same day the Medical Staff filed this action in superior
court.

      D.     The Medical Staff Files a Petition for Writ of Mandate
             Seeking Mandamus, Injunctive, and Declaratory
             Relief
       The Medical Staff filed a petition for writ of mandate
against the Hospital seeking a writ of mandate under Code of
Civil Procedure section 1085, injunctive relief, and declaratory
relief. The Medical Staff alleged, among other things, the
Hospital “terminated” the emergency services contract “as a
vehicle for further eroding the ability of the physicians at [the
Hospital] to provide independent, patient-centered, quality
healthcare to their patients and further eliminating from Medical
Staff leadership positions physicians who advocate against the
Hospital on issues relating to patient care and Medical Staff self-
governance.” The Medical Staff claimed section 2282.5 gave it
authority for “‘front line’ oversight of the quality of health care
delivered in the Hospital.”
       Specifically, the Medical Staff alleged the Hospital failed to
give appropriate weight to the Medical Staff’s recommendations
on group contracts, improperly usurped the HCB’s authority to
approve amendments to the Medical Staff’s bylaws and blocked
reasonable changes to the bylaws, eroded the Medical Staff’s
authority by creating the Physician Advisory Council, and
violated the terms of a 2018 agreement between the Hospital and
the California Attorney General. According to the Medical Staff,
that agreement required the Hospital to maintain “privileges for
current medical staff at [the Hospital] who are in good standing

                                 11
as of the closing date” and to retain the “medical staff officers,
committee chairs, [and] independence of the medical staff . . . for
the remainder of their tenure at [the Hospital].” The Medical
Staff claimed the agreement also required the Dignity Health
Board to consult with the HCB “prior to making changes to
medical services . . . at least sixty days prior to the effective date
of such changes . . . .” The Medical Staff also alleged it had
exhausted its administrative remedies because further attempts
to meet and confer with the Hospital about these disputes were
futile.
        In its first cause of action for a writ of mandate, the
Medical Staff alleged the Hospital had a “clear ministerial duty
to comply with the [Medical Staff] Bylaws, which require [the
Hospital] to consult meaningfully with, and to obtain the
informed advice of, the [Medical Executive Committee], giving its
findings on quality of care ‘great weight’ in its decision to
terminate the existing [emergency room (ER)] Group and 40-year
old relationship, initiating an RFP process, and selecting a new
ER group.” The Medical Staff alleged the following actions were
violations of that ministerial duty: (1) “the Hospital’s announced
termination of the ER Group”; (2) “the initiation of the RFP
process, and selection of the new ER Group without meaningful
prior consultation with, and advice of, the [Medical Executive
Committee]”; (3) Caldwell’s “unilateral creation” of the Physician
Advisory Council; (4) the Hospital’s “unilateral elimination of the
[HCB’s] sole authority for approving Bylaw amendments”; and
(5) the Hospital’s “wholesale disregard” of the Medical Staff’s
bylaws, even though the Hospital had “agreed to be bound” by
them.

                                  12
       The Medical Staff asked the court to issue a writ of
mandate ordering the Hospital to (1) “Restore the [HCB’s] sole
role in approving Bylaw amendments”; (2) “Maintain the existing
make-up of the Medical Staff and its [Medical Executive
Committee]”; (3) Disband the Physician Advisory Council;
(4) “Solicit and obtain the meaningful consultation and advice of
the [Medical Executive Committee] before terminating any
additional exclusive contracts and give the [Medical Executive
Committee]’s review and recommendation great weight in
making such a decision”; (5) “Solicit and obtain the meaningful
review and recommendation of the [Medical Executive
Committee] before initiating any future RFP process”; and
(6) “Comply with all requirements of the Medical Staff Bylaws
pertaining to the Medical Staff’s rights and duties for oversight of
the quality of patient care at the Hospital and for the Medical
Staff’s self-governance.”
       In its second cause of action for injunctive relief, the
Medical Staff sought an injunction under sections 526 and 527 of
the Code of Civil Procedure to restrain conduct that allegedly
violated the Hospital’s ministerial duties. The Medical Staff
alleged it was likely to prevail on the merits because the Hospital
had a ministerial duty, as alleged in the first cause of action, and
the Hospital’s conduct as alleged violated that duty. The Medical
Staff also alleged it would suffer irreparable harm if the court did
not issue a preliminary injunction because the Hospital would
“continue to pursue its ‘campaign to neuter the Medical Staff by
undermining its independence through . . . the elimination of key
members.’” The Medical Staff sought a preliminary and
permanent injunction to restrain the Hospital from (1) “Violating
the terms of [the Medical Staff’s] Bylaws in their entirety and as

                                13
deemed approved”; (2) “Violating the terms of the Agreement
with the [Attorney General]”; (3) “Preventing the [HCB] from
carrying out its Bylaw amendment function”; (4) “Terminating
and/or entering into any contract for professional services
without first obtaining the review and recommendation of the
[Medical Executive Committee] and giving great weight to that
recommendation”; and (5) “Maintaining the current make-up of
the Medical Staff and its [Medical Executive Committee].”
       The Medical Staff’s third cause of action for declaratory
relief alleged there was an actual and present controversy
regarding whether the proposed amendments to the bylaws must
be “deemed approved” by the HCB pursuant to the Medical
Staff’s bylaws. The Medical Staff sought a judicial declaration
that (1) the HCB did not act on the proposed amendments to the
bylaws within 60 days; (2) the proposed amendments were
“deemed ‘approved’” by operation of the bylaws; and (3) even if
the 60-day period did not lapse, the HCB “was required to
consent to the Bylaw changes because withholding consent would
have been unreasonable.”
       The Hospital opposed the petition for writ of mandate and
argued the Medical Staff did not identify any ministerial duties
that would support a writ of mandate. The Hospital argued that
it did not have a ministerial duty to approve the proposed
amendments to the Medical Staff’s bylaws or to follow the
Medical Staff’s recommendations on exclusive contracts, that the
Medical Staff lacked standing to enforce the Hospital’s
obligations to the Attorney General, that the Medical Staff did
not submit any evidence the Physician Advisory Council
exercised the authority of the Medical Staff, and that the Medical
Staff failed to exhaust its administrative remedies. The Hospital

                                14
also argued the Medical Staff’s causes of action for injunctive and
declaratory relief were “untethered to a cognizable claim” and
lacked merit.
       The Medical Staff’s reply brief relied heavily on section
2282.5, subdivision (c), which states: “With respect to any
dispute arising under this section, the medical staff and the
hospital governing board shall meet and confer in good faith to
resolve the dispute. Whenever any person or entity has engaged
in or is about to engage in any acts or practices that hinder,
restrict, or otherwise obstruct the ability of the medical staff to
exercise its rights, obligations, or responsibilities under this
section, the superior court of any county, on application of the
medical staff, and after determining that reasonable efforts,
including reasonable administrative remedies provided in the
medical staff bylaws, rules, or regulations, have failed to resolve
the dispute, may issue an injunction, writ of mandate, or other
appropriate order.” The Medical Staff argued: “Whether labeled
an ‘injunction,’ ‘writ of mandate,’ or ‘declaratory relief,’ certainly
the Court has the power to issue some sort of edict to protect and
enforce the Medical Staff’s rights in section 2282.5.”
       In the context of section 2282.5, the Medical Staff identified
its rights to select and remove medical staff officers (§ 2282.5,
subd. (a)(3)) and to initiate, develop, and adopt medical staff
bylaws, rules, regulations, and amendments, subject to the
approval of the hospital governing board, approval of which the
hospital could not unreasonably withhold (id., subd. (a)(6)). The
Medical Staff argued the Hospital violated these and other rights
under section 2282.5 and suggested section 2282.5 authorized a
writ of mandate to remedy such violations even in the absence of
a ministerial duty.

                                 15
       The Medical Staff argued in the alternative the Hospital
had ministerial duties “not to withhold approval of the proposed
bylaw amendments” and to comply with the Medical Staff’s
bylaws. The Medical Staff argued its bylaws required the
Hospital, among other things, to acknowledge only the HCB had
authority to approve or reject proposed amendments to the
Medical Staff bylaws, approve the proposed amendments,
meaningfully consult with the Medical Staff about contracting
decisions, and disband the Physician Advisory Council. The
Medical Staff reiterated its assertion the Hospital violated the
terms of an agreement with the Attorney General and argued it
was “at least a third party beneficiary” of that agreement.
       Finally, the Medical Staff argued it made reasonable efforts
under section 2282.5 to resolve its disputes with the Hospital,
including by engaging in “extensive meet and confer efforts” and
attempting to invoke the ad hoc dispute resolution committee.
The Medical Staff contended the Dignity Health Board “dragged
out the [dispute resolution process] until June 2020—long enough
to accomplish its goal of unilaterally terminating the
Anesthesiology, Radiology, Emergency Services, and other
longstanding hospital groups.” The Medical Staff also argued
that it exhausted its administrative remedies under the bylaws
and that additional meet-and-confer efforts would have been
futile. The Medical Staff based its request for injunctive and
declaratory relief on section 2282.5.

                                16
      E.     The Trial Court Denies the Medical Staff’s Petition for
             Writ of Mandate and Related Requests for Injunctive
             and Declaratory Relief
       The trial court denied the Medical Staff’s petition for writ
of mandate and related requests for injunctive and declaratory
relief. The court, after observing the Medical Staff had identified
section 2282.5 as “authority for a writ of mandate” for the first
time in its reply brief, went on to address the merits of the
Medical Staff’s assertion section 2282.5 supplanted the
requirements for a writ of mandate under Code of Civil Procedure
section 1085. The court stated that the Medical Staff had not
cited any authority for the proposition Code of Civil Procedure
section 1085 did not apply to the Medical Staff’s “self-governance
claim” and that the Medical Staff’s “reliance on alleged violations
of [section 2282.5] without regard to the requirements of [Code of
Civil Procedure section 1085] does not entitle it to writ relief.”
Thus, the court concluded, the Medical Staff had to show a “clear
and present duty” that is “‘unqualifiedly required.’”
       The court found, however, the Medical Staff had not shown
there was any such duty. The court first ruled the Hospital did
not have a ministerial duty to approve or comply with the
proposed amendments to the Medical Staff bylaws. The court
concluded that the relevant provisions of the bylaws of the
Medical Staff, the HCB, and the Hospital gave the Hospital
discretion to accept or reject the proposed amendments and that
the Medical Staff did not allege the Hospital acted arbitrarily or
capriciously in exercising that discretion. The court also ruled
the Medical Staff’s failure to show the Hospital had a ministerial
duty to approve or comply with the proposed amendments
precluded the Medical Staff’s request for an order requiring the

                                17
Hospital to maintain the composition of the Medical Staff before
the Hospital entered into exclusive contracts with new provider
groups.
       The court also denied mandamus relief based on the
proposed amendments to the Medical Staff’s bylaws because the
court found the Medical Staff failed to exhaust its administrative
remedies to resolve the dispute over the bylaws. The court stated
the Medical Staff “commenced the internal administrative
remedy but provide[d] no evidence it completed the [ad hoc
dispute resolution committee] process as to [the Medical Staff’s]
proposed Bylaw amendments.”
       Regarding the Medical Staff’s request for an order
requiring the Hospital to disband the Physician Advisory Council,
the trial court stated the Medical Staff identified no legal
authority supporting such relief, “pursuant to a non-discretionary
ministerial duty or otherwise.” The court also found the Medical
Staff failed to show the Hospital gave the Physician Advisory
Council authority to represent the Medical Staff, which the
Medical Staff claimed would violate its bylaws.
       Regarding the Medical Staff’s request for an order directing
the Hospital to “obtain the meaningful consultation and advice”
from the Medical Staff in connection with the RFP process and in
selecting providers, the court stated the Medical Staff had
expanded its claim by arguing in its brief in support of the
petition the Hospital “ignore[d],” as opposed to merely failed to
consider, the Medical Staff’s unanimous recommendations. The
court found the Hospital did not have a ministerial duty “to
accept (as opposed to consider)” the Medical Staff’s
recommendations. The court also found the Medical Staff’s
bylaws gave the Medical Staff a right to review and make

                                18
recommendations about “medical service arrangements,” but not
the RFP process.
      The court denied the Medical Staff’s request for relief based
on the Hospital’s agreement with the Attorney General because
the claim arose from an alleged breach of contract, which does
not support relief in mandamus. The court also found it was
unlikely the Medical Staff was a third party beneficiary of that
agreement because “it does not appear [the Hospital] or the
Attorney General intended to benefit [the Medical Staff] as
opposed to the public generally.” The court transferred the
Medical Staff’s remaining claim not based on Code of Civil
Procedure section 1085, which requested a declaration “‘the
[HCB] was required to consent to the Bylaw changes because
withholding consent would have been unreasonable,’” to the
supervising judge of the civil department for assignment to an
individual calendar courtroom.
      The Medical Staff dismissed its remaining cause of action
for declaratory relief without prejudice, and the trial court
entered judgment for the Hospital. The Medical Staff timely
appealed.

                         DISCUSSION

      The Medical Staff states it never contended section 2282.5
supplanted Code of Civil Procedure section 1085’s requirements
for a writ of mandate. Therefore, we assume the Medical Staff
agrees with the trial court’s conclusion (and governing law) that
to obtain a writ of mandate the Medical Staff had to comply with
the requirements of Code of Civil Procedure section 1085,
including that it had no adequate alternative remedy and that

                                19
the Hospital had a clear and present ministerial duty. The
Medical Staff failed to satisfy these requirements.2

         A.    Applicable Law and Standard of Review
         Traditional mandamus is available “to enforce a
nondiscretionary duty to act on the part of a court, an
administrative agency, or officers of a corporate or administrative
agency.” (Unnamed Physician v. Board of Trustees of Saint
Agnes Medical Center (2001) 93 Cal.App.4th 607, 618; see Code
Civ. Proc., § 1085, subd. (a) [a writ of mandate may compel
“a corporation, board, or person” to perform “an act which the law
specially enjoins”]; Pacifica Firefighters Assn. v. City of
Pacifica (2022) 76 Cal.App.5th 758, 765 [mandamus may be
“‘sought to enforce a nondiscretionary duty to act on the part of
. . . officers of a corporate or administrative agency’”].) “To obtain
relief, a petitioner must demonstrate (1) no ‘plain, speedy, and
adequate’ alternative remedy exists [citation]; (2) ‘a clear,
present, . . . ministerial duty on the part of the respondent’; and
(3) a correlative ‘clear, present, and beneficial right in the
petitioner to the performance of that duty.’” (People v.
Picklesimer (2010) 48 Cal.4th 330, 340; accord, Rutgard v. City of
Los Angeles (2020) 52 Cal.App.5th 815, 824.)
         A petitioner seeking traditional mandamus “‘“must first
invoke and exhaust the remedies provided by that organization
applicable to his grievance.”’” (Eight Unnamed Physicians v.

2      The Medical Staff also argues the trial court erred in
relying on the Medical Staff’s failure to make this argument in its
petition or its opening brief in the trial court. As discussed,
however, the trial court rejected the Medical Staff’s argument
under section 2282.5 on the merits.

                                 20
Medical Executive Com. (2007) 150 Cal.App.4th 503, 511; see
Unnamed Physician v. Board of Trustees of Saint Agnes Medical
Center, supra, 93 Cal.App.4th at pp. 619-620.) The exhaustion
requirement “‘speaks to whether there exists an adequate legal
remedy. If an administrative remedy is available and has not yet
been exhausted, an adequate remedy exists and the petitioner is
not entitled to extraordinary relief.’” (Eight Unnamed
Physicians, at p. 511; see City of Oakland v. Oakland Police &
Fire Retirement System (2014) 224 Cal.App.4th 210, 235;
Unnamed Physician, p. 620.) “‘[A]n administrative remedy is
exhausted only upon “termination of all available, nonduplicative
administrative review procedures.”’” (Trejo v. County of Los
Angeles (2020) 50 Cal.App.5th 129, 148; see City of Oakland, at
p. 235.)
       A ministerial act is an act that must be performed “‘“in a
prescribed manner in obedience to the mandate of legal authority
and without regard to [one’s] own judgment or opinion concerning
such act’s propriety or impropriety, when a given state of facts
exists.”’” (CV Amalgamated LLC v. City of Chula Vista (2022)
82 Cal.App.5th 265, 279; see Lockyer v. City and County of San
Francisco (2004) 33 Cal.4th 1055, 1082.) “Mandate will not issue
to compel action unless it is shown the duty to do the thing asked
for is plain and unmixed with discretionary power or the exercise
of judgment.” (Unnamed Physician v. Board of Trustees of Saint
Agnes Medical Center, supra, 93 Cal.App.4th at p. 618.)
       “When an appellate court reviews a trial court’s judgment
on a petition for a traditional writ of mandate, it applies the
substantial evidence test to the trial court’s findings of fact and
independently reviews the trial court’s conclusions on questions
of law.” (California Public Records Research, Inc. v. County of

                                21
Stanislaus (2016) 246 Cal.App.4th 1432, 1443; accord,
CV Amalgamated LLC v. City of Chula Vista, supra,
82 Cal.App.5th at p. 280; Trejo v. County of Los Angeles, supra,
50 Cal.App.5th at p. 140.) “Whether there is a ‘“plain, speedy and
adequate remedy, in the ordinary course of law”’ . . . usually is
regarded as a question of fact that requires an evaluation of the
circumstances of each particular case.” (Villery v. Department of
Corrections & Rehabilitation (2016) 246 Cal.App.4th 407, 414.)
We review de novo whether the respondent had a ministerial
duty capable of direct enforcement because that determination
requires interpretation of the legal authority for the duty. (See
CV Amalgamated LLC, at p. 280; Smith v. Adventist Health
System/West (2010) 182 Cal.App.4th 729, 754-755.)

      B.    The Medical Staff Had an Alternative Remedy for the
            Dispute over the Contested Bylaw Amendments

            1.      The Medical Staff Does Not Challenge the Trial
                    Court’s Finding the Medical Staff Failed To
                    Exhaust Its Administrative Remedies
       As stated, the trial court found the Medical Staff did not
exhaust its administrative remedies regarding the dispute over
the proposed amendments to the Medical Staff bylaws. The trial
court also found the dispute resolution process established by
section 10.4 of the Medical Staff bylaws “provided [the Medical
Staff] with a plain, speedy and adequate remedy as to [the
Hospital’s] rejection of [the Medical Staff’s] proposed bylaws.” In
its opening brief, the Medical Staff does not argue substantial
evidence did not support those findings. The Hospital
appropriately contends the trial court’s findings are “binding”

                                22
and provide a basis to affirm the trial court’s rulings on the
proposed amendments.
       In its reply brief, the Medical Staff asserts it argued in the
trial court and in its opening brief on appeal it took “reasonable
efforts to avail itself of the administrative remedies offered in the
[Medical Staff] Bylaws and why those efforts were futile.” What
the Medical Staff argued in the trial court is not relevant to the
arguments the Medical Staff makes on appeal (except to show the
argument is preserved), and nowhere in its opening brief did the
Medical Staff argue substantial evidence did not support the trial
court’s finding the Medical Staff failed to exhaust its
administrative remedies regarding the proposed amendments.
       In the statement of facts section of its opening brief,3 the
Medical Staff asserts Dr. McFarland wrote to the HCB
“requesting that the present dispute be resolved by resorting to
the dispute resolution process contained in the Medical Staff’s
Bylaws.” The letter the Medical Staff cites, however, concerned
the dispute over the clinical services contracts, not the proposed
bylaw amendments. The Medical Staff did not address in its
opening brief or in its reply brief the facts underlying the trial
court’s finding the Medical Staff failed to exhaust its
administrative remedies regarding the dispute over the proposed
bylaw amendments. In particular, the trial court cited a
declaration from a member of the HCB, who was also a member
of the dispute resolution committee convened to address the
bylaw amendment dispute, who said the committee’s work had

3      The Medical Staff’s reply brief cites page 161 of its opening
brief. There is no such page. We assume the Medical Staff
intended to cite page 16.

                                 23
just begun on the day the Medical Staff filed its petition for writ
of mandate.4
        To the extent the Medical Staff does not challenge the trial
court’s findings that the Medical Staff did not exhaust its
administrative remedies and that the Medical Staff’s bylaws
provided a plain, speedy, and adequate alternative remedy, the
Medical Staff has failed to demonstrate the trial court erred in
denying the petition for writ of mandate based on the proposed
amendments to the bylaws. (See City of Glendale v. Marcus
Cable Associates, LLC (2014) 231 Cal.App.4th 1359, 1388-1389
[appellant conceded the trial court’s factual findings by failing to
challenge them on appeal].) To the extent the Medical Staff
challenged those findings on appeal for the first time in its reply
brief, the Medical Staff has forfeited the argument. (See Chicago
Title Ins. Co. v. AMZ Ins. Services, Inc. (2010) 188 Cal.App.4th
401, 427-428 [appellant who challenged factual findings for the
first time in its reply brief forfeited the argument substantial
evidence did not support the findings].) And even if the Medical
Staff did not forfeit the argument by failing to raise it in its
opening brief on appeal, the Medical Staff failed to “set forth,

4      Thus, the Medical Staff also failed to comply with the
dispute resolution procedure of its bylaws, which is a prerequisite
to relief under section 2282.5. As stated, that statute authorizes
a trial court to issue an injunction, writ of mandate, or other
appropriate order only “after determining that reasonable efforts,
including reasonable administrative remedies provided in the
medical staff bylaws, rules, or regulations, have failed to resolve
the dispute.” (§ 2282.5, subd. (c).) As discussed, section 10.4 of
the Medical Staff bylaws precludes a party from initiating any
legal action until a dispute resolution committee convened to
resolve the dispute “has completed its efforts to resolve the
dispute.”

                                 24
discuss, and analyze all the evidence on that point, both favorable
and unfavorable” (Doe v. Roman Catholic Archbishop of Cashel &
Emly (2009) 177 Cal.App.4th 209, 218) or “explain why the
evidence cited by the trial court does not support its findings”
(Shenouda v. Veterinary Medical Bd. (2018) 27 Cal.App.5th 500,
515), thus again forfeiting the argument. (See Sanchez v.
Martinez (2020) 54 Cal.App.5th 535, 548 [“An appellant ‘who
cites and discusses only evidence in [his] favor fails to
demonstrate any error and waives the contention that the
evidence is insufficient to support the judgment.’”]; Delta
Stewardship Council Cases (2020) 48 Cal.App.5th 1014, 1075
[“When an appellant fails to raise a point, or asserts it but fails to
support it with reasoned argument and citations to authority, we
treat the point as forfeited.”].)5

            2.    Most of the Medical Staff’s Claims and
                  Arguments on Appeal Arise from the Contested
                  Amendments
      The Medical Staff’s claims that the Hospital violated
section 2282.5 by “divesting the HCB of its sole authority to

5      At oral argument counsel for the Medical Staff asserted the
ad hoc dispute resolution committee procedure set forth in the
Medical Staff bylaws was not an adequate remedy because the
committee’s decisions are nonbinding. (See Unnamed Physician
v. Board of Trustees of Saint Agnes Medical Center, supra,
93 Cal.App.4th at p. 620 [exhaustion doctrine “‘is inapplicable
where “the administrative remedy is inadequate [citation]; where
it is unavailable [citation]; or where it would be futile to pursue
such remedy”’”].) The Medical Staff forfeited this argument by
not making it in its opening brief (or even in its reply brief). (See
Dameron Hospital Assn. v. AAA Northern California, Nevada &
Utah Ins. Exchange (2022) 77 Cal.App.5th 971, 982.)

                                 25
approve proposed bylaw amendments,” that the proposed bylaw
amendments were “deemed approved,” and that the Hospital
unreasonably withheld its approval of the amendments, all stem
from the Medical Staff’s dispute over the proposed amendments
to its bylaws. Because the Medical Staff did not exhaust its
administrative remedies regarding the bylaw amendments, the
Medical Staff had an adequate legal remedy and was not entitled
to mandamus relief on these claims. (See Eight Unnamed
Physicians v. Medical Executive Com., supra, 150 Cal.App.4th at
p. 511.)
       Three of the Medical Staff’s four remaining arguments on
appeal also arise from or relate to the dispute over the bylaw
amendments and similarly fail for failure to exhaust
administrative remedies. First, the Medical Staff claims the
Hospital violated section 2282.5 by improperly terminating the
clinical services contracts, which caused the removal of Medical
Staff officers. The Medical Staff’s argument on appeal (as it was
in the trial court) is not that the Hospital did not have authority
to allow the existing contracts to expire or to contract with other
groups, but that the Hospital refused “to allow the Bylaw
amendment that would have resolved the dispute” by protecting
the staff privileges of existing officers.6 That’s a claim based on
the proposed bylaw amendments.

6     To the extent the Medical Staff contends the termination of
group contracts violated the Hospital’s agreement with the
Attorney General, the Medical Staff has not shown such a claim
is redressable through mandamus. The Medical Staff does not
address this aspect of the trial court’s ruling and argues only
(and unconvincingly) it is a third party beneficiary of that
agreement. (See Jameson v. Desta (2018) 5 Cal.5th 594, 609 [“the
burden is on an appellant to demonstrate . . . that the trial court

                                26
       Second, the Medical Staff argues the trial court erred in
ruling the Hospital did not have a ministerial duty to accept the
Medical Staff’s recommendations on clinical services contracts.
In the trial court the Medical Staff claimed its bylaws required
the Hospital to solicit and obtain (and accept) the Medical Staff’s
recommendations on exclusive service contracts and RFPs. On
appeal, however, the Medical Staff argues the trial court’s ruling
in this regard “ignored the ministerial duties imposed by [section]
2282.5, one of which required [the Hospital] not to unreasonably
withhold its consent to the Medical Staff’s Bylaw amendments.”
That, too, is an issue about the contested bylaw amendments.
The Medical Staff otherwise assigns no error to the trial court’s
ruling regarding the Hospital’s duty to solicit and obtain the
recommendation of the Medical Staff on exclusive contracts and
RFPs.
       Finally, the Medical Staff argues the trial court erred in
rejecting its contention the Hospital breached the terms of the
Medical Staff bylaws, which the Medical Staff asserts create a
binding contract. In the trial court, the Medical Staff made this
argument in connection with its claim the Hospital violated the
Medical Staff’s bylaws by removing the HCB’s authority to
approve the proposed amendments. Again, that’s a claim about
the proposed bylaw amendments.
       Because these three arguments arise from or relate to the
dispute over the proposed amendments to the Medical Staff’s
bylaws, and the Medical Staff failed to exhaust its administrative
remedies to resolve that dispute, the Medical Staff did not satisfy
the requirements of Code of Civil Procedure section 1085 for

committed an error that justifies reversal”]; Kinsella v.
Kinsella (2020) 45 Cal.App.5th 442, 464 [same].)

                                 27
obtaining mandamus relief. (See City of Oakland v. Oakland
Police & Fire Retirement System, supra, 224 Cal.App.4th at
p. 235; Eight Unnamed Physicians v. Medical Executive Com.,
supra, 150 Cal.App.4th at p. 511; Unnamed Physician v. Board of
Trustees of Saint Agnes Medical Center, supra, 93 Cal.App.4th at
p. 620.) Therefore, the trial court did not err in denying the
Medical Staff’s petition for a writ of mandate for claims based on
the proposed bylaw amendments.7

      C.     The Medical Staff Bylaws Do Not Create a Ministerial
             Duty Prohibiting the Hospital from Establishing the
             Physician Advisory Council
       That leaves the Medical Staff’s fourth remaining argument,
which is that the Medical Staff bylaws, in particular section
10.1.1, gave it the “legal authority” to disband the Physician
Advisory Council and that the trial court erred in requiring the
Medical Staff to show “a complete overlap” between the Medical
Staff’s authority and the authority of the Physician Advisory
Council. But because the Medical Staff cited only sections 10.3.1
and 10.3.2 in the trial court, it forfeited any argument under
section 10.1.1. (See Meridian Financial Services, Inc. v.
Phan (2021) 67 Cal.App.5th 657, 697, fn. 12.)

7      At oral argument counsel for the Medical Staff conceded
that all but two of the Medical Staff’s claims were related to the
contested bylaws. One of those claims is the one concerning the
Hospital’s acceptance of Medical Staff recommendations on
clinical services contracts. As discussed, however, that claim is
related to the contested bylaws, which counsel for the Medical
Staff subsequently acknowledged at oral argument. The other
claim is the one concerning the Physician Advisory Council,
which we address next.

                                28
       In any event, section 10.1.1 does not create a ministerial
duty on the part of the Hospital to disband the Physician
Advisory Council. Section 10.1.1 states: “The Medical Executive
Committee . . . shall be the standing committee of the Medical
Staff. Unless otherwise specified, the Chairperson and members
of all committees shall be appointed by the Chief of Staff and may
be removed by the Chief of Staff subject to consultation with and
approval by the Medical Executive Committee. These
committees are advisory to the Medical Executive Committee and
shall make their recommendations to the Medical Executive
Committee. They shall have only the power specifically granted
to them by the Medical Executive Committee and shall be
responsible to the Medical Executive Committee.” This provision
arguably makes the Medical Executive Committee the only entity
that can represent the Medical Staff at large, but it does not say
the Medical Executive Committee is the only entity that may give
the Hospital feedback on matters concerning the Medical Staff.
Therefore, section 10.1.1 does not establish a ministerial duty
preventing the Hospital from creating a committee like the
Physician Advisory Council. To the extent the Physician
Advisory Council initiated changes to the Medical Staff’s “rules
and policies,” section 13.1.6 of the Medical Staff’s bylaws
arguably precludes such changes.8 But the Medical Staff did not
present evidence documenting any work the Physician Advisory
Council actually did, nor did the Medical Staff cite section 13.1.6
as the source of a ministerial duty. The Medical Staff has not
shown the trial court committed any error in analyzing the

8    Section 13.1.6 states: “The mechanisms described [in the
bylaws] shall be the sole methods for the initiation, adoption,
amendment, or repeal of the Medical Staff rules and policies.”

                                29
comparative authorities of the Medical Staff and the Physician
Advisory Council.

                        DISPOSITION

      The judgment is affirmed. The Hospital is to recover its
costs on appeal.

                                         SEGAL, J.

     We concur:

           PERLUSS, P. J.

           FEUER, J.

                               30