Lee v. Trinity Lutheran Hosp.

Citation408 F.3d 1064
Decision Date20 July 2005
Docket NumberNo. 04-1553.,04-1553.
PartiesSharon D. LEE, M.D., Kansas City Family Health Care, Inc., Appellants, v. TRINITY LUTHERAN HOSPITAL, Health Midwest, Appellees.
CourtUnited States Courts of Appeals. United States Court of Appeals (8th Circuit)

M. Corinne Corley, Kansas City, MO, for appellant.

George E. Leonard, Kansas City, MO, for appellee.

Before MURPHY, McMILLIAN and BYE, Circuit Judges.

MCMILLIAN, Circuit Judge.

Dr. Sharon D. Lee appeals from a final judgment entered in the District Court for the Western District of Missouri1 granting summary judgment in favor of Trinity Lutheran Hospital and its sole shareholder, Health Midwest (collectively the hospital), on her federal and state claims. For reversal, Dr. Lee argues that the district court erred in holding that the hospital was immune from her suit for money damages under the Health Care Quality Improvement Act of 1986, 42 U.S.C. §§ 11101-52 (HCQIA).2 We affirm.

BACKGROUND

On May 27, 1994, Dr. Lee, a family practice physician on the hospital's staff, prescribed two drugs to treat an HIV patient for pneumocystis carinii pneumonia (PCP). A nurse was concerned about the combination of the two drugs and contacted Dr. James Wooten, the supervisor of the hospital's pharmacy services. Dr. Wooten researched the matter, but could find no information regarding usage of the drugs in combination. He contacted the manufacturers of the drugs for more information. By letters dated June 1 and June 2 of 1994, the drug manufacturers wrote to Dr. Wooten; neither manufacturer could recommend using the drugs in combination. In the meantime, Dr. Wooten talked to Dr. Lee, expressing his concern about the safety of using the two drugs in combination, noting that if she proceeded to use the drugs in combination she might expose the hospital to liability. Dr. Lee responded that she would use the drugs in combination, even if it meant discharging the patient from the hospital. Pursuant to hospital protocol, Dr. Wooten contacted the hospital's Pharmacy and Therapeutic Committee. Dr. Beth Henry, a member of the committee, agreed that using the two drugs in combination was inappropriate and advised peer review of the matter.

On June 1, 1994, the Peer Review on Medicine Committee (Peer Review Committee) met to discuss Dr. Lee's use of the drugs. Dr. Mollie O'Connor, chief of the hospital's infectious diseases department, presented the matter, noting that the patient's chart did not contain adequate documentation concerning the PCP diagnosis and that the two drugs were not compatible and had highly toxic effects on a patient's bone marrow. The Peer Review Committee voted unanimously to suspend use of the drugs and to have Dr. Joan Akers, chair of the hospital's family practice section, talk to Dr. Lee. On June 2, Dr. Akers and several others physicians talked to Dr. Lee. The Peer Review Committee met again on July 6, 1994, and recommended that a sub-committee talk to Dr. Lee and review her patient records prospectively. The subcommittee, composed of Drs. Akers, Daniels and Sly, met with Dr. Lee to discuss her interactions with physicians, practice patterns and appropriate use of medications. Dr. Akers met again with Dr. Lee to set up a protocol for pharmacy review. On October 5, 1994, the Peer Review Committee noted that the subcommittee had reported that Dr. Lee had a consistent problem with drug usage, including "unapproved uses of approved drugs or toxic combinations in HIV patients," and approved prospective review of her charts and pharmacy review for six months.

In December 1994, Dr. Kathy Chase, director of the pharmacy, expressed concern to Dr. Akers about Dr. Lee's care of another patient. Dr. Akers then asked an infectious disease specialist and an oncologist to review the patient's chart. Both doctors believed that Dr. Lee had not conducted an adequate work-up. On December 7, 1994, the Peer Review Committee met and Dr. Akers discussed the subcommittee's chart review, noting the review had indicated that Dr. Lee had used drugs without adequate indications, had made probable diagnoses without corroborating studies, and inadequately documented her thought processes. To avoid a conflict of interest, the Peer Review Committee recommended that an outside specialist review Dr. Lee's charts.

At a January 4, 1995, Peer Review Committee meeting, Dr. Lee read a letter expressing her concerns with the peer review process, including that she had not been invited to attend the meetings and that the committee had breached confidentiality. On March 1, 1995, the Peer Review Committee met to discuss the chart of another of Dr. Lee's patients and asked her to supply additional documentation pertaining to a diagnosis. On April 5, 1995, the Peer Review Committee met to review the charts of two more of Dr. Lee's patients. As to one of the patients, the committee noted a possible premature death, rated the chart a 4, which meant the "clinical practice was unexpected and unacceptable," and sent Dr. Lee a letter of inquiry about the patient. As to the chart of the other patient, the committee noted that Dr. Lee had already been asked to supply documentation pertaining to diagnosis and completion of the patient's history and physical, but had not done so. On May 3 and June 7, 1995, the Peer Review Committee again discussed the charts, noting that Dr. Lee's responses to the letters of inquiry did not address the concerns in the letters.

Pursuant to the Peer Review Committee's recommendation, in June 1995, Dr. Akers asked Dr. Glen Hodges, a physician at the Veteran Administration Medical Center in Kansas City, Missouri, and chairman of the medical center's AIDS task force, to review the charts of five of Dr. Lee's patients. Dr. Hodges, who had eight years experience at the medical center reviewing charts for documentation and medical care purposes, concluded that in four of five of the cases Dr. Lee had not met the standard of care. Dr. Hodges found numerous documentation deficiencies and other problems in the cases. Dr. Hodges also questioned the standard of care in the fifth case. At a July 26, 1995, Peer Review Committee meeting, Dr. Akers presented Dr. Hodges's report. After the presentation, Dr. Lee joined the meeting and submitted a letter in which she rebutted Dr. Hodges's report. She also expressed her belief that she was the subject of a "witch hunt." Dr. Lee was excused from the meeting, and the committee voted nine to two to suspend her clinical privileges pending her completion of a personalized education program for physicians, which included a psychiatric evaluation. By letter dated July 26, 1995, Dr. Akers advised Dr. Lee of the committee's decision to suspend her privileges and that the action was being taken because of her sub-standard treatment of the four patients whose charts Dr. Hodges had reviewed and her sub-standard treatment of three other patients, noting that the sub-standard care had placed the patients in potential imminent danger.

At an August 2 meeting, the Peer Review Committee reviewed two more of Dr. Lee's charts, rating them a 4. On August 3, 1995, the Executive Committee of the Medical Staff (Executive Committee) met with Dr. Lee to discuss the decision of the Peer Review Committee to suspend her privileges. Dr. Lee stated that she had provided her patients with the highest standard of care, but admitted that recordkeeping was a problem. She asked that an ad hoc committee be appointed to review the charts that resulted in her suspension. Dr. Lee was excused from the meeting and after discussion of her comments, the committee voted to uphold the suspension pending review by an ad hoc committee's evaluation of the seven cases cited in Dr. Akers's letter. However, the Executive Committee rejected the Peer Review Committee's requirement that Dr. Lee attend the physician education program.

By letter dated August 22, 1995, Dr. O'Connor wrote to Dr. Scott Thompson, who was chairman of the Ad Hoc Committee, regarding Dr. Hodges's report. Dr. O'Connor noted agreement with many of the report's concerns, including lack of documentation supporting drug usage, but also noted her disagreement with several specific items. By letter dated August 28, 1995, Dr. Thompson invited Dr. Lee to a September 14 meeting of the committee to discuss patient care issues, which were set forth on an enclosed document entitled "Clinical Issues." The document listed nine categories of issues, including inappropriate use of medications, failure to follow established protocols for drug use, treatment based on presumptive diagnosis, inadequate or poor documentation, failure to address abnormal patient care data, and failure to obtain appropriate consults. Under each category were sub-categories with specific citations to the care of seventeen of Dr. Lee's patients. Dr. Lee attended the September 14 meeting and discussed the clinical issues, but the specifics of each patient were not discussed. On September 27, the Ad Hoc Committee sent a report to the Executive Committee recommending that Dr. Lee's staff privileges be revoked, noting that she did not meet the hospital's standard of care. The report further noted that there was "no evidence of change in clinical practice from the first documented problem from a case in June 1994 as to the two most recent cases admitted in July 1995, despite numerous interventions."

On October 3, 1995, the Executive Committee unanimously adopted the Ad Hoc Committee's recommendation. By letter dated October 4, 1995, Ronald Ommen, chief executive officer and president of the hospital, notified Dr. Lee of the Executive Committee's decision to revoke her privileges. Ommen stated that the decision was based on the previously identified clinical issues and enclosed the document setting forth the issues. Ommen advised Dr. Lee that pursuant to the hospital by-laws sh...

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