Lewin v. St. Joseph Hospital of Orange
| Decision Date | 29 June 1978 |
| Citation | 82 Cal.App.3d 368,146 Cal.Rptr. 892 |
| Court | California Court of Appeals Court of Appeals |
| Parties | Laurence LEWIN, M.D., Plaintiff and Respondent, v. ST. JOSEPH HOSPITAL OF ORANGE, a corporation, Defendant and Appellant. Civ. 19171. |
Musick, Peeler & Garrett, Joseph A. Saunders, and James B. Bertero, Los Angeles, for defendant and appellant.
Harry Liddicote, Jr., Newport Beach, for plaintiff and respondent.
The ultimate question presented by this case is whether the governing board of a "private" nonprofit hospital corporation may validly make a policy decision, based on its reasonable judgment that it is in the best interests of good patient care and sound administration of the hospital, to operate the hospital's chronic renal hemodialysis facility on a "closed-staff" basis (i. e., by arranging for exclusive use and practical administration of the facility with a single group of nephrologists associated together in their practice of medicine and who devote all but an insubstantial proportion of their professional endeavors to the practice of nephrology at the hospital) or whether the hospital is compelled by law to operate that facility on an "open-staff" basis (i. e., permitting all qualified physicians to use the facility, each performing dialysis on his own patients), the judgment of its governing board to the contrary notwithstanding.
The trial court granted the petition of Dr. Laurence Lewin for a peremptory writ of mandate commanding St. Joseph Hospital of Orange (hereafter hospital or St. Joseph), in effect, to operate its chronic hemodialysis facility on an "open-staff" basis. The court also appointed a referee to ascertain what, if any, monetary damages Dr. Lewin had suffered as a result of hospital's operating the facility on a "closed-staff" basis. Hospital appeals. We reverse the judgment with directions to the trial court to enter judgment for hospital.
Although some factual details will be included in our discussion of the several issues, we set forth at the outset the facts necessary to an understanding of the contentions.
Renal hemodialysis may be performed either on an acute or a chronic basis. 1 The difference was explained by Dr. Lewin as follows: "Chronic hemodialysis is a procedure that is required for a prolonged period of time, usually lifetime, to sustain a patient's life, and there to amplify that, acute hemodialysis may begin on a patient and gradually merge into chronic hemodialysis when that patient fails to recover from the acute insult or has underlying kidney disease that prevents his recovery." Chronic hemodialysis is usually performed on an out-patient basis. 2 Many hospitals find it advantageous to operate their chronic and acute hemodialysis facilities as separate "units."
St. Joseph Hospital of Orange is a "private" 3 hospital located in the City of Orange organized as a California nonprofit corporation. Along with a number of other hospitals 4 and "free-standing" organizations 5 located in Orange County, St. Joseph maintains and operates a renal hemodialysis facility consisting of both a chronic hemodialysis unit and an acute hemodialysis unit. The hemodialysis facility at St. Joseph was opened in May 1971 upon the initiation and under the medical direction of Drs. Miller and Gentile. From its inception and until shortly after October 16, 1975, the hemodialysis facility at St. Joseph was operated on a "closed-staff" basis as to both the acute and chronic units. Shortly after October 16, 1975, apparently as a result of the hearing held in connection with Dr. Lewin's request for hemodialysis privileges, hospital decided to operate its acute hemodialysis unit on an "open-staff" basis. However, it was determined that operation of the chronic hemodialysis unit should be continued on a "closed-staff" basis.
Under the "closed-staff" arrangement, practical administration and operation of the chronic hemodialysis unit is exclusively in the hands of a group of four physicians associated in practice as the Nephrology Specialists Medical Group, Inc. (hereafter nephrology group). Drs. Miller and Gentile were the original members of the group. All four physicians are certified by the American Board of Internal Medicine in both internal medicine and nephrology, and all of them devote all but an insubstantial proportion of their respective professional endeavors to the practice of nephrology at St. Joseph Hospital. 6 These nephrologists are regarded as independent contractors, but there exists no formal contract between the group and hospital except for an oral understanding with respect to patient billings and the manner in which collected charges are allocated to professional and medico-administrative component, on the one hand, and hospital service component on the other. The relationship between the group and hospital is terminable at the will of either.
Under the "closed-staff" arrangement the chronic hemodialysis unit is operated in two shifts from 8 a. m. to 10 p. m. each day. During these hours one or more members of the nephrology group is physically present on the unit or nearby. A member of the group is in attendance at all times any patient is undergoing dialysis except sometimes during the last 30 minutes of treatment of the last patient of the day. During dialysis, emergencies do occur from time to time with respect to which it is advantageous to have a qualified physician on the scene within a few minutes.
The amount and cost of technical equipment and the number of trained, technical personnel (some 35 persons) required for operation of the unit are large in relation to the number of physicians required. The nephrology group supervises and trains the technical personnel. Morale and esprit de corps are important factors in delivering quality service. The members of the nephrology group meet daily to confer on operational and patient problems. They meet and confer with the nurses in the unit once a week and periodically with physicians and nurses from other departments such as pediatrics and radiology.
Some 70 to 75 chronic dialysis patients are serviced by the unit. On each shift one member of the nephrology group makes rounds discussing problems with patients and making progress notes on the patients' charts. Thus, all members of the group become acquainted with virtually all the patients and familiar with their special problems. Scheduling this number of patients for treatment presents a considerable problem, particularly in view of the fact that frequent changes in scheduling are required to accommodate patients and their needs.
Dr. Lewin is a physician duly licensed to practice medicine in the State of California. Although he is not certified as a nephrologist, he performed a one-year residency in internal medicine and a 22-month fellowship in renal medicine and limits his practice to nephrology and internal medicine. Neither his qualifications nor competence are in any way in issue in this case. He frequently utilizes renal hemodialysis in the care and treatment of his patients. His offices are located near Palm Harbor General Hospital where he performs a good deal of hemodialysis. He was the director of Palm Harbor's hemodialysis facility in 1975. In addition to the privileges he exercises at Palm Harbor General Hospital, he has been granted hemodialysis privileges at a substantial number of other hospitals in Orange County including Mercy General Hospital, Santa Ana-Tustin Community Hospital, the Orange County Medical Center, Fountain Valley, Pacifica, and St. Jude. He also exercises hemodialysis privileges at Nephron, Inc., a proprietary hemodialysis facility established by him and of which he is the medical director and principal owner. At a number of other Orange County hospitals having hemodialysis facilities, Dr. Lewin has not requested privileges. Dr. Lewin is a member of the inactive courtesy staff of St. Joseph's medical staff, having been admitted to the staff in 1972, and has been granted "Class I Internal Medicine" clinical privileges.
On March 25, 1975, 7 Dr. Lewin addressed a letter to the head of hospital's department of medicine requesting hemodialysis privileges. This request was considered by the Medical Committee of the Medical Staff Association on April 4, 1975. The chairman of the committee asked the members of the committee if they knew of any reason why dialysis privileges should not be granted to Dr. Lewin. None were forthcoming and the Medical Committee forwarded its recommendation to the Executive Committee that Dr. Lewin be granted acute dialysis privileges. 8 No recommendation regarding chronic dialysis privileges was made, the committee having assumed that Dr. Lewin's request was for acute dialysis privileges only.
On June 2, 1975, the recommendation of the Medical Committee was reviewed by the Executive Committee. It was noted that the hemodialysis facility had always operated on a "closed-staff" basis. Because there had been no complaint from the medical staff as to the quality of care and because it was thought to be in the best interest of the hospital to continue to operate the hemodialysis facility on a "closed-staff" basis, the Executive Committee recommended to hospital's Board of Trustees that Dr. Lewin's application be denied. On June 26, 1975, the Executive Committee's recommendation was approved by the Board of Trustees.
On June 17, 1975, through his attorney, Dr. Lewin requested a hearing with respect to this decision. The chief of staff appointed a hearing committee which was instructed to evaluate the justification in terms of the medical reasons for maintaining a "closed-staff" operation. The hearing...
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