Tenet Health Ltd. v. Zamora
| Decision Date | 10 February 2000 |
| Citation | 13 S.W.3d 464 |
| Parties | (Tex.App.-Corpus Christi 2000) TENET HEALTH LTD., D/B/A BROWNSVILLE MEDICAL CENTER Appellant, v. JOSE ZAMORA, M.D. AND CARLOS CHAVEZ, M.D., Appellees. NO. 13-99-572-CV |
| Court | Texas Court of Appeals |
On appeal from the 138th District Court of Cameron County, Texas. [Copyrighted Material Omitted]
Before Justices Dorsey, Chavez, and Rodriguez
Tenant Healthcare, Ltd., d/b/a/ Brownsville Medical Center ("the hospital), appellant, has offered its patients a cardiovascular surgery program since 1993. Over the past several years, the program became troubled. In 1998, it experienced what the hospital calls a "surge of deaths." Its mortality rate was 11%, compared to the national average of 3%.
After hiring an outside consultant to study the problem in 1999, the hospital retained an experienced cardiovascular surgeon, Dr. Louis Elkins, and entered into an exclusive provider contract with him. Under the terms of this contract, Elkins would serve as the "exclusive provider" of cardiovascular surgery services at the hospital, and only he and his employees, partners, or independent contractors under contract with him could provide cardiovascular surgery services at the hospital. This would put the responsibility and control for all cardiovascular surgery with one person, as had been recommended by the consultant. The hospital notified all cardiac surgeons practicing at the hospital of the new arrangement.
Drs. Zamora and Chavez (collectively "Zamora"), appellees, are surgeons who had "staff privileges" at the hospital, including privileges in the cardiovascular surgery program, for a number of years at the time the exclusive contract was entered into. Zamora contends that the exclusive provider contract would effectively diminish his own hospital "privileges" with respect to cardiovascular surgery. Accordingly, he contends that before his privileges were reduced, he was entitled to a hearing under the hospital bylaws and under Texas Health & Safety Code Ann. §241.101(c) (Vernon Supp. 2000). He filed suit seeking, among other things, injunctive relief requiring the hospital to allow him to continue practicing cardiovascular surgery at the hospital. On March 20, the trial court entered such an order. From this temporary injunction, the hospital appeals.
The Bylaws of Brownsville Medical Center is a document that sets forth the terms between the "medical staff" and the hospital administrator and board of directors (herein "hospital management"). "Medical staff" is defined as "all duly licensed physicians . . . holding current Texas licences, who are privileged to attend patients in the hospital." The bylaws state that "membership on the medical staff of Brownsville Medical Center is a privilege which shall be extended only to professionally competent physicians, dentists and podiatrists who continuously meet the qualifications, standards and requirements set forth in the bylaws." The qualifications for membership on the medical staff include maintenance of a current license to practice medicine, agreement to abide by the American Medical Association's principles of medical ethics and maintenance of medical malpractice insurance.
The purposes of the "medical staff organization" are:
1. To insure that all patients admitted to or treated in . . . the hospital shall receive a high quality of care;
2. To insure high level of professional performance . . . in the hospital through the appropriate delineation of the clinical privileges that each practitioner may exercise in the hospital, and through an ongoing review and evaluation of each practitioner's performance in the hospital;
3. To provide an appropriate educational setting . . .;
4. To initiate and maintain rules and regulations for self-government of the medical staff; and
5. To provide a means whereby issues concerning the medical staff and the hospital may be discussed by the medical staff with the [hospital management].
Appointments and reappointments to the medical staff are done by the hospital management, but only after there has been a recommendation from the medical staff. The bylaws also set forth at length the qualifications for and privileges held by various categories of "medical staff," and the procedures for applying for medical staff privileges.
The medical staff is divided into active, provisional, courtesy, senior and honorary medical staff. Every doctor practicing at the hospital, whether medical staff or not, must be granted "clinical privileges" in the specific areas of practice in which the doctor desires to practice. The doctor has to provide evidence that he is competent to practice in the clinical areas in which he seeks privileges, and the hospital must approve the clinical privileges. Temporary and emergency privileges may be granted, as well.
Under Article VII of the bylaws, corrective action may be instituted against any medical staff member when his activities or professional conduct fall below the standards of the medical staff, are detrimental to patient safety or to the delivery of quality patient care, or are disruptive to hospital operation. Corrective action may be initiated by any officer of the medical staff, by the chairman of any department, by the administrator of the hospital or by the board of directors. Varying levels of corrective action are set forth, and provisions are included to provide notice to the target of a corrective action and the procedure for administering the corrective action.
Finally, the bylaws provide for hearing and appeal procedures. The purpose of a hearing is "intra-professional resolution of matters bearing on professional competency or conduct." This section applies only to doctors who already have medical staff or other privileges, not to applications for new appointments. It allows a practitioner to request a hearing when one of the following occurs:
1) denial of requested advancement in medical staff membership;
2) denial of medical staff reappointment;
3) demotion to lower staff category;
4) suspension of medical staff membership;
5) expulsion from medical staff membership;
6) reduction in privileges;
7) suspension of privileges;
8) termination of privileges; and
9) denial of increase in privileges.
The procedure for such a hearing is also set forth in detail. The person requesting the hearing must be in attendance and may not have an attorney present. Both sides have the opportunity to present evidence, but formal rules of evidence are not followed. The matter is decided by the "hearing committee," which is a group of at least five appointed members of the active medical staff. An appeal is allowed on the grounds of either (1) substantial failure to comply with the procedures contained in the bylaws which denied a fair hearing, or (2) arbitrary or capricious action.
The remainder of the bylaws relates to committee appointments, qualifications, termination of appointments to certain positions, and other general provisions.
Zamora filed suit against the hospital seeking damages and injunctive relief. All his causes of action arose from the hospital's actions in entering the exclusive contract agreement with Dr. Elkins. Specifically, he claims that (1) the hospital breached the contract created by the bylaws entitling him to a hearing before his privileges may be reduced; (2) the hospital denied him procedural due process as mandated by Tex. Health & Safety Code Ann. § 241.101(c).
The trial court ordered the hospital to desist and refrain from preventing Zamora from practicing cardiovascular surgery at the hospital until judgment is rendered. The hospital was expressly allowed to make reasonable rules and specify procedures to facilitate operations at the hospital, but was ordered to "desist and refrain from adopting, implementing or enforcing procedures, rules and regulations which do not afford the Plaintiff physicians the same rights of access and schedule as those rights afforded any other physician practicing cardiac surgery, until judgment . . . is rendered . . . ." Finally, the injunction states that it "shall not alter the terms of the Medical Staff Bylaws or the rights and obligations of Dr. Zamora and Dr. Chavez and the Hospital thereunder, including without limitation the Hospital's right to take action reducing, modifying or terminating privileges as set forth therein."
To be entitled to an injunction, a plaintiff must show (1) that a wrongful act occurred (i.e., that the plaintiff has a cause of action against the defendant); (2) that the plaintiff will likely succeed on the merits of his cause of action; and (3) that the plaintiff will likely suffer harm. Garcia-Marroquin v. Nueces County Bail Bond Bd., 1 S.W.3d 366, 344 (); Walling v. Metcalfe, 863 S.W.2d 56, 57 (Tex. 1993). The "probable harm" element has three components. The plaintiff must show that the harm is imminent, that the injury would be irreparable, and that the plaintiff has no other adequate legal remedy. Garcia-Marroquin, id.
We review the grant or denial of a temporary injunction for abuse of discretion, which the trial court commits when it either acts arbitrarily and unreasonably, without reference to guiding rules or principals, or misapplies the law to the established facts of the case. Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 241-42 (Tex. 1985). While abuse of discretion does not exist if the trial court heard conflicting evidence, and substantive, probative evidence appears in the record that reasonably supports the trial court's decision, Davis, 571 S.W.2d at 862, we will apply a de novo standard of review when the issue turns on a pure question of law. See State v. Heal, 917 S.W.2d 6, 9 (Tex. 1996); ...
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