Blaine et al v. North Brevard County Hospital District

Filing 94

ORDER denying 67 Motion for Preliminary Injunction. Signed by Judge Roy B. Dalton, Jr. on 2/4/2019. (PKK)

UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
ORLANDO DIVISION
GERMAINE BLAINE; CYNTHIA
BRYANT; JUAN CASTRO; ASHISH
DALAL; FIRAS MUWALLA;
BRENDAN PRENDERGAST;
RICHARD SPRAWLS,
Plaintiffs,
v.

Case No. 6:18-cv-487-Orl-37DCI

NORTH BREVARD COUNTY
HOSPITAL DISTRICT,
Defendant.
ORDER
Before the Court is Plaintiffs’ Motion for Preliminary Injunctive Relief. (Doc. 67
(“Motion”).) Defendant North Brevard County Hospital District (“PMC”) responded
(Doc. 77), and the Court heard argument on December 18, 2018 (Docs. 90, 91 (“Hearing”)).
On review, the Motion is due to be denied.
I.

BACKGROUND

This case concerns the rescission of medical privileges for Plaintiffs, a group of
oncologists, to practice at PMC, a public hospital located in Brevard County, Florida.
(Docs. 1, 81.) Plaintiffs initiated this action bringing two claims seeking injunctive relief
and damages against PMC based on: (1) violations of Plaintiffs’ procedural due process
under 42 U.S.C. § 1983; and (2) breach of PMC’s Bylaws. (Doc. 1, ¶¶ 46–67.) Along with
Plaintiffs’ Complaint, Plaintiffs moved for a preliminary injunction. (Doc. 5 (“First PI
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Motion”).) After full briefing and a hearing (Docs. 5, 6, 11–13, 32, 33, 35, 39, 40), the Court
granted in part Plaintiffs’ First PI Motion on the procedural due process claim (Doc. 42
(“PI Order”)). 1 Specifically, the Court found that under PMC’s Bylaws, Plaintiffs were
entitled to a hearing before their applications for reappointment of medical privileges
could be denied. (Id. at 10–15.) Therefore, the Court ordered PMC to restore Plaintiffs’
privileges pending an impartial hearing on Plaintiffs’ reappointment applications in
conformity with the Bylaws. (Id. at 19–20.)
PMC complied. (See Doc. 67, pp. 1–2.) PMC restored Plaintiffs medical privileges
and set a hearing on Plaintiffs’ reappointment applications before an Ad Hoc Committee
of PMC’s medical staff. (Doc. 81, ¶¶ 36–37.) The hearing took place on July 19 and 20,
2018. (Id. ¶ 37; see also Docs. 66-4, 66-5.) In line with the Bylaws, the parties were
represented by counsel and presented witness testimony and evidence. (Doc. 81-1, Ex. E.)
On July 30, 2018, the Committee issued its written findings and recommendation that
Plaintiffs’ reappointment applications be denied. (Id.) In short, the Committee found that:
(1) Plaintiffs refused to comply with repeated requests from PMC for patient data; (2)
under PMC’s Bylaws, clinical competency is not the sole basis for denying reappointment
applications; (3) Plaintiffs’ failure to provide the requested data hinders the delivery of
quality patient care at PMC; and (4) denying Plaintiffs’ reappointment applications based
on Plaintiffs’ refusal to provide, or cause to be provided, the patient data is appropriate
under the Bylaws. (Id. at 4.)

1

The Court assumes the reader’s familiarity with the PI Order.
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As the Bylaws permit (Doc. 81-1, Ex. A § 9.2-4(E)(4)), Plaintiffs submitted
exceptions to the Committee’s Ruling and appealed the decision to PMC’s CEO George
Miktarian, Jr. (Doc. 81-1, Ex. F.) Mr. Miktarian denied Plaintiffs’ exceptions (Doc. 81-1,
Ex. G.) and issued a written disposition affirming the Committee’s decision to deny
Plaintiffs’ reappointment applications based on their failure to provide the requested
patient data (Doc. 81-1, Ex. H (“Disposition”)). Plaintiffs sought appeal from PMC’s
Board of Directors—it upheld Mr. Miktarian’s Disposition. (Doc. 81-1, Ex. I.) Now,
Plaintiffs no longer hold medical staff privileges at PMC. (Id.; see also Doc. 81, ¶ 50.)
Unsatisfied with the denial of their reappointment applications following this
process, Plaintiffs moved for another preliminary injunction. (Doc. 67.) Plaintiffs contend
injunctive relief is warranted for each claim they bring. (Id. at 15–22.) First, for the Breach
of Bylaws claim, Plaintiffs claim that PMC violated the Bylaws by not exclusively
considering medical competency and quality of patient care as grounds for
reappointment. (Id. at 15–19.) Second, Plaintiffs maintain their procedural due process
claim still supports a preliminary injunction—no longer because their reappointment
applications were denied without a hearing, but instead because some evidence Plaintiffs
sought to submit was excluded at the hearing. (Id. at 19–20.) Last, Plaintiffs added a
substantive due process claim (see Docs. 62, 66, 80, 81) and claim that PMC’s decision to
deny Plaintiffs’ reappointment applications based on their failure to provide patient data
amounts to such a violation because it imposes an arbitrary, unreasonable, and capricious
standard. (Id. 20–22.) Following briefing and the Hearing (Docs. 77, 90, 91), the matter is
ripe.
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II.

LEGAL STANDARD

A district court may issue a preliminary injunction when the movant
demonstrates: (1) a substantial likelihood of success on the merits; (2) that irreparable
injury will be suffered unless the injunction issues; (3) the threatened injury to the movant
outweighs whatever damage the proposed injunction may cause the opposing party; and
(4) if issued, the injunction would not be adverse to the public interest. See Four Seasons
Hotels & Resorts, B.V. v. Consorcio Barr, S.A., 320 F.3d 1205, 1210 (11th Cir. 2003); see also
Nken v. Holder, 556 U.S. 418, 434 (2009) (describing traditional elements of a stay in
removal proceedings). Preliminary injunctions are “drastic” and “extraordinary”
remedies, not to be issued unless the movant has “clearly established” the burden of
persuasion on each element. Four Seasons, 320 F.3d at 1210 (citation omitted). They are the
exception, not the rule. Id.
III.

D ISCUSSION

As the Court previously found Plaintiffs satisfied elements two through four (Doc.
42, pp. 16–19), Plaintiffs focus their legal argument on the first factor—whether the record
as it stands supports a substantial likelihood of success on the merits of their three claims.
(Doc. 67, pp. 15–22.) Plaintiffs submit that the record “remains unchanged” since the PI
Order but “recent developments” strengthen their claims to injunctive relief, so seek a
restoration of their privileges pending trial. (Id. at 2.) In turn, PMC points out that it has
complied with the PI Order and provided Plaintiffs full procedural due process for their
reappointment applications, so additional injunctive relief on that claim is not supported.
(Doc. 77, pp. 1–4.) And because the decision to deny Plaintiffs’ applications was based on
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appropriate criteria under applicable law and the Bylaws, PMC contends that Plaintiffs
fail to establish a substantial likelihood of success on the merits for their breach of contract
and substantive due process claims. (Id. at 5–11.) The Court agrees with PMC.
First, the Court finds that Plaintiffs haven’t established a substantial likelihood of
success on the merits of their breach of contract claim. To meet this, Plaintiffs claim that
the Bylaws circumscribe the basis for reappointing medical privileges such that
nonclinical criteria cannot be considered when a physician seeks reappointment. (Doc.
67, pp. 3–9.) Because PMC based its denial decision on Plaintiffs’ refusal to comply with
the data requests—which Plaintiffs categorize as nonclinical criteria—Plaintiffs claim that
PMC breached its Bylaws. (Id. at 7–9.) Yet on review of the Bylaws and applicable law,
the Court agrees with PMC—clinical competence is not the only proper criteria for
privileges decisions.
Under the Bylaws, PMC staff members are required to “[a]bide by the medical
staff bylaws and by all other lawful standards, policies and rules of the Hospital,” (Doc.
81-1, Ex. A § 3.3(B)) which includes the responsibility to “[a]ccount to the Board for the
quality and efficiency of patient care through regular reports” (Id. § 2.2(D)). Staff
members seeking

reappointment are evaluated “based upon such member’s

demonstrated professional ability and clinical judgment in the treatment of his patients,
professional ethics, discharge of staff obligations, compliance with these Bylaws, and the Rules
and Regulations, and good physical and mental health.” (Id. § 6.4-4 (emphasis added)
(criteria for recommendation from Credentials and Medical Ethics Committee)). So,
clearly, the Bylaws allow issues outside the realm of clinical competence to be considered
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when evaluating a staff member’s reappointment application—and such is the case here.
The Ad Hoc Committee determined that “a staff member’s lack of support for
[PMC] quality initiatives is a ground for denial of reappointment” under the Bylaws.
(Doc. 81-1, Ex. E, p. 2.) Because Plaintiffs’ failure to turn over requested patient data fit
this bill, the Ad Hoc Committee found that the Medical Executive Committee could
rightfully recommend denial of Plaintiffs’ reappointment applications under the Bylaws
(id. at 4); and this decision could rightfully be upheld following a hearing before the Ad
Hoc Committee, a review by the CEO, and ultimate disposition by the Board (See Docs.
81-1, Exs. G, H, I). And at this stage, the Court finds no fault in this course of action—
rather, the Bylaws contemplate denial of reappointment on such grounds so long as the
reappointment process is followed. (See Doc. 81-1, Ex. A §§ 6.3, 6.4; Article 9.)
Accordingly, the Court is not persuaded by Plaintiffs’ argument that PMC breached the
Bylaws in deciding to deny their reappointment applications based on their failure to
turn over patient data. Thus, Plaintiffs have not established a substantial likelihood of
success on the merits to warrant a preliminary injunction on this claim.
The same goes for Plaintiffs’ other claims. To show a substantial likelihood of
success on the merits of their substantive due process claim, Plaintiffs need establish that
PMC’s decision to terminate their medical privileges was “arbitrary, capricious, and
discriminatory.” Shawahy v. Harrison, 875 F.2d 1529, 1533 (11th Cir. 1989). This is a high
bar to reach; the Court cannot “substitute [its] judgment for that of the hospital’s
governing board or . . . reweigh the evidence regarding the renewal or termination of
medical staff privileges.” Id. Rather:
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[T]he court is charged with the narrow responsibility of assuring that the
qualifications imposed by the Board are reasonably related to the operation
of the hospital and fairly administered. In short, so long as staff selections
are administered with fairness, geared by a rationale compatible with
hospital responsibility, and unencumbered with irrelevant considerations,
a court should not interfere.
Id. PMC’s decision here clears this bar. Each reviewing body at PMC found that Plaintiffs’
failure to comply with PMC’s request for patient data hindered the cancer program and
the delivery of quality of patient care and could cause the loss of accreditation in the
future. (Doc. 81-1, Ex. E, p. 4; Ex. H, pp. 2–12; Ex. I pp. 2–3.) Such grounds are “reasonably
related to the operation of the hospital,” “fairly administered,” and relevant
considerations for PMC. See Shahawy, 875 F.2d at 1533. As such, at this stage the Court
cannot find that PMC’s denial of Plaintiffs’ reappointment constituted a violation of
Plaintiffs’ substantive due process rights. Id. Thus, Plaintiffs’ request for injunctive relief
for this claim fails.
So too for Plaintiffs’ procedural due process claim. The landscape has changed
remarkably since the PI Order for this claim—there, the Court ordered limited injunctive
relief because Plaintiffs’ reappointment applications had been denied without the process
they were due. (See Doc. 42, pp. 11–16.) The PI Order guaranteed Plaintiffs would receive
that process, in the form of a Bylaws-compliant hearing before a neutral decisionmaker
where Plaintiffs were represented by counsel and could present evidence. (Id. at 12–16.)
That hearing sought to determine whether PMC could deny Plaintiffs’ reappointment
applications based on their failure to turn over, or cause to be turned over, the requested
patient data. (Id. at 19.) No change in outcome was guaranteed. (See id.) And now that
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Plaintiffs have received such process—a “full panoply of due process protections”—the
Court’s role is limited. See Shahawy, 875 F.2d at 1533; see also Woodbury v. McKinnon, 447
F.2d 839, 844 (5th Cir. 1971). 2 The question becomes whether the type of hearing Plaintiffs
received comports with the requirements of due process in this context. Darlak v. Bobear,
814 F.2d 1055, 1062 (5th Cir. 1987) (first citing Cleveland Bd. of Educ. v. Loudermill, 470 U.S.
532, 542 (1985); then citing Mathews v. Eldridge, 424 U.S. 319, 334–35 (1976)). Three factors
are considered: (1) the private interest that will be affected by the official action; (2) the
risk of erroneous deprivation of such an interest through the procedures used and the
probable value, if any, of additional or substitute procedural safeguards; and (3) the
Government’s interest. Id. (quoting Mathews, 424 U.S. at 334–35).
Plaintiffs focus on the second factor, claiming that PMC prevented them from
introducing evidence of their medical competency and quality of patient care at the
hearing, which led to an erroneous outcome. (Doc. 67, pp. 19–20.) But as PMC points out,
this is because Plaintiffs’ clinical competency was not in question—it was not why the
Medical Executive Committee issued its adverse recommendation in the first place. (See
Doc. 77, pp. 12–15; Doc. 42, pp. 4–5.) Instead, at issue was whether Plaintiffs’ inability or
refusal to turn over patient data was an appropriate basis to deny them reappointment.
(Doc. 42, pp. 4–9, 14–16, 19.) So the Ad Hoc Committee focused on that question and
admitted evidence accordingly. (Doc. 81-1, Ex. E; see also Docs. 66-4, 66-5.) This evidence

The decisions of the former Fifth Circuit rendered before October 1, 1981 are
binding on this circuit. Bonner v. City of Prichard, 661 F.2d 1206, 1207 (11th Cir. 1981)
(en banc).
2

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included testimony from one Plaintiff, Dr. Dalal, who agreed that providing data and
getting reaccredited is a component of delivery of quality of patient care at PMC. (Doc.
66-5, p. 109: 4–8.) Plaintiffs were also provided the opportunity to appeal the Ad Hoc
Committee’s decision, which they did. (Doc. 81-1, Ex. F.) They received additional
process from that—a written ruling from the CEO and his Disposition. (Doc. 81-1, Exs. G,
H.) Ultimately, after a full review of the record, the Board ruled in favor of denying
Plaintiffs’ privileges. (Doc. 81-1, Ex. I, p. 2.)
With all this, the Court simply cannot agree with Plaintiffs that the process
afforded to them suffered risk of erroneous deprivation of their privileges such that they
need additional or substitute procedures. See Darlak, 814 F.2d at 1062–63. Thus, Plaintiffs
have failed to demonstrate a substantial likelihood of success on the merits of their
procedural due process claim. The request for preliminary injunctive relief is denied.
IV.

CONCLUSION

Accordingly, it is ORDERED AND ADJUDGED that Plaintiffs’ Motion for
Preliminary Injunctive Relief (Doc. 67) is DENIED.
DONE AND ORDERED in Chambers in Orlando, Florida, on February 4, 2019.

Copies to:
Counsel of Record
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