UPDATED: State Takes TRMC to Task for Medical Staff Feud

Editor’s note: This article has been updated to reflect statements from HCCA/TRMC under the subheading “Hospital Responds.” The full response is available for viewing here.

The State of California has once again stepped into the feud between between the Tulare Regional Medical Center’s (TRMC) Board of Directors and doctors representing its prior Medical Executive Committee (MEC), and it’s got choice words for both sides.

A new report, published by the California Department of Public Health, originally obtained by the Visalia Times-Delta, and available below, comes as the district battles a lawsuit from the prior MEC.

Key parts of the report claim that board members failed to attempt to resolve their differences with the prior MEC, instead casting them aside in favor of a new medical staff and executive committee.

In doing so, the state’s inspectors wrote, the district violated its own bylaws — and state laws that guarantee the self-governance of a medical staff.

“The Board’s failure to respect [the old MEC]’s right to self-govern disrupted medical staff functions, interrupted clinical oversight of department responsibilities, and removed 174 medical staff members from Active status without due process, just cause, or their consent to give up their self-governance,” the report stated.

In an interview with state inspectors, Sherrie Bell, the former chairman of the Tulare Local Healthcare District (TLHCD) Board, acknowledged that the district had not attempted to work with the old MEC after a report from the Center for Medicare and Medicaid Services (CMS) that hospital officials felt could result in the closure of the hospital.

Instead, the board voted to push the old group aside, installing a new medical staff headed by a new Medical Executive Committee.

That new committee included Dr. Parmod Kumar, a board member now up for recall; his wife, Dr. Parul Gupta; and Dr. Ronald Ostrom, who also serves as the medical director for both Southern Inyo Hospital and the Student Health & Wellness Center at Bakersfield College. Ostrom is the current Chief of Medical Staff for TRMC’s new MEC.

The New Report

The new report from the Department of Public Health, dated February 17, is a product of inspections conducted in October and November of 2016. Inspectors with the department also wrote the prior CMS report that hospital officials believed would cause the closure of Tulare Regional Medical Center.

The latest report found that, in reacting to the January, 2016 CMS/DPH report, the hospital’s board violated its own bylaws by disassociating from the old MEC; in the process, the new MEC effectively cancelled the status of 174 members of the old medical staff, placing them under “provisional” status with the new MEC. The change meant that those 174 members could not vote on matters involving patient care, serve as leaders on committees or departments, or serve as medical staff officers.

The unilateral changes prevented “active members of [the old MEC from participating] in matters governing patient care through their elected officials and their authority to vote on patient care policies,” the report stated.

“These failures resulted in potential for disruption of critical patient care systems overseen by a medical staff, thereby putting patients at risk for errors and adverse events,” it continued.

The switch-up and effective demotion of medical staff even caused some doctors to leave the hospital, inspectors were told. Identities of doctors in the report were anonymized, though some have been identified by the Voice due to their specific roles noted in the report.

“MD 8 stated that problems between the Board and the leadership of MS 1 were longstanding, going back perhaps 10 years,” the report reads. “MD 8 stated that several of the former MS 1 leaders no longer worked at the hospital and did not remain members of MS 2.”

Michael Amir, a lawyer representing the old MEC in its lawsuit against TRMC, said that he believes the report vindicates the old group.

“The board really was out of touch with what was going on with the medical staff,” Amir said. “If you look at the report as a whole, it reflects a finding that the board really failed in doing its job, including in monitoring the medical staff.”

Hospital Responds

Officials with Healthcare Conglomerate Associates (HCCA), the company which runs TRMC, state that the actions that were taken by the board were not only correct, but absolutely necessary – and they’re confident they’ll be proven to be the correct ones.

“The Board, which is ultimately responsible for Hospital operations, took the only action that would resolve the problem within the very limited time-period provided: it disaffiliated from the old medical staff and affiliated with a new medical staff that was committed to performing its essential functions in overseeing staff performance and working cooperatively with the Board to enhance patient safety,” a statement from the hospital’s spokesperson read.

“The Hospital firmly believes [CDPH’s] conclusions are unjustified and based on a misunderstanding or misapplication of the applicable law.”

The hospital also makes the accusation that the complaints leading up to the survey appeared to have been submitted “by the disgruntled physicians who no longer work at the Hospital, and the small group of community dissidents who support them,” stating that the motives behind such complaints would be to “influence the pending lawsuit and/or to influence public opinion connection with Dr. Kumar’s recall.”

“These frivolous and unwarranted complaints are nothing more than an inappropriate pressure tactic being used by the CMA and the old medical staff to force the Hospital out of business, or to force it to capitulate to the personal economic interests of the disgruntled physicians,” the hospital’s statement read.

“These complaints are cost free to the malcontented.  But these are contrary to good public policy, as the limited resources of the regulatory agencies are being squandered for harassment purposes. Simply put, the costs associated with defending the frivolous complaints in legal and administrative actions literally take health care services away from Tulare residents.”

The 2016 Report

Inspectors with the California Department of Public Health came to the hospital in late 2015 and early 2016, presenting its findings to the federal Centers for Medicare & Medicaid Services. That DPH/CMS report was, hospital administrators stated, the impetus for the ouster of the old MEC.

In a deposition for the ongoing lawsuit filed by members of the old MEC, Bell stated she was under the impression the ouster — that the state now takes issue with — was almost required.

All of the board members were informed of the CMS report’s results by Dr. Benny Benzeevi, the CEO of HCCA, she told the state’s inspector.

“My understanding was from multiple sources that [CMS] literally said our medical staff was dysfunctional, they were not doing our job, that they had seen medical staffs close hospitals before, and we had the ultimate responsibility,” Bell said in her deposition, “as a board over our hospital, and the implication was we had been negligent.”

During the deposition, Bell stated that the board felt that they were “under the gun,” and that they had acted before the written CMS report was issued.

During her campaign for re-election to the hospital board, Bell stated on her campaign’s Facebook page that the action to scrap the old MEC “complied with the mandates of the CMS.”

“When the CMS issued a report on the hospital in January of [2016], they dedicated nearly half of the report to the shortcomings of the MEC, including that they failed even to properly credential themselves,” Bell’s campaign post stated. “They noted that the lack of quality control over doctors put patients’ health and safety at risk, and in an unprecedented decision, stated the MEC needed to be changed or the hospital would close. A group of doctors loyal to the hospital stepped up and presented themselves as the new MEC. The board chose to affiliate with this new MEC and thus complied with the mandates of the CMS.”

According to the state’s report, Bell acknowledged that there were no efforts made to allow the prior MEC to pursue a corrective course.

Indeed, the state’s review of board meeting minutes from January, 2015 to January, 2016 showed no agenda items or discussion related to the performance of the former medical staff until the January 26 meeting in which the board chose to replace it with the new group.

“The solution [to the problems presented by the CMS report] had presented itself,” Bell said, referring to the founding of a new MEC, “and we were grateful. There was no other option.”

“Help Keep The Hospital Running”

In the fallout from the CMS report, Ostrom told inspectors he was approached by Kumar and asked to “help keep the hospital running” by joining the new MEC’s founding group. Ostrom was told, the report stated, that the only two options were to form a new staff or shut the hospital down.

Bell stated in her deposition that the founding group of doctors later “came [forward] and had said they had formed a medical staff.” That initial group was comprised of Drs. Frank Macaluso, Gary Walter, Anthony Trujillo, Rebecca Zulim, Kumar, Ostrom and Gupta.

“I can’t remember for sure if it was my attorney [Bruce Greene, also attorney for HCCA & TRMC] or Dr. Benzeevi, but we were told that probably [January 26], I think,” Bell said, “or maybe the day before the meeting.”

In addition to interviewing Bell, inspectors with the state also conducted interviews with Benzeevi. They both agreed that “the Board was ultimately responsible for the management and operations of the hospital, as well as ensuring the safety and quality of medical care” and that the medical staff was “authorized to self-govern without undue interference by the Board,” as codified in board bylaws and state law.

In the interview with inspectors, Bell stated that the board made many attempts to resolve the issues during, and before, her four-year tenure on the board.

“They never came to meetings, never sent reports,” Bell said.

Ostrom told inspectors that he “did not see efforts by either side to use the [Joint Conference Committee], the CEO, or a neutral 3rd party mediator” during his time as a department chair on the original MEC.

In her December deposition, Bell gave her perspective on why Joint Conference Committee meetings, required by TLHCD Bylaws to occur, did not happen.

“There was always a stipulation attached. Mostly, they wanted me to apologize, to come begging kind of thing,” Bell said. “Which, meet with me and let me know your problems, and if I need to apologize, I will, but you don’t not meet.”

While minutes from the old MEC showed that it met its general responsibilities in submitting reports and policy recommendations to the board, the state’s report said, the group would not allow Benzeevi or district officials to attend its meetings.

Though this was the case, TLHCD board minutes “did not reflect discussion of the exclusion of the CEO and administrative staff from MEC meetings, of failures to cooperate, and/or failures to communicate.”

Amir stated that there was no question the board and the MEC didn’t get along – but that it’s not uncommon.

“There’s no hospital in the State of California where the medical staff and the board always get along. There’s always going to be some type of discord,” Amir said. “What the big difference [between this hospital and others] is, where there is discord, there are procedures that are in place — there’s a formal resolution process.”

“Medical Staff Development Plan”

Amir points to the management agreements between the Tulare Local Healthcare District and Healthcare Conglomerate Associates as proof that the ouster of the old MEC was engineered and planned – not a desperate act in a time of crisis.

“If you look at the HCCA Management Agreement, two years before the CMS survey, there was a provision in there where they specifically state that they want to change the composition of the medical staff,” Amir said.

The contract states a joint goal of the district and HCCA is to create a “Medical Staff Development Plan” and that, specifically, “[t]he parties recognize that changes established pursuant to the Medical Staff Development Plan implementation may result in a smaller, more accountable Medical Staff being appointed.”

“You see HCCA taking a much bigger role in determining the composition and the shape of the medical staff, and its bylaws,” Amir continued. “My position at trial, and what I think this will show, is that this whole CMS survey and report was a pretext — this is something they wanted to do from day one, if you look at the May 2014 agreement.”

The old MEC’s lawsuit against the district will head to trial on April 3 at 9am in Department 2 of the Tulare County Superior Court.

Requests for comment from Linda Wilbourn have not been answered.