Ungurian, S. v. Beyzman, A., M.D. ( 2020 )

J-A03042-20
2020 Pa. Super. 105
SUSAN UNGURIAN, INDIVIDUALLY : IN THE SUPERIOR COURT OF
AND AS GUARDIAN OF JASON : PENNSYLVANIA
UNGURIAN, AN INCAPACITATED :
PERSON :
:
:
v. :
:
: No. 298 MDA 2019
ANDREW BEYZMAN, M.D.; ROBERT :
BURRY, CRNA; NORTH AMERICAN :
PARTNERS IN ANESTHESIA :
(PENNSYLVANIA), LLC, :
INDIVIDUALLY AND D/B/A NAPA; :
NORTH AMERICAN PARTNERS IN :
ANESTHESIA, LLP, INDIVIDUALLY :
AND D/B/A NAPA; WILKES-BARRE :
HOSPITAL COMPANY, LLC, :
INDIVIDUALLY AND D/B/A WILKES- :
BARRE GENERAL HOSPITAL, :
WYOMING VALLEY HEALTH CARE :
SYSTEM, COMMONWEALTH HEALTH :
AND/OR COMMONWEALTH HEALTH :
SYSTEMS, INC.; COMMUNITY :
HEALTH SYSTEMS, INC., :
INDIVIDUALLY AND D/B/A WILKES- :
BARRE GENERAL HOSPITAL, :
WYOMING VALLEY HEALTH CARE :
SYSTEM, COMMONWEALTH HEALTH :
AND/OR COMMONWEALTH HEALTH :
SYSTEM :
:
:
APPEAL OF: WILKES-BARRE :
HOSPITAL COMPANY, LLC D/B/A :
WILKES BARRE GENERAL HOSPITAL
Appeal from the Order Entered February 1, 2019
In the Court of Common Pleas of Luzerne County Civil Division at No(s):
2018-08789
SUSAN UNGURIAN, INDIVIDUALLY : IN THE SUPERIOR COURT OF
AND AS GUARDIAN OF JASON : PENNSYLVANIA
J-A03042-20
UNGURIAN, AN INCAPACITATED :
PERSON :
:
:
v. :
:
: No. 300 MDA 2019
ANDREW BEYZMAN, M.D.; ROBERT :
BURRY, CRNA; NORTH AMERICAN :
PARTNERS IN ANESTHESIA :
(PENNSYLVANIA), LLC, :
INDIVIDUALLY AND D/B/A NAPA; :
NORTH AMERICAN PARTNERS IN :
ANESTHESIA, LLP, INDIVIDUALLY :
AND D/B/A NAPA; WILKES-BARRE :
HOSPITAL COMPANY, LLC, :
INDIVIDUALLY AND D/B/A WILKES- :
BARRE GENERAL HOSPITAL, :
WYOMING VALLEY HEALTH CARE :
SYSTEM, COMMONWEALTH HEALTH :
AND/OR COMMONWEALTH HEALTH :
SYSTEMS, INC.; COMMUNITY :
HEALTH SYSTEMS, INC., :
INDIVIDUALLY AND D/B/A WILKES- :
BARRE GENERAL HOSPITAL, :
WYOMING VALLEY HEALTH CARE :
SYSTEM, COMMONWEALTH HEALTH :
AND/OR COMMONWEALTH HEALTH :
SYSTEM :
:
:
APPEAL OF: WILKES-BARRE :
HOSPITAL COMPANY, LLC, :
INDIVIDUALLY AND D/B/A WILKES- :
BARRE GENERAL HOSPITAL
Appeal from the Order Entered February 6, 2019
In the Court of Common Pleas of Luzerne County Civil Division at No(s):
2018-08789
SUSAN UNGURIAN, INDIVIDUALLY : IN THE SUPERIOR COURT OF
AND AS GUARDIAN OF JASON : PENNSYLVANIA
UNGURIAN, AN INCAPACITATED :
PERSON :
:
-2-
J-A03042-20
:
v. :
:
: No. 722 MDA 2019
ANDREW BEYZMAN, M.D.; ROBERT :
BURRY, CRNA; NORTH AMERICAN :
PARTNERS IN ANESTESIA :
(PENNSYLVANIA) LLC, INDIVIDUALLY :
AND D/B/A NAPA; NORTH AMERICAN :
PARTNERS IN ANESTHESIA LLP, :
INDIVIDUALLY AND D/B/A NAPA; :
WILKES-BARRE GENERAL HOSPITAL, :
WYOMING VALLEY HEATHCARE :
SYSTEM, COMMONWEALTH HEALTH :
AND/OR COMMONWEALTH HEALTH :
SYSTEM, INC. INDIVIDUALLY AND :
D/B/A WILKES-BARRE GENERAL :
HOSPITAL, WYOMING VALLEY :
HEALTHCARE SYSTEM, :
COMMONWEALTH HEALTH AND/OR :
COMMONWEALTH HEALTH SYSTEMS :
:
:
APPEAL OF: WILKES-BARRE :
HOSPITAL COMPANY, LLC D/B/A :
WILKES-BARRE GENERAL HOSPITAL :
Appeal from the Order Entered April 24, 2019
In the Court of Common Pleas of Luzerne County Civil Division at No(s):
08789-2018
SUSAN UNGURIAN, INDIVIDUALLY : IN THE SUPERIOR COURT OF
AND AS GUARDIAN OF JASON : PENNSYLVANIA
UNGURIAN, AN INCAPACITATED :
PERSON :
:
:
v. :
:
: No. 949 MDA 2019
ANDREW BEYZMAN, M.D.; ROBERT :
BURRY, CRNA; NORTH AMERICAN :
PARTNERS IN ANESTHESIA :
(PENNSYLVANIA), LLC, :
INDIVIDUALLY AND D/B/A NAPA; :
-3-
J-A03042-20
NORTH AMERICAN PARTNERS IN :
ANESTHESIA, LLP, INDIVIDUALLY :
AND D/B/A NAPA; WILKES-BARRE :
HOSPITAL COMPANY, LLC, :
INDIVIDUALLY AND D/B/A WILKES- :
BARRE GENERAL HOSPITAL, :
WYOMING VALLEY HEALTH CARE :
SYSTEM, COMMONWEALTH HEALTH :
AND/OR COMMONWEALTH HEALTH :
SYSTEMS, INC.;COMMUNITY HEALTH :
SYSTEMS, INC., INDIVIDUALLY AND :
D/B/A WILKES-BARRE GENERAL :
HOSPITAL, WYOMING VALLEY :
HEALTH CARE SYSTEM, :
COMMONWEALTH HEALTH AND/OR :
COMMONWEALTH HEALTH SYSTEM :
:
:
APPEAL OF: WILKES-BARRE :
HOSPITAL COMPANY, LLC D/B/A :
WILKES-BARRE GENERAL HOSPITAL :
Appeal from the Order Entered June 6, 2019
In the Court of Common Pleas of Luzerne County Civil Division at No(s):
08789-2018
SUSAN UNGURIAN, INDIVIDUALLY : IN THE SUPERIOR COURT OF
AND AS GUARDIAN OF JASON : PENNSYLVANIA
UNGURIAN, AN INCAPACITATED :
PERSON :
:
:
v. :
:
: No. 950 MDA 2019
ANDREW BEYZMAN, M.D.; ROBERT :
BURRY, CRNA; NORTH AMERICAN :
PARTNERS IN ANESTESIA :
(PENNSYLVANIA) LLC, INDIVIDUALLY :
AND D/B/A NAPA; NORTH AMERICAN :
PARTNERS IN ANESTHESIA LLP, :
INDIVIDUALLY AND D/B/A NAPA; :
WILKES-BARRE GENERAL HOSPITAL, :
WYOMING VALLEY HEATHCARE :
SYSTEM, COMMONWEALTH HEALTH :
-4-
J-A03042-20
AND/OR COMMONWEALTH HEALTH :
SYSTEM, INC. INDIVIDUALLY AND :
D/B/A WILKES-BARRE GENERAL :
HOSPITAL, WYOMING VALLEY :
HEALTHCARE SYSTEM, :
COMMONWEALTH HEALTH AND/OR :
COMMONWEALTH HEALTH SYSTEMS :
:
:
APPEAL OF: WILKES-BARRE :
HOSPITAL COMPANY, LLC D/B/A :
WILKES-BARRE GENERAL HOSPITAL :
Appeal from the Order Entered June 6, 2019
In the Court of Common Pleas of Luzerne County Civil Division at No(s):
08789-2018
BEFORE: LAZARUS, J., STABILE, J., and DUBOW, J.
OPINION BY DUBOW, J.: FILED APRIL 28, 2020
Appellant, Wilkes-Barre Hospital Company, LLC d/b/a Wilkes-Barre
General Hospital (“Hospital”), appeals from five Orders entered in the trial
court compelling production of documents that Hospital alleges are privileged
by the Patient Safety Quality Improvement Act (“PSQIA”), 42 U.S.C. § 299b-
22(a), and the Peer Review Protection Act (“PRPA”), 63 P.S. § 425.4. After
careful review, we affirm.
Briefly, this matter arises in the context of a medical malpractice action
brought by plaintiff, Susan Ungurian, against multiple corporate and individual
defendants. Mrs. Ungurian alleges that, on March 5, 2018, the negligence of
defendants caused the total and permanent incapacity of her son, Jason
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Ungurian, who was undergoing a cystoscopy1 at Hospital. In the course of
discovery, on August 7, 2018, August 17, 2018, and September 13, 2018,
Mrs. Ungurian propounded requests for production of documents and
interrogatories on all defendants, including Hospital.
On October 8, 2018, and October 10, 2018, Hospital served Mrs.
Ungurian with responses and objections to her First and Second Requests for
Production of Documents, and responded and objected to her First Set of
Interrogatories. Hospital asserted that these documents were privileged
pursuant to, inter alia, the PRPA and the PSQIA, and served Mrs. Ungurian
with a privilege log, listing five documents Hospital was withholding.
Relevantly, Hospital’s privilege log identified the following documents as
privileged:
1. Event Report completed on March 5, 2018[,] by Robert Burry,
CRNA [(“Burry Event Report”)] for event date of March 5,
2018[,] relating to “Surgery, Treatment, Test, Invasive
Procedure” reviewed by Jacqueline Curley, R.N., Clinical
Leader, on March 21, 2018[,] and Elizabeth Trzcinski, R.N.,
Risk Coordinator, on March 8, 2018;
2. The SSER (Serious Safety Event Rating) Meeting Summary
dated April 12, 2018[,] prepared by Elizabeth Trzcinski, R.N.,
Risk Coordinator;
3. Meeting Minutes from the Patient Safety Committee held on
May 15, 2018[,] prepared by Joan DeRocco, R.N., Director
Patient Safety Services, and Elizabeth Trzcinski, R.N., Risk
Coordinator;
4. Root Cause Analysis Report dated April 12, 2018; and
____________________________________________
1A cystoscopy is an endoscopy of the bladder via the urethra. Jason Ungurian
underwent a cystoscopy to remove kidney stones.
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5. [Hospital’s] Quality Improvement Staff Peer Review completed
by Dale A. Anderson, M.D. on April 15, 2018.
Privilege Log, 10/8/18, at 2-3.
On December 3, 2018, Mrs. Ungurian filed a Motion to Strike Objections
and Compel Responses to her First and Second Requests for the Production of
Documents and First Set of Interrogatories Propounded upon Hospital. In her
Motion, Mrs. Ungurian argued that Hospital had failed to establish that PSQIA
and PRPA privileges applied to the documents in Hospital’s privilege log.
Hospital filed a Response to the Motion, claiming that two documents—
the Burry Event Report and the Root Cause Analysis—were patient safety work
product privileged by the PSQIA. Hospital also asserted that the PRPA
Privilege protected it from producing the Burry Event Report and the Root
Cause Analysis along with other documents, including the Quality
Improvement Peer Review Meeting minutes, the Serious Safety Event Rating
Meeting, minutes from the Patient Safety Committee, and certain
credentialing files. Hospital supported its privilege claims with an affidavit
from Joan DeRocco-DeLessio, Director of Patient Safety Services (“Affidavit”).2
In addition to baldly asserting that each of the requested documents were
“specifically designated as privileged peer review information[,]” the Affidavit
describes the relevant documents as follows.
The Burry Event Report
____________________________________________
2 The Affidavit is the only evidence Hospital provided to the court in support
of its assertions of privilege.
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Hospital described the Burry Event Report as a two-page document
“completed on March 5, 2018,” which was the day of the incident that gave
rise to this action. Privilege Log, 10/8/18, at 2. CRNA Robert Burry completed
the Report in compliance with Hospital’s “Event Reporting Policy.” 3 Affidavit,
12/18/18, at ¶ 10.
The Root Cause Analysis Report
Hospital’s Root Cause Analysis Committee produced the Root Cause
Analysis Report on April 12, 2018, ostensibly “during the course of a peer
review concerning [Jason] Ungurian’s medical care on March 5, 2018.”
Affidavit at ¶ 26. Hospital purports that it prepared the Root Cause Analysis
Report to evaluate Jason Ungurian’s care and to improve patient safety and
quality of care. Id. at ¶¶ 27-28. Hospital stated that it maintains the Root
Cause Analysis Report within its ERS4 for reporting to CHS PSO, LLC,5 and that
it electronically submitted the Root Cause Analysis Report to CHS PSO, LLC.
Id. at ¶¶ 30-31.
The Quality Improvement Peer Review
Hospital referred to the Quality Improvement Peer Review as the
“initiating part of the peer review process.” Affidavit at ¶ 21. Dr. Dale
____________________________________________
3 Hospital attached a copy of its “Event Reporting Policy” to the Affidavit.
4 An “ERS” is an “event reporting system.”
5 A “PSO” is a “patient safety organization.”
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Anderson was the physician reviewer of the Quality Improvement Medical
Staff Peer Review Form. Id. at ¶ 20. According to Hospital’s Privilege Log,
Dr. Anderson completed the Quality Improvement Peer Review on April 15,
2018, more than one month after the incident in question. Privilege Log at 3.
The Serious Safety Event Meeting Summary
Hospital asserted that Elizabeth Trzcinski, R.N., Risk Coordinator,
prepared the Serious Safety Event Meeting dated April 12, 2018, to summarize
the meeting of Hospital’s Serious Safety Event Committee. Privilege Log at
2; Affidavit at ¶ 23. In its Affidavit, Hospital does not provide the date the
Committee met or who comprised the committee.
The Patient Safety Committee Meeting Minutes
Hospital held the relevant Patient Safety Committee Meeting on May 15,
2018. Affidavit at ¶ 34. The Affidavit describes the Committee as “a
multidisciplinary group whose membership is representative of both the
hospital and community it serves.” Id. at ¶ 36.
The January 30, 2019 Order
The court held a hearing on Appellee’s Motion after which, on January
30, 2019, it issued an Order ( “January 30, 2019 Order”) directing Hospital to
produce the Burry Event Report, the Root Cause Analysis, and the Quality
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Improvement Peer Review. The court found that neither the PSQIA nor the
PRPA privileges protected any of these documents.6
The February 5, 2019 Order
On February 5, 2019, the court amended the January 30, 2019 Order
directing Hospital to produce, within 15 days, Dr. Andrew Beyzman’s and
CRNA Robert Burry’s complete credentialing files and the National Practitioner
Data Bank Query Response7 ( “February 5, 2019 Order”).
On February 22, 2019, Mrs. Ungurian filed a Motion to Compel
production of the Serious Safety Event Rating Meeting Summary and the
Patient Safety Committee Meeting Minutes.
____________________________________________
6 The January 30, 2019 Order also directed Hospital to provide the court within
fifteen days with information about Serious Safety Event Rating Meeting and
the Patient Safety Committee Meeting Minutes to help it determine whether a
privilege attached to these documents. This information included: (1) the
author of the document; (2) the purpose of the document; (3) the attendees
at the meeting; and (4) any other recipients of the document.
7 The National Practitioner Data Bank is a “web-based repository of reports
containing information on medical malpractice payments and certain adverse
actions related to health care practitioners, providers, and suppliers.” About
US, National Practitioner Data Bank,
https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp (last visited April 9,
2020). Congress established the data bank as a “tool that prevents
practitioners from moving state to state without disclosure of discovery of
previous damaging performance.” Id.
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The April 24, 2019 Order
On April 16, 2019, the court held a hearing on the Motion to Compel. 8
Following the hearing, on April 24, 2019, the court issued an Order (“April 24,
2019 Order”) directing Hospital to produce the Serious Safety Event Rating
Meeting Summary and the Patient Safety Committee Meeting Minutes .
On June 3, 2019, Mrs. Ungurian filed an Emergency Motion to Strike
Objections and Compel Discovery Responses from Defendants Andrew
Beyzman, M.D., Robert Burry, CRNA, North American Partners In Anesthesia
(Pennsylvania), LLC, Individually and d/b/a NAPA (“NAPA PA”), and North
American Partners In Anesthesia, LLP, Individually and d/b/a (“NAPA LLP”)
(collectively, the “NAPA Defendants”). Mrs. Ungurian also moved for sanctions
against those defendants. Relevantly, she averred that through supplemental
discovery responses from the NAPA Defendants, she learned that the NAPA
Defendants also possessed the Quality Improvement Peer Review, which,
despite Hospital’s privilege assertion, the court had previously ordered
Hospital to produce.
The court held a hearing on Mrs. Ungurian’s Emergency Motion. Mrs.
Ungurian argued at the hearing that the PRPA did not protect the Quality
____________________________________________
8 At this hearing, Hospital asserted that in its January 30, 2019 Order the court
had ordered an in camera review of the Serious Safety Event Rating Meeting
Summary and the Patient Safety Committee Meeting Minutes. The court
rejected this contention, emphasizing that it ordered Hospital to provide it
with information about those documents to assist it in determining whether
the documents were privileged, not because it intended to review the
documents in camera.
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Improvement Peer Review because Dr. Anderson prepared it and he was not
a licensed medical professional. Hospital and the NAPA Defendants argued
that the privilege applied because Dr. Anderson had conducted the review at
Hospital’s request.
At the hearing, the parties also discussed the production of the
credentialing files for Hospital employees involved in Jason Ungurian’s care9
and of correspondence between Joan Keis, Hospital’s chief quality officer, and
Dr. Thomas James, the senior medical director for Hospital’s insurer,
Highmark, about the substance of the Root Cause Analysis. Mrs. Ungurian
argued that Hospital’s asserted privileges over the Root Cause Analysis were
inapplicable. Hospital countered with the policy argument that an insured
should be freely able to discuss certain events with its insurer in an effort to
maintain coverage. With respect to the credentialing files, Hospital claimed
that it withheld production because it believed the files were either peer review
protected or irrelevant.
The June 6, 2019 Orders
On June 6, 2019, the court ordered NAPA PA to produce a complete copy
of the Quality Improvement Peer Review (“June 6, 2019 QIPR Order”). The
court concluded that the PRPA privilege did not apply to the Quality
Improvement Peer Review because: (1) Dr. Anderson was not licensed to
____________________________________________
9 These people included Katelyn Farrell, RN, JoAnn Thomas, RN, Kristen
Yavorski, RN, Kayla Barber, ST, Kimberly Barron, ST, Lisa Cernera, RNFA,
BSN, Calvin Dysinger, MD, Shay Robinson, MD, John Amico, CRNA, Jason
McDade, RN, and Daniel Walton, RN.
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practice medicine in Pennsylvania when he prepared the Quality Improvement
Peer Review; (2) he was a managing partner of NAPA LLP, a non-healthcare
provider; (3) the contract between Hospital and NAPA LLP did not provide for
the provision of peer review services; and (4) NAPA LLP, an original source,
also possessed the Quality Improvement Peer Review.
That same day the court entered a separate Order directing Hospital to
produce the requested credentialing files, excluding limited personal
information and any National Practitioner Data Bank Query Responses (“June
6, 2019 Credentialing Order”).
Hospital filed appeals from each of these Orders, which this court
consolidated.10 Both Hospital and the trial court have complied with Pa.R.A.P.
1925.
Hospital raises the following issues on appeal:
1. Whether the [t]rial [c]ourt erred in holding that the [Burry]
Event Report prepared by CRNA Burry and the Root Cause
Analysis are not protected from discovery by virtue of the
PSQIA?
____________________________________________
10 “[M]ost discovery orders are deemed interlocutory and not immediately
appealable because they do not dispose of the litigation.” Veloric v. Doe,
123 A.3d 781, 784 (Pa. Super. 2015) (quotation marks and citation omitted).
Nevertheless, “[a]n appeal may be taken as of right from a collateral order of
[a] . . . lower court.” Pa.R.A.P. 313(a). “A collateral order is an order
separable from and collateral to the main cause of action where the right
involved is too important to be denied review and the question presented is
such that if review is postponed until final judgment in the case, the claim will
be irreparably lost.” Pa.R.A.P. 313(b). “When a party is ordered to produce
materials purportedly subject to a privilege, we have jurisdiction under
Pa.R.A.P. 313 . . . .” Yocabet v. UPMC Presbyterian, 119 A.3d 1012, 1016
n.1 (Pa. Super. 2015) (citation omitted).
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2. Whether the [Burry] Event Report is privileged pursuant to the
PRPA?
3. Whether the [t]rial [c]ourt erred in holding that the Root Cause
Analysis is not protected from discovery by virtue of the PRPA?
4. Whether the [t]rial [c]ourt erred in holding that the Quality
Improvement Peer Review performed by Dr. Dale Anderson is
not protected from discovery by virtue of the PRPA?
5. Whether the [t]rial [c]ourt erred in holding that the Serious
Safety Event Rating and Patient Safety Committee Minutes are
not protected by virtue of the PRPA?
6. Whether the [t]rial [c]ourt erred in holding that the complete,
unredacted credentialing files for Dr. Andrew Beyzman and
CRNA Robert Burry are not protected from discovery by virtue
of the PRPA?
7. Whether the [t]rial [c]ourt erred in holding that the unredacted
personnel and/or credentialing files of Katelyn Farrell, RN,
JoAnn Thomas, RN, Kristen Yavorski, RN, Kayla Barber, ST,
Kimberly Barron, ST, Lisa Cernera, RNFA, BSN, Calvin
Dysinger, MD, Shay Robinson, MD, John Amico, CRNA, Jason
McDade, RN, and Daniel Walton, RN are not protected from
discovery by virtue of the PRPA?
Hospital’s Brief at 4-5.
PSQIA Claim
Issue 1 - The Burry Event Report and the Root Cause Analysis
In its first issue, Hospital claims that the trial court erred when it
determined that the PSQIA did not privilege from discovery the Burry Event
Report and the Root Cause Analysis.
In order to evaluate the argument of Hospital, we must analyze the
language of PSQIA. We start with general principles of statutory construction.
“Where the issue is the proper interpretation of a statute, it poses a question
of law; thus, our standard of review is de novo, and the scope of our review
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is plenary.” Yocabet v. UPMC Presbyterian, 119 A.3d. 1012, 1019 (Pa.
Super. 2015) (quotation marks and citations omitted). Generally, courts
disfavor evidentiary privileges. Leadbitter v. Keystone Anesthesia
Consultants, Ltd., --- A.3d ---, 2020 WL 702486 *3 (Pa. Super. 2020).
The PSQIA provides, generally, that “patient safety work product shall
be privileged[.]” 42 U.S.C. § 299b-22(a). The Act defines “patient safety
work product” as “any data, reports, memoranda, analyses (such as root
cause analyses), or written or oral statements . . . which . . . are assembled
or developed by a provider for reporting to a patient safety organization and
are reported to a patient safety organization[.]” Id. at § 299b-21(7)(A)(i)(I)
(emphasis added).
Relevantly, “patient safety work product” excludes “information that is
collected, maintained, or developed separately, or exists separately, from a
patient safety evaluation system.” Id. at § 299b-21(7)(B)(ii). “Such separate
information or a copy thereof reported to a patient safety organization shall
not by reason of its reporting be considered patient safety work product.” Id.
The party asserting a privilege bears the burden of producing facts
establishing proper invocation of the privilege. Custom Designs & Mfg. Co.
v. Sherwin-Williams Co., 39 A.3d 372, 376 (Pa. Super. 2012). “[T]hen the
burden shifts to the party seeking disclosure to set forth facts showing that
disclosure will not violate the [] privilege.” Id. (citation omitted). “Absent a
sufficient showing of facts to support [a] privilege . . . the communications are
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not protected.” Ford-Bey v. Professional Anesthesia Services of North
America, LLC, --- A.3d ---, 2020 WL 830016 *5 (Pa. Super. 2020).
The Burry Event Report
Hospital argues it met its burden to establish that the Burry Event Report
is protected by the PSQIA privilege because it asserted in the Affidavit that:
1. Hospital has maintained a relationship with a patient safety
organization (“PSO”) (CHS PSO, LLC) since 2012;
2. the purpose of the relationship with the PSO is to allow the
confidential and protected exchange of patient safety and quality
information in the conduct of patient safety activities;
3. Hospital has maintained a patient safety evaluation system
(“PSES”), facilitated by the use of an event reporting system
(“ERS”), as its internal process for collecting, managing, and
analyzing information that may be reported to its PSO;
4. the PSES encompasses information assembled, developed,
deliberated upon, or analyzed from patient safety and quality
activities and includes information that may result in documents
such as occurrence reports, cause analyses, and root cause
analyses;
5. Hospital prepares the documents sought by Mrs. Ungurian for
the express purpose of improving patient safety and care quality
and are maintained within Hospital’s PSES for reporting to the PSO
6. Hospital did not collect, maintain, or develop the Burry Event
Report separately from its PSES, did not disclose the Burry Event
Report and the Burry Event report is not required to be publicly
disclosed or reported.
Hospital’s Brief at 24-25.
The trial court determined that Hospital failed to meet its burden to
establish that the Burry Event Report was “patient safety work product” under
the PSQIA because Hospital failed to allege in the Affidavit that it developed
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the Burry Event Report for reporting to or by a PSO. Trial Ct. Op., 8/14/19,
at 17-18. The court found Hospital’s assertions that it: (1) prepared the Burry
Event Report “for the express purpose of improving patient safety and
quality;” (2) maintained the Burry Event Report “within [Hospital’s] ERS for
reporting to CHS PSO, LLC;” and (3) the “ERS is used to manage information
that only MAY be reported to the PSO” were insufficient to establish that
Hospital developed the Burry Event Report for the purpose of reporting to the
PSO. Id. at 18. It noted that the averments in the Affidavit only “confirm
that the [Burry] Event Report could have been developed for a purpose other
than reporting to a PSO and still be managed within the ERS.” Id. (emphasis
added).
The trial court interpreted PSQIA as “requir[ing] that, to be considered
patient safety work product, a document must be developed for the purpose
of reporting to a PSO.” Id. (emphasis added). The trial court concluded,
therefore, that because Hospital failed to assert that Hospital developed the
Burry Event Report for the purpose of reporting to a PSO, the Burry Event
Report was not patient safety work product entitled to the protection of the
PSQIA privilege. Id.
We agree with the trial court’s analysis that the PSQIA requires that, in
order to be considered patient safety work product, Hospital had the burden
of initially producing sufficient facts to show that it properly invoked the
privilege. Stated another way, Hospital had to allege that it prepared the
Burry Event Report for reporting to a PSO and actually reported them to a
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PSO. Because Hospital did not so allege,11 it did not meet its burden to
establish that the Burry Event Report was entitled to protection under the
PSQIA’s patient safety work product privilege.
The Root Cause Analysis
With respect to the Root Cause Analysis, the court found Hospital’s
failure to proffer in the Affidavit that the Root Cause Analysis was “developed
for the purpose of reporting to the PSO” was fatal to its PSQIA privilege claim.
Id. at 19. The court also found that Hospital admitted that the information
contained in the Root Cause Analysis “is not contained solely in the PSES.”
Id. at 19-20 (citing Hospital’s counsel’s admission that an email between Joan
Keis and Dr. Thomas James specifically references the Root Cause Analysis).
The court found that Hospital’s admission that the Root Cause Analysis existed
outside of the PSES defeated its claim that the Root Cause Analysis is
privileged patient safety work product.
We agree with the trial court’s analysis that the PSQIA imposed a burden
on Hospital to proffer evidence that it developed the Root Cause Analysis for
the purpose of reporting to a PSO. Hospital did not proffer such evidence.
Moreover, Hospital admitted that the Root Cause Analysis exists outside of
____________________________________________
11 Hospital asserts in its appellate Brief that it submitted the Burry Event
Report to the PSO. Hospital’s Brief at 27. As noted above, however, Hospital
did not assert that it had submitted the Burry Event Report to the PSO in the
Affidavit in support of its privilege claim and Hospital has not supported this
assertion with citation to the record.
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Hospital’s patient safety evaluation system, also defeating its privilege claim.
Therefore, Hospital failed to satisfy its burden of proving that the Root Cause
Analysis was entitled to protection under the PSQIA’s patient safety work
product privilege.
PRPA
Issue 2 – the Burry Event Report
In its second issue, Hospital claims that the trial court erred in
compelling it to produce the March 5, 2018 Burry Event Report. Hospital’s
Brief at 42-45. Hospital argues that the PRPA peer review privilege protects
it from producing the Burry Event Report because: (1) Hospital is a
“professional health care provider” under PRPA; and (2) the Burry Event
Report was not in the nature of an “incident report.” Id.
The PRPA provides an evidentiary privilege for “peer review” documents.
Section 425.4 provides, in relevant part, as follows:
The proceedings and records of a review committee shall be held
in confidence and shall not be subject to discovery or introduction
into evidence in any civil action against a professional healthcare
provider arising out of the matters which are the subject of
evaluation and review[.]
63 P.S. § 425.3.
The PRPA defines “[p]eer review” as “the procedure for evaluation by
professional health care providers of the quality and efficiency of services
ordered or performed by other professional health care providers . . . .” 63
P.S. § 425.2.
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Under the PRPA, a “[p]rofessional healthcare provider” includes
“individuals who are approved, licensed[,] or otherwise regulated to practice
or operate in the healthcare field under the laws of the Commonwealth.” 63
P.S. § 425.2(1).
The PRPA defines a peer “[r]eview organization” as “any committee
engaging in peer review . . . to gather and review information relating to the
care and treatment of patients for the purposes of (i) evaluating and improving
the quality of health care rendered; (ii) reducing morbidity and mortality; or
(iii) establishing and enforcing guidelines designed to keep within reasonable
bounds the cost of healthcare.” 63 P.S. § 425.2.
In contrast, hospital incident and event reports are business records of
a hospital and not the records of a peer review committee. Atkins v.
Pottstown Memorial Medical Center, 634 A.2d 258, 260 (Pa. Super.
1993). Incident reports are, therefore, not entitled to the confidentiality
safeguards of the PRPA. Id. Additionally, the PRPA does not protect
documents available from other sources or documents that have been shared
outside of the peer review committee. 63 P.S. § 425.4.
Hospital argues that the Burry Event Report is privileged pursuant to the
PRPA because it “was prepared for the express purpose of improving patient
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safety and quality of care . . . pursuant to Hospital’s ‘Policy/Procedure 8-2’”12
and “was initiated by a professional healthcare provider under the Act, namely
the Hospital.” Hospital’s Brief at 42-43. It disputes that the Burry Event
Report is in the nature of an incident report. Id. at 43.
The trial court found that the PRPA peer review privilege did not apply
to the Burry Event Report because Hospital failed to support its privilege claim
with sufficient proof of the privilege’s applicability, namely the identity of the
members of the review committee. Trial Ct. Op. at 28. It also found that the
PRPA privilege did not apply to the Burry Event Report because the Report
was not generated in the context of a peer review and “is similar to the type
of incident report that is not protected by the PRPA.” Id. at 31. See also id.
at 32-33 (where the court explained that “if the Burry Event Report was
generated pursuant to [Hospital’s] Event Reporting Policy as asserted in the
Privilege Affidavit, it is an incident report that is not afforded the protections
of the PRPA.”).
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12Hospital appended a copy of its “Event Reporting Policy” to the Affidavit.
The Policy’s stated purpose is to: (1) “establish a standardized mechanism by
which to report events internally and to the CHS PSO, LLC involving patients
and/or visitors events of harm;” (2) “track and trend processes at risk that
impact patient safety by using a Patient Safety Evaluation System, [ERS];”
(3) “track and trend all severity levels of harm;” (4) “analyze trends to prevent
harm, improve patient safety, healthcare quality[,] and healthcare outcomes;”
and (5) “function as an organization[-]wide policy for [the] Event Report[.]”
Policy, 6/2005, at § A-E. Nowhere in the Policy does Hospital refer to peer
review or a peer review organization or committee.
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Following our review of the record, we agree with the trial court that
Hospital did not generate the Burry Event Report during the course of peer
review. Instead, the Report, produced in accordance with Hospital’s Event
Reporting Policy, is in the nature of an incident report. It is, therefore, not
entitled to the confidentiality safeguards of the PRPA. Moreover, even if the
Burry Event Report was not merely an incident report, because the PRPA
requires that peer review activities be conducted by professional healthcare
providers, Hospital’s failure to identify the members of its peer review
committee is fatal to its claim that the PRPA privilege applies.
Issue 3 – The Root Cause Analysis
In its third issue, Hospital claims that the trial court erred in determining
that the Root Cause Analysis is not privileged simply because Hospital did not
provide a list of all individuals involved in the production of the Root Cause
Analysis. Hospital’s Brief at 46. Hospital argues that the privilege applies
because “the peer review was initiated by a professional healthcare
provider[.]” Id. Hospital also argues that the trial court erred when it held
that the PRPA privilege does not apply to the Root Cause Analysis because the
Root Cause Analysis was the subject of correspondence between Hospital and
Highmark. Id.
Hospital asserted in its Affidavit that its Root Cause Analysis Committee
produced the April 12, 2018 Root Cause Analysis Report. Affidavit at ¶ 26. It
did not, however, identify the members of the Root Cause Analysis
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Committee. Because the PRPA privilege only applies to the observations of
and materials produced during an evaluation by “professional health care
providers,” Hospital’s failure to identify the members of the Root Cause
Analysis Committee as “professional healthcare providers” is, as the court
concluded, fatal to their privilege claim. Hospital is, therefore, not entitled to
relief.13
Issue 4 – The Quality Improvement Medical Staff Peer Review
In its fourth issue, Hospital claims that the trial court erred in compelling
NAPA to produce the Quality Improvement Medical Staff Peer Review
performed on April 15, 2018, by Dr. Dale Anderson. Hospital’s Brief at 47.
Hospital asserts that the PRPA privilege applies because Dr. Anderson
performed the review as the initiating part of the Hospital’s peer review
process expressly at Hospital’s behest. Id. at 49.
As mentioned above, under the PRPA, a “[p]rofessional healthcare
provider” includes “individuals who are approved, licensed[,] or otherwise
regulated to practice or operate in the healthcare field under the laws of the
Commonwealth.” 63 P.S. § 425.2(1).
Relying on the representations in Hospital’s Affidavit and the testimony
adduced at the January 23, 2019 hearing, the trial court determined that the
PRPA privilege did not apply to the Quality Improvement Medical Staff Peer
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13 In light of our disposition, we do not address Hospital’s alternate arguments.
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Review. The court based its conclusion on the fact that Dr. Anderson’s
Pennsylvania medical license expired in 2014 and, thus, he did not qualify as
a “professional healthcare provider” under the PRPA at the time he performed
the “peer review.” Trial Ct. Op. at 25. The court also considered that Dr.
Anderson was the managing partner of NAPA LLP, a non-healthcare provider,
and, therefore, he could not have conducted peer review on NAPA’s behalf. 14
Id. at 26.
In rejecting Hospital’s argument that Dr. Anderson conducted peer
review because he performed the Quality Improvement Medical Staff Peer
Review at Hospital’s behest, the court noted that neither Hospital nor the NAPA
Defendants had presented the court with the contract between those parties
to prove that Dr. Anderson performed the Quality Improvement Medical Staff
Peer Review for Hospital. Id. at 27. Instead, the court noted that the only
information of record regarding the relationship between Hospital and Dr.
Anderson came from the argument of counsel. Id. Therefore, the court
concluded that “the record lacks sufficient evidence that [Hospital] contracted
with NAPA[] and/or Dr. Anderson for the provision of peer review services.”
Id.
We agree with the trial court that, in order for the PRPA privilege to
apply to the Quality Improvement Medical Staff Peer Review, Hospital had to
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14Neither Hospital nor the Napa Defendants dispute that the NAPA Defendants
are not “professional healthcare providers” as defined by the PRPA.
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prove that a “professional healthcare provider” conducted it. Neither Dr.
Anderson nor the NAPA Defendants are “professional healthcare providers”
under the PRPA, and, as noted by the trial court, Hospital did not proffer
anything more than bald allegations to support its claim that Dr. Anderson
performed the Quality Improvement Medical Staff Peer Review at its request.
Accordingly, the trial court did not err in compelling Hospital to produce the
Quality Improvement Medical Staff Peer Review.
Issue 5 – the Serious Safety Event Rating and Patient Safety
Committee Meeting Minutes
In its fifth issue, Hospital claims that the trial court erred in concluding
that the PRPA privilege does not apply to the April 12, 2018 Summary of its
Serious Safety Event Rating Meeting because Hospital did not identify the
members of the Serious Safety Event Rating committee. Hospital’s Brief at
53. Hospital argues that the identity of the committee members is irrelevant
because the members participate on behalf of and at the request of Hospital,
which is a “professional healthcare provider” under the PRPA. Id.
In its Affidavit in support of this particular claim of privilege, Hospital
asserted only that: (1) “The Serious Safety Event Meeting Summary, dated
April 12, 2018, was prepared to summarize the meeting of the Serious Safety
Event Committee at [Hospital;]” (2) “This Committee meets for the purpose
of reviewing and assessing the quality of patient care at [Hospital;]” and (3)
“The Serious Safety Event Committee Summary is specifically designated as
privileged peer review information.” Affidavit at ¶¶ 23-25.
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These bald claims, without more, do not satisfy Hospital’s evidentiary
burden of proving applicability of the PRPA privilege. Hospital’s unilateral
assertion that the Meeting Summary is “privileged peer review information”
does not, without more, entitle this document to protection under the PRPA.
Accordingly, the trial court did not err in ordering Hospital to produce to Mrs.
Ungurian the Serious Safety Event Committee Meeting Summary.
The Patient Safety Committee Meeting Minutes
Hospital also argues that the court erred in ordering it to produce the
minutes from the May 15, 2018 Patient Safety Committee Meeting. Hospital’s
Brief at 58-64. Following our review of Hospital’s Affidavit in support of this
claim, we conclude that the trial court did not err. Notably, Hospital averred
in its Affidavit that “[t]he Patient Safety Committee is a multidisciplinary group
whose membership is representative of both the hospital and the community
it serves.” Affidavit at ¶ 36. Because the Patient Safety Committee includes
members of the community served by Hospital, the Committee is not
exclusively comprised of “professional healthcare providers.” Accordingly,
Hospital failed to satisfy its evidentiary burden of proving the applicability of
the PRPA privilege to the Patient Safety Committee Meeting Minutes.
Issue 6 and 7– The Credentialing Files
Because Hospital’s sixth and seventh issues are related, we address
them together. In its sixth issue, Hospital claims that the trial court erred in
compelling it to produce the complete unredacted credentialing files for Dr.
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Andrew Beyzman and CRNA Robert Burry.15 Hospital’s Brief at 58-64. In
particular, Hospital claims that the doctors’ performance reviews are
privileged under the PRPA. Id. at 63. Hospital asserts that its own
credentialing committee, staffed by physicians, evaluates the performance of
other physicians. Id. at 62. It concludes, therefore, that its “[c]redentialing
[c]ommittee falls within the PRPA’s definition of qualifying ‘review committee’
as opposed to a non-qualifying ‘review organization.’” Id.
Similarly, in its seventh issue, Hospital claims that the trial court erred
in compelling it to produce the “competency and performance evaluations” of
certain of its staff members who participated in Jason Ungurian’s care. Id. at
66. Hospital argues that Hospital itself conducted the performance
evaluations of CRNA John Amico, registered nurses Katelyn Farrell, JoAnn
Thomas, Kristin Yavorksy, Lisa Cernera, Daniel Walton, and Jason McDade,
and surgical technicians Kayla Barber and Kimberly Barron to evaluate “the
quality and efficiency of . . . services performed.” Id. (citing 63 P.S. 425.2).
It argues that the performance reviews within the credentialing files of doctors
Calvin Dysinger and Shay Robinson are privileged under the PRPA because
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15 Hospital produced a redacted version of the files. It noted in its Privilege
Log that it had redacted from the credentialing files, ”inter alia, malpractice
insurance carrier questionnaires and credentialing reports, National
Practitioner Data Bank Query Responses, Hospital Credentialing Risk
Assessment Checklists, Claims Experience Reports, Ongoing Professional
Practice Evaluations, letters from the malpractice insurance carrier, and
department assessments and reports.” Id. at 59 (referring to Hospital’s
Privilege Log).
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Hospital’s “own credentialing committee initiates and executes its
credentialing review, which implicitly is done for the purpose of ensuring
quality of care in [] Hospital.” Id. at 66-67. Thus, it concludes, “Hospital is
itself ‘a committee engaging in peer review.’” Id. at 67.
Credentialing review is not entitled to protection from disclosure under
the PRPA. Reginelli v. Boggs, 181 A.3d 293, 306 n.13 (Pa. 2018). See also
Estate of Krappa v. Lyons, 211 A.3d 869, 875 (Pa Super. 2019), appeal
denied, 222 A.3d 372 (Pa. 2019) (Table) (citation omitted) (“The PRPA’s
protections do not extend to the credentialing committee’s materials, because
this entity does not qualify as a ‘review committee.’”).
Hospital predicates its argument in support of the privilege attaching to
the aforementioned credentialing files on its assertion that its credentialing
committee is a PRPA-qualifying review committee. However, noted supra,
credentialing committees are not review committees under the PRPA, whose
materials are entitled to its statutory privilege. Krappa, 211 A.3d at 875.
Accordingly, the documents Hospital seeks to withhold are not protected by
the PRPA privilege and the trial court did not err in directing Hospital to
produce them to Mrs. Ungurian. Hospital is, therefore, not entitled to relief.
Orders affirmed.
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Judgment Entered.
Joseph D. Seletyn, Esq.
Prothonotary
Date: 04/28/2020
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