McKeesport Hospital v. Pennsylvania State Board of Medicine

PALLADINO, Judge.

McKeesport Hospital (Hospital) appeals from an order of the State Board of Medicine (Board) dismissing its complaint against the Accreditation Council for Graduate Medical Education (ACGME).¹ We vacate and remand to the Board for further proceedings.

The Hospital is a teaching hospital which operates graduate medical training programs, commonly referred to as residencies, in several specialties. The Hospital’s general surgery residency training program (Program) has been accredited since 1961. Since 1979, when its accreditation was first withdrawn and, then upon reconsideration, was granted on a provisional basis, the Program’s accreditation has been provisional. The ACGME, through its Residency Review Committee (Committee),² reviews the Program annually.

Following a site inspection on November 6, 1990 and a review of the Program by the Committee, the Committee advised the Hospital on July 29, 1991 that the Program’s accreditation was being withdrawn. The withdrawal of the Program’s accreditation, which had an effective date of June 30, 1992, was based on the Program’s alleged failure to be in substantial compliance with the Essentials of Accredited Residencies. The Hospital filed a request for reconsideration which was denied by the Committee. The effective date for withdrawal, however, was extended to' June 30, 1993. The Hospital then appealed to the Board of Appeals which sustained the Committee’s action.³

On June 9, 1992, the ACGME adopted the recommendation of the Board of Appeals, and by letter dated June 10,1992, the ACGME advised the Hospital of its decision to withdraw accreditation.⁴ The Hospital subsequently filed a complaint against the ACGME with the Board. The complaint requested, inter alia,⁵ that a hearing be scheduled before the Board wherein the Program would be able to present evidence that the ACGME’s action was unjustified, improper and without just cause.⁶

Without a hearing, the Board issued an order dismissing the Hospital’s complaint. Specifically, the Board concluded that it has no authority under the Act to affect the internal accreditation process of the ACGME. The Board further concluded that because the Program failed to meet one of the two criteria required to enable it to serve as a medical training facility, the Board has no jurisdiction over the subject matter of the complaint and therefore may not provide any of the relief sought by the Hospital.

On appeal to this court, two issues are presented: 1) whether the Board is the final arbiter in matters involving the accreditation of medical training facilities in Pennsylvania; and 2) whether the Hospital is entitled to a hearing before the Board prior to its accreditation being withdrawn.⁷

With respect to whether the Board is the final arbiter in matters involving the accreditation of medical training facilities in Pennsylvania, the Medical Practice Act of 1985 (Act)⁸ and the regulations promulgated by the Board are instructive. Section 23 of the Act provides that in order to qualify candidates for medical licensure in Pennsylvania, the curricula and training to be offered by medical training facilities,⁹ such as the Hospital, “shall meet the requirements set by the board and any accrediting body which may be recognized by the board.” 63 P.S. § 422.23(a).

Section 23 further provides that:

[i]t shall be the duty of the board, in its discretion, periodically to ascertain the character of the instruction and the facilities possessed by each of ... medical training facilities offering or desiring to offer medical training in accordance with the requirements of this act.... In enforcing this provision, the board shall give due notice to any ... hospital upon which it has rendered a decision that its training and facilities do not meet the standards required by the board.

63 P.S. § 422.23(b).

In the event the Board determines that a medical training facility has failed to provide adequate facilities, curricula or training, the Act provides that the Board shall not recognize the education or degrees obtained from the medical training facility during the period of inadequacy. 63 P.S. § 422.23(c).

A plain reading of the statute indicates that the final authority with respect to accreditation rests with the Board and not with a private accrediting body. Although the Board may recognize an accrediting body, it is not required to do so. All authority remains with the Board unless the Board affirmatively appoints an accrediting body. Furthermore, nowhere in the Act is an accrediting body given sole discretion to set the standards by which residency programs are evaluated.

Nor does the Act give an accrediting body the power to enforce the Act or the power to regulate or eliminate a program without the Board’s review. Instead, it is the Board which, in enforcing the provisions of the Act, must give notice to any hospital upon which it has rendered a decision that its training and facilities do not meet the requisite standards. Clearly, the Act vests the Board with the primary authority to accredit residency programs and otherwise enforce and give effect to the Act.

The Board’s regulations further define the role of the Board in the accreditation process. Pursuant to 49 Pa.Code Section 17.23, the Board is responsible for determining the character of instruction and the facilities possessed by each of the hospitals which carries out graduate medical education programs in this Commonwealth. This regulation also explains the role of the ACGME and its interaction with the Board. Specifically, the regulation provides as follows:

The Council on Medical Education of the American Medical Association[¹⁰] possesses the facilities and staffing required to perform evaluations of the qualifications of the various programs and also the mechanism for accreditation of acceptance programs. The Board and the [Council] work cooperatively in evaluating and approving the training programs in this Commonwealth. A comity exists between the Board and the [Council] under which all intended observations of training programs for accreditation are communicated to the Board and the Board makes all requests for accreditation or investigation of training programs to the [Council]. If an investigation of the programs of the various institutions in this Commonwealth is to be conducted, the Board will provide one of its members or appoint an individual to accompany the investigator on each occasion. An institution within this Commonwealth seeking approval of its programs by the [Council] will be informed that action taken by the accrediting agency will be related to the Board.

49 Pa.Code § 17.23 (footnote added).¹¹

A plain reading of the Board’s regulations also supports the conclusion that the final authority regarding accreditation of medical training facilities rests with the Board. Accreditation by the ACGME merely is a tool which establishes critical facts leading to the Board’s recognition of whether the curricula and training offered by a particular medical training facility meet or do not meet its accreditation standards. The delegation to the ACGME is- made in recognition of the fact that the ACGME’s resources are more efficient and better suited for the task of accrediting medical training facilities. Generally, such delegations are held permissible where the private entity is merely a fact finding vehicle upon which the action of the agency depends. See Pennsylvania Chiropractic Federation v. Foster, 136 Pa.Commonwealth Ct. 465, 583 A.2d 844 (1990). Moreover, as previously stated, the ultimate authority to determine accreditation is vested with the Board.¹²

With respect to whether the Hospital is entitled to a hearing before the Board, Section 9 of the Act provides that “[a]ll actions of the board shall be taken subject to the right of notice, hearing and adjudication, and the right of appeal therefrom, in accordance with the provisions of Title 2 of the Pennsylvania Consolidated Statutes (relating to administrative law and procedure).” 63 P.S. § 422.9(a). Therefore, we con-elude that the Program’s accreditation may not be withdrawn without giving the Hospital an opportunity to be heard before the Board.

Based upon the foregoing, we vacate the order of the Board and remand the matter for further proceedings.

ORDER

AND NOW, June 28, 1993, the order of the State Board of Medicine in the above-captioned matter is vacated and the case remanded for further proceedings. It also is ordered that the accreditation of the general surgery residency training program of the McKeesport Hospital remain in effect pending a hearing before the Board and the Board’s rendering of a final appealable order in this matter.

Jurisdiction relinquished.

1 . ACGME is a non-profit, private organization comprised of several medical associations and societies. It operates a national program of accreditation and review based upon a written set of standards that it has promulgated, entitled Essentials of Accredited Residencies. The Board recognizes the ACGME as an accrediting body for graduate medical training in Pennsylvania.

2 . In order to accomplish the review and evaluation of residency programs throughout the nation, the ACGME had organized Residency Review Committees for each medical specialty. Each Residency Re- . view Committee is responsible for reviewing and evaluating all residency programs within its area of specialty pursuant to the Essentials of Accredited Residencies.

3 . The proceeding before the Board of Appeals is the final appeal which may be taken within the framework of the ACGME.

4 . Prior to the ACGME’s final determination, the chairman of the Board accompanied the Residency Review Committee on two of the site’ visits conducted with respect to the Program.

5 . The complaint also requested that the Board find that the Essentials of Accredited Residencies are invalid and improper; find that the Essentials of Accredited Residencies do not provide proper guidelines for the operation of the Program and are insufficient as standards for the operation of residency training programs in Pennsylvania, and order the discontinuance of their use in Pennsylvania as they presently exist; find that the ACGME has exceed its delegated authority and has abused its discretion in deciding to withdraw the Program’s accreditation; refuse to sustain the action of the ACGME; continue to recognize the Program; and direct the ACGME to continue the accreditation of the Program.

6 . Although the proceeding filed with the Board was a complaint against the ACGME, we will treat the Hospital’s complaint as a petition for a hearing before the Board.

7 . Our scope of review is limited to determining whether constitutional rights were violated and whether the decision is in accordance with the law and supported by substantial evidence. Cassella v. State Board of Medicine, Bureau of Professional and Occupational Affairs, 119 Pa.Commonwealth Ct. 394, 547 A.2d 506 (1988), petition for allowance of appeal denied, 522 Pa. 585, 559 A.2d 528 (1989).

8 . Act of December 20, 1985, P.L. 457, 63 P.S. §§ 422.1-422.45.

9 . Section 2 of the Act defines “medical training facility” as “a hospital ... which provides courses in the art and science of medicine and surgery and related subjects for the purpose of enabling a matriculant to qualify for a license to practice medicine and surgery, graduate medical training....” 63 P.S. § 422.2.

10 . The ACGME succeeded the Council on Medical Education of the American Medical Association (Council), and the ACGME assumed Council's functions.

11 . The Board's regulations also provide:

A member of the Board or a Board designee may be present during formal review sessions by a Residency Review Committee. Commonwealth hospitals have the affirmative duty of informing the Board when a residency program has been approved, probationed or disapproved. The Board may at the request of either of the parties act as a mediator in disputes that may arise from alleged deficiencies in graduate medical education programs.

49 Pa.Code § 17.25.

12 . Although the Act vests the Board with ultimate authority in matters involving accreditation, we must agree with the Board that the Act does not confer upon the it the authority to intervene in the internal accreditation process of a private body, such as the ACGME.