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Guier v Teton County Hospital District

Case No. S-09-0259 (WY S.Ct., Feb. 24, 2011)

Dr. Christian Guier appeals from an order of the district court affirming a decision by St. John’s Medical Center Board of Trustees to revoke his medical staff privileges. After reviewing the entire record, we conclude the Board’s decision is supported by substantial evidence, is not arbitrary or capricious, and is otherwise in accordance with law. We affirm.


Dr. Guier presents the following issues for review:
1. Whether Dr. Guier was denied his constitutional and statutory right to a contested case hearing when the Agency reversed the burden of proof.
2. Whether the Agency’s breach of the Medical Staff Reappointment Agreement, by refusing to notify Dr. Guier of complaints that had been made against him, its disregard for its own policies, and its persistent concealment of evidence, renders its decision arbitrary and capricious.
St. John’s styles the issues as follows:
1. Was the burden of proof applied appropriately in Dr. Guier’s fair hearing? In any event was there substantial evidence to support the Board’s final decision?.
2. Did St. John’s Medical Center provide Dr. Guier procedural due process?
3. Did St. John’s Medical Center act arbitrarily and capriciously?


Teton County Hospital District, doing business as St. John’s Medical Center, is a Wyoming Governmental Agency organized pursuant to Wyo. Stat. Ann. §§ 35-2-401 through 35-2-404. St. John’s Board of Trustees (Board of Trustees or Board) is an “agency” as defined by Wyo. Stat. Ann. § 16-3-101(b)(i). Medical Staff Bylaws govern the management of the Hospital and were adopted pursuant to Wyo. Stat. Ann. § 35-2-113. As a requirement of continuing medical staff membership, all physicians must periodically submit an application for reappointment. The application for reappointment requires physicians to abide by all of the Bylaws, including those governing standards of professional conduct, and to sign a Code of Conduct resolution.


Judge(s): E. James Burke
Jurisdiction: Wyoming Supreme Court
Supreme Court Judge(s)
James Burke
Michael Golden
William Hill
Marilyn Kite
Barton Voigt

Trial Court Judge(s)
Nancy Guthrie

Appellant Lawyer(s) Appellant Law Firm(s)
Anna Olson Park Street Law Office
Weston W. Reeves Park Street Law Office

Appellee Lawyer(s) Appellee Law Firm(s)
Mark Kadzielski Fulbright & Jaworski, LLP
Janet Lewis Janet Lewis PC
Thomas Lubnau, II Lubnau Law Office, PC



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not be predicated solely upon the type of degree of procedural due process? admitting a patient or providing medical treatment unless they have been granted [24] the wapa does not mandate a clear and convincing burden of proof for patients or visitors. this includes responding to six separate incidents when he displayed anger or responded inappropriately 1) [31] the judicial review committee and the board of trustees found that all of dr. guier asserts that the burden-shifting under the bylaws logically requires him substantial evidence [32] we also cannot find error in the board's conclusion that dr. guier did not and regulations to be followed by physicians using the hospital facilities. board there are reasonable grounds to believe your conduct procedure and, during that procedure, to surgical items that were available but medicine, doctors of osteopathy, doctors of [1] dr. christian guier appeals from an order of the district court affirming a particular hospital. we have previously recognized that a hospital is entitled to july 20, 2006: two nurses testified that dr. guier themselves in a professional and cooperative individuals who did not actually witness the outbursts. case hearing is controlled by the wyoming administrative procedure act, and whether the exclusion was made on a rational basis, committee violated his due process rights, dr. guier makes much of the fact that the hospital's object of ensuring patient welfare. this evidence "in support of" its action and recommendation, then, according to section medical staff appointee to persuade the jrc that the action should not be taken. together or in teams, and a member who, because of operating room staff. the petition stated: including but not limited to, nurses, administrative approval, registration, charter or similar form of permission required by law." monitor and assess the quality of professional practice in the hospital and (2) to promote quality cooperatively with others, to relate to others in a civil, collegial, and courteous provided for in the bylaws. the bylaw governing the burden of proof at hearings arbitrary, capricious, or an abuse of discretion, the fragment. a nurse involved in the incident testified does not apply, bylaw viii.d.7 is not reasonable because it places the burden evidence." see, e.g., in re greene, 2009 wy 42, 10, 204 p.3d 285, 290 (wyo. [34] the jrc, as the trier of fact, was in the best position to determine the inability to relate to others in a civil, collegial, and courteous manner. the ann. 35-2-401 through 35-2-404. st. john's board of trustees (board of are based on evidence that a reasonable mind might 731 p.2d 1181, 1184 (wyo. 1987). a "preponderance of the evidence" is defined the extensive testimony regarding dr. guier's conduct in the operating room, and behavior expected of those with medical staff privileges. we find no error in the mec's action and recommendation. [22] dr. guier also asserts that his loss of privileges is similar to the loss of his recommendation. once that evidence is produced, the burden shifts to the beginning. 402(a)(xxvi)(a), a license may be revoked based on any action by a health care any one particular standard. dale, 23, 188 p.3d at 561. to the opening of an extra set of sponges; 2) to the suction not working properly inappropriate behavior. some of these incidents were verbally relayed to huffaker v. bailey, 540 p.2d 1398, 1400-01 (or. 1975) (footnotes omitted). facts licenses, are specific to individual hospitals, and decisions regarding staff license to practice medicine in montana or wyoming. we do not dispute that the are granted medical privileges agree to conduct might adopt, we cannot find that it is unreasonable or that it conflicts with the the competency and character of each applicant. needs to be granted to all individuals from the (e) unsupported by substantial most other courts have found that the factor of ability dr. guier's interaction with operating room personnel, and noted that all of the practice at st. john's and other facilities where he had privileges. summary suspension, the mec appointed an ad hoc committee to investigate the reappointment agreement, by refusing to notify concerning the management and operation of a health care facility. gonzales v. privileges." wyo. stat. ann. 35-2-113. staff privileges, in contrast to medical "[r]epeated instances of behavioral issues with dr. guier have created a strain in cooperativeness an important factor, and in these medical staff bylaws of st. john's medical staff shall remain in full force and his tenure, dr. guier exhibited disruptive behavior in the operating room on authority or limitations or lacking medical license because it has impacted his ability to earn a living by practicing find there is a clear and important distinction between hospital privileges and a and to adhere to a professional code of conduct, which includes "the ability to footnotes contrary to the other wapa review standards yet is not easily categorized or fit to october 9, 2006: a nurse testified that dr. guier and clinical performance for the entire term of the reappointment. the substantially similar findings. the mec determined that the incidents sufficiently the best or only action to take, or to establish that its physicians to abide by all of the bylaws, including those governing standards of findings and conclusions found to be: identified in the disruptive practitioner policy, the fact that the mec did not follow employees, medical staff members, patients or and that the mec would continue the focused review of his professional conduct work harmoniously with others;" to "work[] cooperatively with members, nurses, reasonable mind might accept in support of the agency's conclusions. dale, courteous manner and in private. proving, "by a preponderance of the evidence" medicine in the state of wyoming, and is able to practice his profession at other of any patient, employee, or other person present at wapa. conflict with the wapa, or other applicable law and this stipulation, in which case current operating room staff at st. john[']s medical of a license." circumstances it seems questionable whether this was arbitrary, capricious, or otherwise not in accordance with law. we affirm the discriminatory, arbitrary, or capricious. suspension of hospital privileges. wyo. stat. ann. 35-2-113 provides broad provided, however, that these hospitals by conversations concerning the behavior. however, the last paragraph of the , 2006. the ad hoc the wapa, or other applicable law and this stipulation, shall control." the request for an investigation pursuant to the bylaws. the mec informed dr. guier [25] dr. guier also argues that, even if a clear and convincing standard of proof supported a recommendation that dr. guier's medical staff membership and order for him to perform operations, admit patients to a hospital, and treat decision is limited to those considerations specified in wyo. stat. ann. 16-3- prerogative, decided that privileging decisions would be subject to a burden of the signatures below support this letter, as a much bylaws was applied at the contested case hearing. dr. guier agreed to be bound had come directly from the administrative agency. id. our review of an agency under the policy. the disruptive practitioner policy is not a rule promulgated by could have apologized and been admonished if necessary. he claims "[t]he workers' safety & comp. div., 2010 wy 85, 31, 233 p.3d 956, 968 (wyo. public funds, shall be open for practice to doctors of [41] affirmed. also maintains that the ad hoc committee learned of several of the incidents from agency to abide by its rules is per se arbitrary and the practitioner, discuss the incident, and document all meetings and viii.d.7 of the bylaws, dr. guier has the burden of became upset when a surgical supply item was vii.b.4. dr. guier was immediately notified of the decision and his right to a of proof conflicts with the burden identified in the bylaws and therefore [28] the medical staff bylaws require a medical staff member to "agree to n.j. super. 531, 90 a.2d 151 (ch. div. 1952). the wyoming statute that governs refusal petition prevented the hospital from properly staffing the or, creating a second occurred sometime between 1994 and 1996. a focused review of dr. treated courteously, respectfully and with dignity. to psychological abuse in a hostile work environment. rule or regulation. we note that the mec failed to adhere to the "critical" 2. whether the agency's breach of the medical staff staff. we have exhausted our pleas for change and preponderance of the evidence, that the decision of the medical executive [37] the medical executive committee was required to follow the formal not a medical license. it points out that dr. guier still has his license to practice hospital asserts that the clear and convincing standard does not apply because policy presents an informal approach to dealing with a supports this position by citing to bylaw v.a.1 which prohibits any person from discretion to a hospital in determining requirements for the ability to practice at a [4] dr. guier, an orthopedic surgeon, joined the medical staff in 1990. during that dr. guier had failed to prove that the mec's decision to permanently casper, wyoming. argument by mr. reeves. contested case hearing was held by the jrc and dr. guier was afforded an and recommendation. to satisfy this initial obligation, wyo. stat. ann. 16-3-101(a)(iii). the hospital argues that staff privileges are and the hospital's ceo, we cannot conclude the jrc erred in determining that be agreed upon in the near future. as a beginning we reappointment agreement, both of which specifically articulated the professional chiropractic, dentistry or podiatry in this state. decisions are granted to different administrative bodies. of his medical license. 2009) (suspension of chiropractor's license); dorr v. wyo. bd. of cert. pub. dr. guier signed the reappointment agreement on july 10, 2006, after writing that if disruptive behavior is reported, the chief-of-staff and ceo shall meet with not opened; and 6) to the potential contamination of a gown. the jrc concluded initial obligation, the mec only must show that its anticipated resolution is needed. should be rejected or modified. pursuant to the bylaws, the medical executive through may 31, 2006.1 staff bylaws. the mec was entitled to proceed under the bylaws and its [27] dr. guier asserts that the record lacks substantial evidence to support power, privilege or immunity; that end, while in st. john's facilities, individuals who prejudicial error. the reviewing court shall: revocation, restriction, or suspension of a medical license. wyo. stat. ann. 33- the authority to admit and treat patients. a medical license, however, confers a [14] it is well-established that a hospital board may prescribe reasonable rules room staff used unauthorized materials. one nurse october 2, 2006: an incident report stated that dr. and 31st were not documented by written reports. of the written reports that were made, bowen v. wyoming real estate comm'n, 900 p.2d 1140, 1142 (wyo. 1995) party and due account shall be taken of the rule of not limited to, nurses, administrative staff or other occasions, as noted in the focused review report, raise questions about your incidents were not as serious as reported. all incidents involved anger, conclude that the board's decision was arbitrary or capricious. while it may have dr. guier also called one other doctor on his behalf, who testified that dr. guier parties also agreed that only dr. guier's behavior, not the quality of care provided a. dr. guier shall not, under any circumstances, its facility, and does not transform a privilege to practice at a particular hospital behalf, and he was provided the opportunity to cross-examine each witness. decision of the jrc to the board of trustees, as provided for in the bylaws. the unprofessional or disruptive behavior while on st. he was doing, became angry and red in the face, was patients, and that privileges therefore meet the definition of a "license." he [36] dr. guier contends that the board's decision was per se arbitrary and issues. he stated that the petition came as a surprise to him because he made dr. guier yelled at operating room personnel during substantial evidence to support the board's final of behavior which would be considered unacceptable under the medical staff issues decision was the "correct" one. rather, to satisfy this st. john's styles the issues as follows: within earshot of any other individual at st. john's, d. dr. guier shall not threaten, physically or physicians. the medical practice act empowers the wyoming board of medicine proof on the medical staff appointee, and to require that the burden be met by a medical license. medical staff privileges allow a physician to use hospital city of lakeland, 158 fla. 151, 28 so. 2d 106 (fla. 1946); jacobs v. martin, 20 members to the appropriate supervisor in a disruptive, abusive, rude, hostile or otherwise bylaws would apply to the contested case hearing unless they conflicted with the christian guier, m.d. v. teton county hosptial district, the nature of the complaint (3) an opportunity to instrument's suction was not working properly. rather, he asserts that had the mec discussed and documented complaints that the mec's action and recommendation must committee reported six incidents between july and october of 2006 that it but that he did not witness dr. guier lose his temper during any of the incidents. to practice medicine," and lists more than thirty specific reasons justifying to catch agency action that prejudices a party's substantial rights or that may be including but not limited to, nurses, administrative (i) compel agency action unlawfully withheld forcefully tore the drapes off the patient and threw a monitoring when deemed appropriate by the medical executive committee." guier stated that he discussed the incident with b. dr. guier shall not, under any circumstances, that clinical privileges be terminated. dr. guier was notified of the mec's decision incidents occurred. he either could not remember the incidents or contends the dr. guier's testimony indicated his awareness of issues relating to his accusers with some exceptions)[.] due process personal collection service, 494 p.2d 201, 206 (wyo. 1972). however, a staff of the hospital advised dr. guier that "the mec is concerned about your six separate incidents of misconduct. dr. guier does not dispute that these by the hospital's ceo and by an ad hoc committee created by the mec. dr. to carry both the burden of production and the burden of persuasion, and that the when the agency reversed the burden of proof. behavior was under intense scrutiny, as indicated by the focused review of his discretion or otherwise not in take his own gown to decrease the possibility of cannot conclude that the mec did not follow its rules and regulations. (wyo. 2008). an administrative agency's conclusions of law are not entitled to hospital privileges provides individual hospitals broad discretion in the regulations, based on an express statutory grant of that power, obviates the need whether the review is conducted in the district court or could severely hinder the effective treatment of burden of proof to be applied. while it is not the level of proof that every hospital ii.e.7; ii.e.14. the code of conduct provides: [26] although somewhat entangled in his standard of proof argument, dr. guier equalization, 7 p.3d 900, 905 (wyo. 2000) (internal citations and quotation marks hospital, reviewed the focused report. in a june 21, 2006 letter, the chief-of- admissions and privileges to hospital administration. as stated above, that and institute some reasonable process to try and deal with some of the issues the suggested steps were taken by the hospital's ceo or chief-of-staff to became angry when surgery was postponed because record of an agency hearing provided by infection. according to the committee's report, dr. manner. all such individuals shall refrain from reasonable hospital bylaws, and was not medicine. he stated that the termination of his privileges was reported to the application for reappointment. the bylaws do not require a clear and convincing center, is a wyoming governmental agency organized pursuant to wyo. stat. staff privileges. after reviewing the entire record, we conclude the board's stated that when dr. guier realized an extra set of facilities and be assisted by hospital staff. as dr. guier points out, this includes faced the revocation of his medical staff privileges. the hospital, pursuant to its of this 16th another doctor, who agreed that dr. guier's reaction day of october 2006, the operating room against the hospital staff or medical staff. due committee presented its findings to the mec on november 9, 2006. the 2011 wy 31 supersedes the provision in the bylaws pursuant to the parties' stipulation. resolve the problems informally. nonetheless, the disruptive practitioner policy threat to the life, health and safety of its patients, summarily suspended dr. decision? admissible in administrative proceedings if it is probative, trustworthy, and decided: 02/24/2011 conditions that dr. guier would sign a medical staff reappointment agreement evidence or, in other words, that its action and this agreement is signed with the understanding, that the applicant and the governing body shall consider entity that adversely affects clinical privileges for a period of thirty or more days. that the hearing examiner erred by applying the burden of proof identified in the otherwise, any person at st. john's, including but judgment in this matter. lubnau law office, pc, gillette, wyoming. argument by mr. lubnau. personality or otherwise, is incapable of getting along, process is defined as (1) notification of a complaint (2) prevent the medical executive committee from be referred to the medical executive committee. and statutory right to a contested case hearing the record," is the assumption that an agency will center. these concerns are in reference to dr. chris in this court, the applicable standard of review is one decision arbitrary and capricious. pertaining to a practitioner's disruptive conduct may *chief justice at time of oral argument. credibility of the witnesses and to weigh the evidence. upon weighing the summarily suspended dr. guier's privileges for 29 days pending investigations recommended a six-month reappointment of dr. guier's privileges, on the the mec does not have to prove that its action was admissions and staff privileges. admission shall v. reports. reporter third. readers are requested to notify the clerk of the supreme court, [15] in his first issue, dr. guier asserts that the burden of proof in his contested of trustees of memorial hospital of sheridan county v. pratt, 262 p.2d 682, 688- reappointment application process. he was aware that failure to abide by the patients or visitors. dr. guier will address any appellee (respondent). internal disruptive practitioner policy. the disruptive practitioner policy provides staff at st. john[']s medical center refuses to 2005). requested a contested case hearing. that it is improper for any court to substitute its judgment for that of a hospital capricious. arbitrary & capricious teton county hospital district, d/b/a st. john's medical center, staff or other employees, medical staff members, exercising its prerogatives in these matters. this testified at the contested case hearing provided evidence of dr. guier's disruptive janet lewis, janet lewis, pc, jackson, wyoming; thomas e. lubnau, ii, reports, but stated that no one had brought up to him that there were behavioral it was the unanimous consensus of the mec that carry his burden of proving, by a preponderance of the evidence, that the (emphasis in original.) the mec discussed the petition with dr. guier at a incidents as required by bylaw vii.b.3. the mec determined that the ad hoc required by law; or green v. city of st. petersburg, 154 fla. 339, 17 so. 2d 517 (fla. 1944); selden wyoming administrative procedure act (wapa) or other applicable law. the the medical staff. as part of its consideration of dr. guier's application, the evidence in a case reviewed on the regarding his professional conduct prior to the workforce refusal petition, he according to the committee's report, dr. guier clearly distinguishes between a license and medical staff privileges. wyo. stat. ann. 33-26-102(a)(ix); see wyo. stat. ann. 33-26-202, 303-409. meeting held the following day. at that meeting, the doctor in charge of the support, either in whole or in part, is derived from great deference in the management of its facility and we afford great deference 89 (wyo. 1953); see also 41 c.j.s., hospitals, 5, p. 336; 28 a.l.r.5th 107; district, county or city thereof, and any hospital whose burke, justice. faced with a similar situation: [20] pursuant to statute, the wyoming board of medicine, not the judicial supreme court building, cheyenne, wyoming 82002, of any typographical or other him call people names," and "i've never heard him use profanity in any form, . . . [t]he professional review body that proposed the are licensed to practice medicine or surgery, room staff who worked directly with dr. guier testified at the contested case controlling question is whether good faith work with dr. guier of the kind pledged had privileges to practice. make discourteous comments, including but not dr. guier of complaints that had been made volume. to his disruptive behavior. the first of these incidents occurred in 1992 and the reappointment agreement could result in the loss of privileges and consequently staff members are frequently required to work (d) without observance of procedure staff. the jrc was assisted by a hearing officer. the parties agreed that the fact is more probable than its non-existence." judd v. state ex rel. wyo. applicability of the terms of an agency action. in disciplinary cases by clear and convincing evidence. painter v. abels, 998 p.2d action that is contrary to law but not readily correctible under the other applicable incident reports generated regarding dr. guier had been discussed with him by statutory provisions, and determine the meaning or were adopted pursuant to wyo. stat. ann. 35-2-113. as a requirement of previously recognized that the standard applicable to an adjudicatory hearing disruptive practitioner, which does not replace the case number: no. s-09-0259 in contested case hearings. see wyo. stat. ann. 16-3-114(c). we have c. dr. guier shall not, under any circumstances, staff members, threw the gown to the floor, and made general right to practice medicine within the boundaries of a particular process was not impacted. the district court determined that the board's decision. that review is limited to a determination of examiners, 845 p.2d 408, 416 (wyo. 1993) (suspension of medical license). the october 11, 2006: the investigation by the ad hoc hearing, as did the chief-of-staff, chief-of-surgery, and operating room issuing letters of admonition, warning or censure, as necessary, and (c) requiring routine supporting evidence, but the medical staff notwithstanding the foregoing, at any time an issue the working relationships between dr. guier and some members of the staff." decision to do so was not arbitrary or capricious. testify that revocation of his hospital privileges resulted in revocation of his [6] in the ensuing months, several employees reported incidents of dr. guier's grabbed the gown from one of the operating room contested case hearing on the matter in accord with bylaw vii.b.5. a board reviewed the entire record and found substantial evidence to support the anna m. reeves olson and weston w. reeves, park street law offices, incident occurred eight days after dr. guier signed the criticisms of or concerns about employees or staff professional conduct. your inappropriate interactions with staff on several me." dr. guier accused the nurse of sabotage when 1275, 1277 (wyo. 2010). when we consider an appeal from a district court's 1990). of a room conflict. another member of the operating continuing medical staff membership, all physicians must periodically submit an evidence, the jrc found that "dr. guier failed to meet his burden of proving, by a hospitals, dr. guier stated that he had lost privileges at a nearby hospital, and (citation omitted). reasonable and uniform rules and regulations covering staff admissions and staff [30] the decision to permanently suspend dr. guier's privileges was based on professional conduct, and to sign a code of conduct resolution. recommendation are not arbitrary or capricious and 11133(a)(1)(a). as a result of the reporting and subsequent notification to other capriciously? [29] the record contains ample evidence of dr. guier's inability to work [16] prior to the contested case hearing, the parties stipulated that "[t]he district court found that some of the procedures used during the investigation and an attempt to address problems in the operating room as they arose. conflict with the wapa and instructed the jrc to apply the burden of proof the mec chose to bypass the hospital's disruptive practitioner policy, and practice medicine in this state issued by the board pursuant to this chapter" and (b) contrary to constitutional right, review committee or the boards of trustees of individual hospitals, oversees story v. wyoming state board of medical examiners, 721 p.2d 1013, 1018 (wyo. focused review shared the findings from the latest focused review report with dr. these incidents were supported by substantial evidence. we agree with this [23] under wyo. stat. ann. 33-26-303(d), the board of medicine may deny must first present evidence "in support of" its action trustees or board) is an "agency" as defined by wyo. stat. ann. 16-3- management of their staffs: statute provides that "hospitals by appropriate bylaws shall promulgate could be interpreted as demeaning. abide by the rules it promulgates. the failure of an committee has the burden of producing evidence supporting its and the ceo also testified during the contested case hearing regarding those the possible contamination of his surgical gown. staff or other employees, medical staff members, national practitioner database as required by federal law. 42 u.s.c. action and recommendation are supported by unequivocal notice that his personal conduct had been an issue and would be hearing examiner determined that the burden of proof in the bylaws did not when he learned of the mishandling of a bone guier and his repeated abuse to the operating room decision by st. john's medical center board of trustees to revoke his medical review the whole record or those parts of it cited by a inappropriate conduct. [21] medical staff privileges, on the other hand, are addressed in the wyoming the hospital has discretion to enact reasonable and uniform rules and [13] we affirm an agency's findings of fact if they are supported by substantial determining whether the action of an agency is and/or modified. october term, a.d. 2010 surgical sponges had been opened he stopped what occurrences in the operating room as well as suspend his privileges should be reversed or modified. dr. guier appealed the center is that all individuals within its facilities be he learned the fragment had been discarded. 1 performance, the reappointment agreement, and correspondence during the physician's assistant who frequently worked with dr. guier testified in support of criticize any individual at st. john's in front of or yelled and was intimidating toward operating room medical staff bylaws. we note initially that the proper allocation of the burden of mistreatment of staff, and disruptive behavior, and all incidents demonstrated an july 21, 2006: two nurses testified that dr. guier burden of proof and allocates the burden to the wyoming board of medicine. supervisors did not discuss the verbal reports with dr. guier at the time they the procedure for not unwrapping items that would be lacked notice of the issues that were considered at the contested case hearing. (emphasis added.) dr guier asserts that the wapa requires the mec to prove [8] dr. guier was given the opportunity to provide information to the ad hoc proof is a matter of law and is reviewed de novo. penny v. state ex rel. wyo. [10] the jrc issued its findings and conclusions following the contested case opportunity to cross-examine witnesses and to present evidence, and the 1. whether dr. guier was denied his constitutional shout or otherwise raise his voice with any to work smoothly with others is reasonably related to be rejected or modified. right of the medical executive committee to exercise arbitrary and capricious standard as a safety net against administrative agency impact a physician's ability to maintain a medical practice. represented by counsel during the hearing, evidence was presented on his medical staff privileges. interactions with operating room personnel and he was clearly aware of the type personnel during a procedure in which an wyo. stat. ann. 33-26-407. the act defines a "license" as "a license to 3. did st. john's medical center act arbitrarily and practical effect of requiring the mec to produce "some evidence" supporting its human resources. dr. guier acknowledged that he had reviewed the incident care facility on that basis alone. also, under wyo. stat. ann. 33-26- mark a. kadzielski, fulbright & jaworski, llp, los angeles, california; was called to hearings before the wyoming and montana boards of medicine. conclusion seems justified for, in the modern hospital, procedural due process principles require reasonable notice and a meaningful [35] in his last issue, dr. guier asserts that the board's decision was arbitrary nurses, administrative staff or other employees, cite as: 2011 wy 31, __ p.3d __ the policy of st. john's medical center & living before kite, c.j., and golden, hill, voigt*, and burke, jj. orders or demands to any individual at st. john's, guier. the doctor explained that the most significant part of the report involved 1986). further, dr. guier did not deny that this incident occurred. the other in reviewing a decision of a public hospital to refuse to certain terms need to be defined, some facts or opportunity to be heard." amoco production co. v. wyoming state bd. of the board of trustees approved the six-month reappointment. wyo. stat. ann. 35-2-113 (lexisnexis 2009) (emphasis added). we have said burden of proof and do not require the burden of proof to be carried by the facilities in the state. dr. guier asserts that staff privileges are required by law in multiple occasions. prior to the events leading to this litigation, the operating decision is supported by substantial evidence, is not arbitrary or capricious, and the mishandling of the bone fragment. however, he denied yelling, approaching formal errors so correction may be made before final publication in the permanent grant or to terminate staff privileges of a physician, also documented in an incident report. medical staff bylaws. likewise, the reappointment agreement is not a hospital such referral may lead to a formal investigation and dr. guier claims they did not contain the level of detail required to determine he dr. guier's fair hearing? in any event was there nurses, technicians, and operating room staff involved in the incidents. he was the summary report from that review stated that agree to due process in the event of any complaint capricious because the medical executive committee did not follow the notice board's conclusion that the "reappointment agreement placed dr. guier on certificate to practice public accounting); devous v. wyoming state bd. of med. policy also provides: guier's performance at the hospital was conducted from december 1, 2005 known as the "medical practice act," provides rules relating to licensing of set forth the following conditions of reappointment: reasonable bylaws and requirements for physicians seeking hospital privileges at appropriate bylaws shall promulgate reasonable its recommended procedures does not violate dr. guier's due process rights. considered disruptive and abusive. the ceo presented a report with guier was notified in writing of the suspension and of the fact that there was a and proof we note that dr. guier did not provide details of those hearings and did not (ii) hold unlawful and set aside agency action, or unreasonably delayed; and guier cites involving license suspensions are inapposite. in this case, dr. guier (a) arbitrary, capricious, an abuse of application for reappointment. the application for reappointment requires decision. reynolds v. west park hospital district, 2010 wy 69, 6, 231 p.3d to operate with dr. guier if his privileges were reinstated. we are satisfied that credible, and otherwise satisfies the requirements of wyo. stat. ann. 16-3-108. its persistent concealment of evidence, renders its procedures provided for in the reappointment agreement or the hospital's any individual who calls to discuss concerns or even when we're out--you know, outside of the or. it's just not in his nature." manner, and to refrain from disruptive conduct. six members of the operating by the bylaws when he initially sought hospital privileges and in his subsequent staff membership and clinical privileges be terminated pursuant to bylaw contaminated gown on the floor was based on hearsay. nonetheless, hearsay is the same deference as its factual findings. we review an agency's conclusions evidence supporting those incidents can be summarized as follows: statute. violated the application for reappointment or the reappointment agreement. he this petition represents repeated documented page of the agreement and was signed by dr. guier. it provided: and efficiency of clinical and hospital services by (a) providing education and counseling, (b) 2. did st. john's medical center provide dr. guier [33] dr. guier also testified at the contested case hearing. he did not recall that were at hand." the typewritten addendum appeared at the bottom of the last the hospital. it is designated a "policy" and does not carry the authority of the discussion conclusion. the incident where dr. guier was alleged to have angrily thrown a discuss concerns or issues regarding dr. guier or representing appellant: shaking, and yelling, "like level 10 yelling." this [38] although he does not expressly argue that the medical executive loss of a bone fragment after surgery; 5) to the postponement of a surgical there is substantial evidence supporting the jrc's decision to revoke dr. guier's opted to address the disruptive conduct under the bylaws, which was its right omitted). dr. guier signed an application for reappointment and a reappointment agreement placed dr. guier on notice of expected standards of and uniform rules and regulations covering staff supervisor. the written reports of the ad hoc committee and the ceo contested case hearing were flawed, but concluded that dr. guier's right to due to patients, was at issue. dr. guier took the pretrial depositions of several dr. guier faced the revocation of his medical staff privileges, not the revocation 2002 wy 142, 7, 54 p.3d 768, 771 (wyo. 2002). we employ the may result in imminent danger to the life, health or each of the six incidents of his misbehavior. he contends that several incidents christian guier, m.d., which accords great deference to a hospital's supervisors and others were also documented in written reports. the were made. the workplace discord reached a crisis level on october 16, 2006 privileges. that bylaw also states that medical staff privileges are "in the nature corrective action as set forth in the medical staff [19] although medical staff privileges may be "in the nature of" a license, we notice: this opinion is subject to formal revision before publication in pacific the mec did not notify him immediately of each incident of inappropriate appellant (petitioner), dr. guier's voice may have taken on a stressor during several of the incidents, when the mec was presented with a "work refusal petition" signed by the entire accordance with the law." dc production service v. wyo. dep't of employment, preponderance of the evidence, is unreasonable. underlying our often repeated statement that "in assistant stated: "i've never heard dr. guier raise his voice. . . . i've never heard [7] at the conclusion of the meeting, the medical executive committee does not replace the right of the mec to exercise its powers under the medical the honorable nancy j. guthrie, judge safety of any such person. thus, the mec decided to conflicting evidence regarding his conduct in the operating room. one (c) to the extent necessary to make a decision and room staff testified that, after a room was arranged, anyone in a threatening manner, or losing his focus on the patient. its powers as set forth in the medical staff bylaws. july 18, 2006: two nurses testified that dr. guier representing appellee: documentation standards of the disruptive practitioner policy, and that none of standards of review. reynolds, 6, 231 p.3d at 1277. the fact that there may be additional consequences to a physician who loses him, a hearing before an impartial tribunal, representation by counsel, the loss of privileges at a particular hospital or health care facility may seriously substantial evidence. substantial evidence is relevant evidence which a against him, its disregard for its own policies, and effect, and shall apply to the contested case hearing except where they are in to "[g]rant, refuse to grant, suspend, restrict, revoke, reinstate or renew licenses supported by substantial evidence, in accordance with guier's privileges for 29 days according to bylaw vii.c.1. following the accountants, 2006 wy 144, 13, 146 p.3d 943, 949 (wyo. 2006) (suspension of making the following determinations, the court shall provides, in pertinent part: physician may not be excluded by rules, regulations, or acts of the hospital's of law de novo, and "[w]e will affirm an agency's legal conclusion only if it is in behavior. we note initially that dr. guier does not actually contend that he modified." the jrc found that the documentary and testimonial evidence hospital administration and others so as to promote high quality patient care;" evidence" standard customarily used in civil cases. willadsen v. christopulos, [40] having reviewed the record we cannot conclude that the board's decision room staff at st. john's had refused to work with dr. guier on two occasions due the revocation of professional licenses required the hospital to prove the hearing. it concluded that the application for reappointment and the terms of the public health and safety statutes relating to hospitals and other care facilities. a focused review is authorized under the medical staff bylaws as part of a "program (1) to is otherwise in accordance with law. we affirm. medical executive committee (mec), the professional review body at the several of the incidents. he admitted to being angry when he found out about any hospital owned by the state, or any hospital continue performing any cases with dr. chris guier. his patients. privileges are within the discretion of hospital management. the cases that dr. defended his behavior by stating that he prefers to if you decide that the mec has presented brought against dr. guier and vice versa, by dr. guier individual at st. john's, including but not limited to, adverse recommendation or action should be rejected became angry during a procedure when the operating [2] dr. guier presents the following issues for review: [5] in may of 2006, dr. guier completed an application for reappointment to ability to work reasonably with others in the hospital." in july, the mec reappointment agreement identified several specific behavioral concerns and dr. guier. in reference to dr. guier's professional behavior, the physician's opportunity to inspect documentary evidence against him. in light of the ample more than one witness. the six members of the operating room staff who 931, 940 (wyo. 2000). dr. guier contends that our cases applying the wapa to respond and (4) call for witnesses (including the before an agency, unless otherwise stated, is the "preponderance of the damage his career. in spite of the terms of his reappointment agreement, dr. guier had not met his burden of proof. bylaws and the reappointment agreement. bylaws. nothing in this policy shall be interpreted to discriminatory. pratt, 262 p.2d at 689. we have stated: impose this temporary precautionary suspension. [17] the language of the wapa does not expressly provide a standard of proof hospital. allegations supporting revocation of his privileges by "clear and convincing pair of scissors during this incident. the incident was [9] the contested case hearing was held over several evenings before a for a discussion regarding the effect of burden-shifting under the bylaws. as conduct. the jrc also concluded that dr. guier violated those standards during [39] "parties to administrative proceedings are entitled to due process of law. garrison v. board of trustees of memorial hospital, 795 p.2d 190, 193 (wyo. relate to others in a civil, collegial, and courteous manner." bylaws ii.b.1.e; appeal from the district court of teton county decision was supported by substantial evidence and affirmed the jrc's decision. 101(b)(i). medical staff bylaws govern the management of the hospital and v. city of sterling, 316 ill. app. 455, 45 n.e.2d 329 (ill. app. ct. 1942); bryant v. on the physician facing charges to show that the adverse recommendation recommendation should be set aside or modified. dr. guier presented some issues regarding dr. guier or his patients. evidence. dale v. s & s builders, llc, 2008 wy 84, 22, 188 p.3d 554, 561 agreement is subject to acceptable amendments to relevant questions of law, interpret constitutional and appointee shall have the burden of proving, by a when presented, the reviewing court shall decide all committee revealed that dr. guier reacted angrily to this petition also represents the concerns of the the ample documentation produced by the investigations of the ad hoc committee closely scrutinized during the period of his reappointment to the medical staff." preponderance of the evidence, that the proposed review of an administrative agency's decision, we review the case as though it that dr. guier "was so angry. he started coming at investigation were submitted as evidence. the head of the ad hoc committee however, dr. guier continued to act in a manner that jeopardized his ability to to the hospital's determination of standards relating to hospital privileges. (c) in excess of statutory jurisdiction, guier became angry with the operating room staff procedures provided for in its bylaws, which were promulgated pursuant to decision does not in any way assuage his burden. however, our conclusion that committee at two meetings held on october 30th its allegations by "clear and convincing evidence." he contends that this burden professional license, and have instead required a licensing board to prove its medical staff members, patients or visitors. this garrison, 795 p.2d at 193. in sum, the hospital was entitled to establish the acknowledged in wyoming, as indicated by the fact that licensing and privileging 26-202(b)(i), 33-26-402(a)(i)-(xxxiv). the act provides a clear and convincing visitors. the hospital and that the failure to take prompt action dr. guier timely appealed to this court. indicated above, we do not find that the hospital's decision to place the burden of reappointment agreement. did not have any behavioral problems at any of the other hospitals at which he a demeaning comment to the staff member. dr. guier according to section viii.d.7 of the bylaws, the mec and his right to a contested case hearing on the matter. he subsequently would have saved his career." dr. guier received notice of the charges against standard generally does not adequately protect the property interest one has in a also appears to contend that the board's decision was not supported by physician licensing matters. title 33, chapter 26 of the wyoming statutes, viii.d.7. burdens of presenting evidence 11, 188 p.3d at 558. court should gainsay the hospitals' experience and includes responding to any individual who calls to chiropractic, doctors of dentistry and podiatrists, who he testified that the or is a very loud and sometimes stressful place and that been possible to resolve informally under the methods of conflict resolution staff privileges, however, does not impair the ability of a hospital to establish [18] a "license" is defined in the wapa as "any agency permit, certificate, d/b/a st. john's medical center e. dr. guier shall not exhibit any other inappropriate, limited to, name calling, or give discourteous incidents were testified to by eye-witnesses and several were corroborated by statute. the record reflects that it did that. the mec, finding that the work as "proof which leads the trier of fact to find that the existence of the contested 2010). we have also recognized that the preponderance of the evidence 114(c) (lexisnexis 2009) which provides, in pertinent part: judicial review committee (jrc) comprised of four physicians from the medical mental health prof. licensing bd., 2005 wy 117, 13, 120 p.3d 152, 160 (wyo. adverse recommendation or action shall present standard & burden of proof and capricious. the arbitrary and capricious standard remains as a "safety net" during a procedure; 3) when a surgical supply item was unavailable; 4) to the proof expressly identified in the bylaws, and the burden of proof set forth in those patients. . . . hospitals uniformly consider appeal to the board of trustees according to bylaws viii.d and viii.e. we jurisdiction. the distinction between a medical license and staff privileges is behavior. all six members of the staff testified that they would continue to refuse 1. was the burden of proof applied appropriately in board's decision for reasons articulated by the oregon supreme court when committee's investigation supported a recommendation that dr. guier's medical accordance with law; [11] dr. guier appealed the board's final decision to the district court. the needed, though they were available in the room. process that was provided to contest the decision of the mec, we cannot unavailable. both nurses testified that dr. guier [12] we review the board's action as we would review any other agency's his own "addendum," which he testified was "an avenue in which we could try accept in support of the actions and recommendation. governing authorities which are unreasonable, arbitrary, capricious, or john's premises. have finally resorted to this method of resolution. as licensure to a person whose privileges have been revoked at a particular health standard of review into a medical license. in this case, dr. guier was aware that his professional and activities pose a threat to the life, health, or safety [3] teton county hospital district, doing business as st. john's medical court ascertains whether the decision is supported by committee to permanently suspend his privileges should be reversed or the statute governing hospital privileges expressly entrusts matters of staff conclusions are in need of verification, and that the demonstrated that dr. guier engaged in unacceptable personal conduct. given (emphasis added.) the hearing examiner instructed the jrc as follows: statutory right;

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