ARTICLE 6
MANAGING QUESTIONS ABOUT MEDICAL STAFF MEMBERS AND ADVANCED PRACTICE PROVIDER STAFF MEMBERS
6. A. INITIAL COLLEGIAL EFFORTS AND OTHER PROGRESSIVE STEPS 6. A. 1. Options Available to Medical Staff Leaders and Administration:
( a) This Policy and other Medical Staff policies( e. g., professional practice evaluation policy, code of conduct policy, practitioner health policy) encourage and outline the use of collegial efforts and other progressive steps to address and resolve questions that may be raised about a member’ s competence, health or behavior.
( b) The goal of these initial collegial efforts and other progressive steps is to arrive at voluntary, responsive actions by the member to resolve the questions that have been raised.
( c) Medical Staff Leaders and Administration have been authorized by the MEC to engage in initial collegial efforts and other progressive steps as part of the Medical Staff’ s professional practice evaluation functions and on behalf of its committees that perform those functions.
( d) Initial collegial efforts include activities such as:
( 1) informal mentoring, coaching, or counseling by a Medical Staff Leader( e. g., advising an individual of policies regarding appropriate behavior, communication issues, emergency call obligations, or the timely and adequate completion of medical records); and
( 2) sharing comparative data, including any variations from clinical practice or evidence-based protocols or guidelines, in order to assist the individual with conforming their practice to appropriate norms.
These efforts are not required to be documented thoroughly, though light documentation may be created in the discretion of the Medical Staff Leader and maintained in the individual’ s confidential credentialing file.
( e) Other progressive steps include, but are not limited to, the following actions:( 1) addressing minor performance issues through an awareness letter;
( 2) sending an educational letter that describes opportunities for improvement and provides specific guidance and suggestions;
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