duties as a committee member or medical staff leader, may participate in the investigating committee, this includes the MEC and the QPRC, or any of the individual members of these committees.
6. F. 4. Investigative Procedures:( a) The investigating committee has the authority to:
( 1) review relevant documents, which may include patient records, incident reports and relevant literature or guidelines;
( 2) conduct interviews and prepare a summary of each interview, which each interviewee will be asked to review, revise, and sign;
( 3) use external review; or
( 4) require an examination or assessment by a health care professional( s) acceptable to it. The individual being investigated will execute a release allowing the investigating committee to discuss with the health care professional( s) the reasons for the examination or assessment and allowing the health care professional to discuss and report the results to the investigating committee. The cost of such health examination will be borne by the Hospital.
( b) If a decision is made to obtain an external review, the individual under investigation will be notified of that decision and the nature of the external review. Upon completion of the external review, the individual will be provided a copy of the reviewer’ s report.
( c) The individual will have an opportunity to meet with the investigating committee before it prepares its final report. Prior to this meeting, the individual will be informed of the questions and / or concerns being investigated. The investigating committee may also ask the individual to provide written responses to specific questions related to the investigation ahead of the meeting.
( d) At the meeting, the individual will be invited to discuss, explain, or refute the questions that gave rise to the investigation or that have been identified by the investigating committee during its review. A summary of the interview with the individual will be made and will be included with the investigating committee’ s report. The interview summary will be shared with the individual prior to the investigating committee finalizing its report. The individual may review the interview summary and recommend suggested changes, but there is no requirement to accept the individual’ s changes.
( e) This meeting is not a hearing, and none of the procedural rules for hearings will apply. Lawyers for neither side willbe present at this meeting.
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