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 , though documentation may be created in the discretion of the Medical Staff Leader and maintained in the individual ’ s confidential 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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