( 3 ) facilitating a formal collegial counseling ( i . e ., a planned , face-to-face meeting between an individual and one or more Medical Staff Leaders ) in order to directly discuss a matter and the steps needed to be taken to resolve it ;
( 4 ) communicating expectations for professionalism and behaviors that promote a culture of safety ; and
( 5 ) developing a voluntary clinical improvement plan or voluntary improvement plan for conduct that can be used to address a concern .
These progressive steps are to be documented and included in a member ’ s confidential file . The written response by the member to any of these progressive steps will also be included in the member ’ s confidential file .
( f ) These efforts are fundamental and integral components of Renown ’ s professional practice evaluation activities and are confidential and protected in accordance with state law .
( g ) Initial collegial efforts and other progressive steps are encouraged , but are not mandatory , and are within the discretion of the appropriate Medical Staff Leaders and Administration . When a question arises , the Medical Staff Leaders and / or Administration may :
( 1 ) address the question in accordance with this Manual or refer the matter to be addressed pursuant to the initial collegial efforts and other progressive steps described in the professional practice evaluation policy , code of conduct policy , practitioner health policy , or other relevant policy ; or
( 2 ) refer it to the MEC for its review and action . 6 . B . GUIDELINES FOR COLLEGIAL INTERVENTION
There will be no recording ( audio or video ) or transcript made of any meetings that involve initial collegial efforts or other progressive steps activities .
6 . B . 1 . No Right to the Presence of Others :
( a ) Credentialing and peer review activities , including all activities set forth in this Article , are confidential and privileged to the fullest extent permitted by law . Accordingly , the individual may not be accompanied by friends , relatives or colleagues when attending a meeting that takes place pursuant to this Article . By agreement of the Chief of Staff and CMO / VPMA , an exception may be made to this general rule .
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