Section 4 .
Initiation and Notice of Hearing
4.1 Initiation of Hearing
Any practitioner eligible for medical staff appointment or physicians eligible for privileges without membership shall be entitled to request a hearing whenever an unfavorable recommendation with regard to clinical competence or professional conduct has been made by the MEC or the Board . Hearings will be triggered only by the following “ adverse actions ” when the basis for such action is related to clinical competence or professional conduct :
a . Denial of medical staff appointment or reappointment ; b . Revocation of medical staff appointment ;
c . Denial or restriction of requested clinical privileges , but only if such suspension is for more than fourteen ( 14 ) calendar days and is not caused by the member ’ s failure to complete medical records or any other reason unrelated to clinical competence or professional conduct ;
d . Involuntary reduction or revocation of clinical privileges ;
e . Application of a mandatory concurring consultation requirement , or an increase in the stringency of a pre-existing mandatory concurring consultation requirement , when such requirement only applies to an individual medical staff member and is imposed for more than fourteen ( 14 ) calendar days ; or f .
Suspension of staff appointment or clinical privileges , but only if such suspension is for more than fourteen ( 14 ) calendar days and is not caused by the member ’ s failure to complete medical records or any other reason unrelated to clinical competence or professional conduct .
4.2 Hearings Will Not Be Triggered by the Following Actions a . Issuance of a letter of guidance , warning , or reprimand ;
b . Imposition of a requirement for proctoring ( i . e ., observation of the practitioner ’ s performance by a peer in order to provide information to a medical staff peer review committee ) with no restriction on privileges ;
c . Failure to process a request for a privilege when the applicant / member does not meet the eligibility criteria to hold that privilege ;
d . Conducting an investigation into any matter or the appointment of an ad hoc investigation committee ;
e . Requirement to appear for a special meeting under the provisions of these bylaws ; f . Automatic relinquishment or voluntary resignation of appointment or privileges ;
g . Imposition of a precautionary ( summary ) suspension or administrative time out that does not exceed fourteen ( 14 ) calendar days ;
h . Denial of a request for leave of absence , or for an extension of a leave ; i . Determination that an application is incomplete or untimely ; j . Determination that an application will not be processed due to misstatement or omission ; k . Decision not to expedite an application ;
MEDICAL STAFF Investigations , Corrective Action , Hearing and Appeal Plan
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