Section 1 .
Collegial , Educational , and / or Informal Proceedings
1.1 Criteria for Initiation
These bylaws encourage medical staff leaders and hospital management to use progressive steps , beginning with collegial and education efforts , to address questions relating to an individual ’ s clinical practice and / or professional conduct . The goal of these progressive steps is to help the individual voluntarily respond to resolve questions that have been raised . All collegial intervention efforts by medical staff leaders and hospital management shall be considered confidential and part of the hospital ’ s performance improvement and professional and peer review activities . Collegial intervention efforts are encouraged , but are not mandatory , and shall be within the discretion of the appropriate medical staff leaders and hospital management . When any observations arise suggesting opportunities for a practitioner to improve , the matter should be referred for peer review in accordance with the peer review and performance improvement policies adopted by the medical staff and hospital . Collegial intervention efforts may include but are not limited to the following :
a . Educating and advising colleagues of all applicable policies , including those related to appropriate behavior , emergency call obligations , and the timely and adequate completion of medical records ;
b . Following up on any questions or concerns raised about the clinical practice and / or conduct of privileged practitioners and recommending such steps as proctoring , monitoring , consultation , and letters of guidance ; and
c . Sharing summary comparative quality , utilization , and other relevant information to assist individuals to conform their practices to appropriate norms .
Following collegial intervention efforts , if it appears that the practitioner ’ s performance places patients in danger or compromises the quality of care , or in cases where it appears that patients may be placed in harm ’ s way while collegial interventions are undertaken , the MEC will consider whether it should be recommended to the Board to restrict or revoke the practitioner ’ s membership and / or privileges . Before issuing such a recommendation the MEC may authorize an investigation for the purpose of gathering and evaluating any evidence and its sufficiency .
MEDICAL STAFF Investigations , Corrective Action , Hearing and Appeal Plan
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