Section 2 .
Investigations
2.1 Initiation
A request for an investigation must be submitted in writing by a medical staff officer , medical staff committee chair , Department Chief , CEO , CMO , or hospital board chair to the MEC . The request must be supported by references to the specific activities or conduct that is of concern . If the MEC initiates an investigation , it shall document its reasons and notify the practitioner .
2.2 Investigation
If the MEC decides that an investigation is warranted , it shall notify the Board . If the Board believes the MEC has incorrectly determined that an investigation is not necessary , it may direct the MEC to proceed with an investigation .
The MEC may conduct the investigation itself or may assign the task to an individual , or appropriate standing or ad hoc committee of the medical staff .
If the investigation is delegated to a committee other than the MEC , such committee shall proceed with the investigation promptly and forward a written report of its findings , conclusions , and recommendations to the MEC as soon as feasible . The committee conducting the investigation shall have the authority to review all documents it considers relevant , to interview individuals , to consider appropriate clinical literature and practice guidelines , and to utilize the resources of an external consultant if it deems a consultant is necessary and such action is approved by the MEC and the CEO . The investigating body may also require the practitioner under review to undergo a physical and / or mental examination and may access the results of such exams . The investigating body shall notify the practitioner in question of the allegations that are the basis for the investigation and provide to the practitioner an opportunity to provide information in a manner and upon such terms as the investigating body deems appropriate . The meeting between the practitioner in question and the investigating body ( and meetings with any other individuals the investigating body chooses to interview ) shall not constitute a “ hearing ” as that term is used in the hearing and appeals sections of these bylaws . The procedural rules with respect to hearings or appeals shall not apply to these meetings either . The individual being investigated shall not have the right to be represented by legal counsel before the investigating body . Despite the status of any investigation , the MEC shall retain the authority and discretion to take whatever action may be warranted by the circumstances , including suspension , termination of the investigative process ; or other action .
2.2.1 An external peer review consultant may be considered when : a . Litigation seems likely ;
b . The hospital is faced with ambiguous or conflicting recommendations from medical staff committees , or where there does not appear to be a strong consensus for a particular recommendation . In these circumstances consideration may be given by the MEC or the Board to retain an objective external reviewer ;
c . There is no one on the medical staff with expertise in the subject under review , or when the only physicians on the medical staff with appropriate expertise are direct competitors , partners , or associates of the practitioner under review .
d . Determined necessary by the MEC , Board or investigating body .
MEDICAL STAFF Investigations , Corrective Action , Hearing and Appeal Plan
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