Medical Staff Bylaws - Arkansas Children's Hospital

ARTICLE 9: INVESTIGATIVE REVIEW MEASURES AND CORRECTIVE ACTION9.1 Policy9.1.1 Whenever the activities, clinical performance, or professional conduct of any Practitionerwith clinical privileges are considered to be lower than the standards or aims of the Medical Staff, or thequalifications, obligations or responsibilities of Practitioners, are disruptive to the operations of theHospital, detrimental to patient safety or delivery of appropriate patient care in the Hospital, in disregardof or contrary to the Medical Staff Bylaws, Rules and Regulations, or Hospital policies, or animpairment to the community's confidence in the Hospital, such activity shall be reported to an officer ofthe Medical Staff, a Chief of any service, the Medical Director, Associate Medical Directors, or theChief Executive Officer.Disruptive behavior involving patients, employees, visitors or members of the Medical Staff will not betolerated as such activity impairs the effective functioning of the Hospital and has an adverse impact onpatient care. “Disruptive Behavior” may involve, but is not limited to, tirades, abusive treatment orsexual harassment involving patients, employees, visitors or other Medical Staff members. (Refer toACH Personnel Policy 400500)9.1.2 The MSEC maintains its authority to evaluate/assess issues, concerns and complaintsregarding activities, clinical performance and/or professional conduct of any Practitioner with clinicalprivileges.9.1.3 In conducting such evaluation/assessment, any actions, reports and records of writtendocumentation generated thereby are absolutely privileged communications pursuant to Ark Code Ann.§16-46-105.9.1.4 The member of the Medical Staff who is accused will be informed that retaliation orintimidation against the individual who has registered a concern can be considered an independent basisfor disciplinary action regardless of the outcome of the original concern.9.2 Investigation of Allegations of Conduct or Performance of Practitioner9.2.1 All allegations regarding conduct or performance of a Practitioner reported to any officerof the Medical Staff, a Chief of any Service, the Associate Medical Directors, or the Chief ExecutiveOfficer, may be reported to the MSEC through the Medical Director. Allegations regarding conduct ofPractitioners who are UAMS physician employees or residents may be reported to the MSEC throughthe UAMS ILLUMINE system.9.2.2 The MSEC may delegate its authority to evaluate/assess allegations, regarding theconduct or performance of a Practitioner, to the Medical Director or the UAMS Senior Advisory Council(“SAC”) pursuant to the UAMS ILLUMINE system, as applicable.29