Medical Staff Bylaws - Arkansas Children's Hospital

9.2.2.1 In conducting such evaluation/assessment on behalf of the MSEC, the MedicalDirector’s and/or SAC’s actions and any reports, records of written documentation generated thereby areabsolutely privileged communication pursuant to Ark. Code. Ann. §16-46-105.9.2.2.2 Allegations involving the Medical Director shall be evaluated/assessed solelyby the Medical Staff Leadership Committee or SAC with the affected Practitioner refraining fromparticipation as a Committee member in any phase of the procedure.9.2.2.3 The Medical Director will notify the involved Practitioner of an allegation aswell as the Chief of Staff and Chief of Service.9.2.2.4 Evaluation/assessment of the concern will be conducted by the MedicalDirector, SAC, and others as needed. The Medical Director may obtain and utilize clinical andprofessional performance data in the evaluation/assessment. Interviews may also be conducted asneeded.9.2.2.5 Confidentiality will be maintained to the extent possible.9.2.3 Documentation of the alleged conduct or performance will include the following ifavailable:9.2.3.1 the date and time of the questionable behavior, conduct or performance;patient;9.2.3.2 if the incident affected or involved a patient in any way, the name of the9.2.3.3 the circumstances which preceded the situation;performance;9.2.3.4 a factual and objective description of the questionable behavior, conduct or9.2.3.5 the consequences, if any, of the behavior, conduct or performance as it relatesto patient care or hospital operations; and9.2.3.6 a record of action taken to remedy the situation including date, time, place,action and names of those who are interviewed.9.2.4 The documentation will be submitted to the Medical Director, who will submit a writtenreport of the evaluation/assessment, including recommendations, if any, for further action to the MedicalStaff Leadership and Chief of Staff.9.2.5 The Medical Staff Leadership will decide if further action is required. Actions whichmay be taken by the Medical Staff Leadership include, but are not limited to, counseling, requiringreferral to the MSHC, further information gathering by the Medical Director or SAC, or recommendingto the MSEC that an Ad Hoc Committee be appointed to formally investigate the matter.30