Medical Staff Bylaws - Arkansas Children's Hospital
Medical Staff Bylaws - Arkansas Children's Hospital
Medical Staff Bylaws - Arkansas Children's Hospital
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9.2.2.1 In conducting such evaluation/assessment on behalf of the MSEC, the <strong>Medical</strong>Director’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 <strong>Medical</strong> Director shall be evaluated/assessed solelyby the <strong>Medical</strong> <strong>Staff</strong> 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 <strong>Medical</strong> Director will notify the involved Practitioner of an allegation aswell as the Chief of <strong>Staff</strong> and Chief of Service.9.2.2.4 Evaluation/assessment of the concern will be conducted by the <strong>Medical</strong>Director, SAC, and others as needed. The <strong>Medical</strong> 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 <strong>Medical</strong> Director, who will submit a writtenreport of the evaluation/assessment, including recommendations, if any, for further action to the <strong>Medical</strong><strong>Staff</strong> Leadership and Chief of <strong>Staff</strong>.9.2.5 The <strong>Medical</strong> <strong>Staff</strong> Leadership will decide if further action is required. Actions whichmay be taken by the <strong>Medical</strong> <strong>Staff</strong> Leadership include, but are not limited to, counseling, requiringreferral to the MSHC, further information gathering by the <strong>Medical</strong> Director or SAC, or recommendingto the MSEC that an Ad Hoc Committee be appointed to formally investigate the matter.30