Medical Staff Bylaws - Arkansas Children's Hospital

9.2.5.1 Any action of Medical Staff Leadership, other than a summary suspension(Paragraph 9.4), which may result in a revision, reduction or revocation of privileges must be made as arecommendation to MSEC.9.2.5.2 Repeated incidents or a single event of significant severity may warrantsubmission to the MSEC and/or SAC for consideration of corrective action.9.2.5.3 The Practitioner will be afforded an opportunity to respond to the allegationsin writing. If the Practitioner desires to respond in writing, the Practitioner will be allowed seven (7)business days from receipt of the allegations in which to submit the written response to the MedicalDirector. The Medical Director may conduct an additional evaluation/assessment if deemed appropriateupon receipt of the Practitioner’s response.9.2.6 When the recommendation of Medical Staff Leadership is to trigger a formalinvestigation or for corrective action, the Chief of Staff or Medical Director will inform the affectedPractitioner, SAC (as appropriate), the Chief Executive Officer and the Chief of Service.9.2.7 If corrective action is determined by the MSEC to be appropriate, the procedure outlinedin these Bylaws will be followed.9.2.8 Documentation of any substantiated complaint will be placed in the Practitioner’sconfidential QI file, including recommendations of the Medical Staff Leadership.9.3 Corrective Action9.3.1 Whenever there are grounds to suspect that a Practitioner with clinical privileges hasengaged in, made or exhibited acts, statements, demeanor, or engaged in personal or professionalconduct or performance, either within or outside the hospital, which is, or is reasonably likely to be:A. Lower than the standards or aims of the Medical Staff or the qualifications,obligation or responsibilities of Practitioners;B. Disruptive to the operations of the hospital;C. Detrimental to patient safety or delivery of appropriate patient care;D. Contrary to or in disregard of the Medical Staff Bylaws, Rules and Regulations, orhospital policies; orE. An impairment to the community's confidence in the hospitalCorrective action against the Practitioner may be instituted and requested by any officer of the MedicalStaff, a Chief of any Service, the Chief Executive Officer, or the Board of Directors. All requests forcorrective action will be in writing, will be made to the MSEC, and shall be supported by reference tothe specific activities or conduct which constitutes the grounds for the request.31