Medical Staff Services

Process for Dealing with Complaints Made to the MEC Committee on Professional Conduct

Purpose:

The purpose of the Committee is to identify, verify and remediate unprofessional behavior among members of the medical staff.

Membership:

The Committee shall consist of a chair, vice-chair and three other members appointed by the Medical Executive Committee. They shall include physician representatives from the Departments of Medicine, Surgery and Pediatrics, one other physician appointed by the Medical Executive Committee from a Department other than Medicine, Surgery or Pediatrics and a resident. The MEC will appoint the chair and vice-chair from among the five members listed above. A quorum of three, including the chair or vice-chair shall be required to conduct business. The committee shall meet at least quarterly for ongoing business as well as to handle complaints and more frequently if warranted by the number of complaints. Any member who has two sequential unexplained absences shall be replaced.

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Reporting:

Complaints of violations of the Code of Professional Conduct will be reported according to the document "How to report a violation or discuss a concern." Faculty performing clinical, teaching or research activities within UMMC should be reported to the Medical Executive Committee's Committee on Professional Conduct. Unprofessional behavior on the part of others is outlined in the document "How to Report a violation or discuss a concern about the Code of Professional Conduct."

Screening Process for Determination of Merits of the Case:

The purposes of the Screening Meeting are to review an allegation to determine the need for a Committee Meeting, the character of the Committee Meeting, and the kinds of evidence that must be gathered to fully deal with the case. The Chair will initiate a Screening Meeting to discuss the allegation and plan the appropriate investigation for a Committee Meeting. The Screening Meeting shall be the first step in the Committee's response to a written allegation that falls within its purview. The Screening Meeting may consist of a sub-committee of the chair or vice-chair and two other members. A member must disqualify himself or herself if familiarity with the parties or the particular case might present actual or perceived bias or conflict of interest. If a matter can be resolved in the Screening Meeting, a Committee Meeting is not required.

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Investigation:

If a Committee Meeting is deemed necessary, the Screening Meeting shall determine if an investigation is needed and the member(s) of the Committee will undertake it. It is appropriate for such an investigation to explore relevant activities of the accused if legitimate questions of character and suitability for professional function are at issue. Any Committee member who conducts such an investigation may present the findings to the full Committee. A Committee Meeting will take place when the necessary preliminaries have been completed.

Committee Meeting:

The purposes of a Committee Meeting are to resolve an allegation of a violation of the Code by a finding of misconduct or no misconduct, and to recommend one or more penalties if the finding is misconduct. The Committee Meeting shall consist of a meeting of the Committee with the person making the complaint as well as a meeting of the Committee with the person against whom the complaint is made. A member must disqualify himself or herself if familiarity with the parties or the particular case might present actual or perceived bias or conflict of interest. If the person against whom the complaint is made refuses to appear, this will be brought to the attention of the MEC and the Dean of the School of Medicine and/or the CEO of UMMS depending upon the circumstances.

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Sanctions:

In the case of a faculty member or resident, a finding of misconduct will be considered grounds for one or more of the following:

A verbal reprimand.
Remediation, e.g. a requirement for supervision, mentorship, a course (e.g. in anger management), monitoring, etc.
A written reprimand, a copy of which will be kept in the physician's medical staff file.
Referral to the MEC for further action, including the possibility of revocation of medical staff privileges.

Written record:

The Committee will keep minutes of all meetings which are protected as medical review documents.

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This page was last updated on: December 6, 2007.

For more information, call the University Physicians Consultation and Referral Service at 1-800-492-5538 (patients) or 1-800-373-4111 (physicians).