An adverse occurrence involving a medical staff member should be evaluated by the Chief of the Medical Staff or another medical staff officer to determine its nature and severity. This can help determine if the event can be resolved simply or require a formal intervention.



(1) Verify that the event occurred.

(2) Determine the type of occurrence.

(3) Determine the severity of the occurrence.

(4) Determine if the practitioner has a documented history of similar or other events.

(5) Evaluate the practitioner’s status (independent, contracted, special arrangement).


Type of occurrence:

(1) criminal action

(2) disruptive behavior

(3) abusive (sexual, physical, verbal), contributing to a threatening work environment

(4) substandard care

(5) impacting patient safety

(6) violation of medical staff bylaws


Severity of the Occurrence



unverified or minimal



mild to moderate


informal resolution



based on contract



formal resolution

very serious


based on contract

very serious


summary suspension



• The severity of an occurrence depends on the type. A moderately disruptive act might be handled by informal resolution, while a moderate criminal or abusive act might require a formal response.


A physician with a special arrangement with the hospital who is involved in a serious or very serious occurrence may have a much greater likelihood of being a problem during formal resolution.


If the patient has a recent history of multiple occurrences, then the conduct should be evaluated. This can be addressed informally or formally, depending on the nature of the occurrences. A key determinant is how well the previous occurrences have been documented.


Informal resolution:

(1) Colleagial intervention with informal discussion.

(2) Educate the practitioner of the consequences if unresolved.

(3) Document the occurrence.

(4) Monitor outcome. If unresolved, repetitive or progressive, then refer to formal resolution.


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