Purpose | Membership | Reporting | Screening Process | Committee Meeting | Sanctions | Written record | "Proxy" complaints | Acts of Retribution | Appeals | Feedback


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


The Committee shall consist of a chair, vice-chair and at least three other members appointed by the Medical Executive Committee. They shall include physician representatives from the Departments of Medicine, Surgery and Pediatrics, at least one other physician appointed by the Medical Executive Committee from a Department other than Medicine, Surgery or Pediatrics and a resident; one representative each from the Hospital and School of Medicine shall also serve ex-officio on the Committee. The MEC will appoint the chair and vice-chair from among the 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.



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." Complaints may also be made by "proxy" (see below).


Screening Process

On receipt of a complaint, the Chair of the Committee will assign the complaint a case number and assign it to a member of the Committee to screen. The Committee member will:

  • Inform the Chair of the Department of the person about whom the complaint is made concerning the complaint and enquire as to prior complaints.
  • Interview the person making the complaint as to the details of the complaint and remedies sought.
  • Interview the person about whom the complaint is made.
  • Discuss with the Chair of the Committee whether further steps should be taken or the case should be discussed at the next meeting of the Committee.


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. When appropriate, the Committee will meet with the person making the complaint as well as 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.



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.


"Proxy" Complaints

"Proxy" complaints will be received and handled according to the policy appended entitled PROCESS FOR DEALING WITH COMPLAINTS MADE TO THE MEC COMMITTEE ON PROFESSIONAL CONDUCT BY "PROXY."


Acts of Retribution

If the process is disrupted by any act of retribution against the person making the complaint, this will be taken very seriously by the committee and will result in more serious sanctions, which may include the recommendation to the Medical Executive Committee for immediate suspension of privileges.



The individual about whom the complaint has been made has the right to appeal the Committee's decisions and sanctions to the Medical Executive Committee which can appoint an ad-hoc subcommittee for such a purpose.



In cases where complaints are made by a "proxy", as in any anonymous complaint, there will be no feedback to the person filing the complaint. (This applies to the two hospital hot-lines (Patient Safety and Compliance) and Professional Assistance Committee.