Excerpt from the PHSA Medical Staff Rules regarding comprehensive reviews:

1. In circumstances where serious concerns arise from the Medical Staff member’s in-depth review, the Senior Site Medical Administrator (or delegate), Senior Medical Administrator (or delegate), and in the case of the Nurse Practitioners, the Senior Nursing Administrator, shall be informed, and a decision shall be made in consultation with the Department Head to undertake a comprehensive review by a Review Committee consisting of:
1. Department Head or delegate of the member’s Department, or if several departments are collaborating, a Department Head from another Department;
2. A medical staff member from the Department of the member being reviewed;
3. A member of the hospital team with whom the member works regularly.
   
2. The Comprehensive Review Committee shall undertake a further in-depth review, which shall include all criteria outlined in item 2.3.2 d and f.
1. The Comprehensive Review Committee shall report to the Department Head(s), the Senior Medical Administrator (or delegate) and Senior Nursing Administrator (if applicable) on the results of the in-depth review, in accordance with the Medical Staff Bylaws Articles 4.5 and 4.6, and shall provide written recommendations to the Department Head regarding requirements for corrective action.
2. After the in-depth review, the LMAC, the HAMAC and PHSA Board shall be notified in writing of recommendations requiring action.