Medical Staff Portal
Medical Staff Bylaws & Rules

Concerns Guide

Covenant Health has established the Medical Staff Bylaws and Medical Staff Rules in order to help assist Practitioners in the workplace. An important section in the Covenant Health Bylaws related to patient safety and professional conduct is Concerns. The Concerns section provides Practitioners with the information required to protect the safety and integrity of their patients, colleagues, clinic/institution and themselves. This document should not be used as a replacement for the Bylaws; it is simply a concise reference to what constitutes a Concern, how to submit a Concern and the process for addressing a Concern.  (See also the Triggered Initial Assessments & Reviews Guide.)

If you have any questions about Medical Appointments, please contact Covenant Health Medical Affairs. For additional information, please refer to Section 6.1 – 6.10.6 in the Covenant Health Medical Staff Bylaws.

Medical Affairs Concern Management Guide Sheet & Process

Patient Relations PATIENT Concern Management Info Package

What is a Concern?

A Concern is a formal written complaint regarding aspects of a Practitioner’s responsibilities and accountability either in general or in relation to a specific event or an episode of care provided to a specific patient. The documentation must be supported by a reasonable degree of detail forming the basis of the Concern. 

What issues could result in a Concern?

A Concern could include, but is not limited to:

  • Quality and safety of patient care;
  • Clinical performance;
  • Ethical conduct;
  • Breaches of responsibilities, expectations or formal agreement with Covenant Health;
  • Issues related to leadership;
  • Professional behavior in patient, visitor, and staff relations; or
  • Health problems that affect the Practitioner’s performance.  

Who can submit a Concern?

A Concern may be submitted by a patient or family member, a colleague, any member of the multi-disciplinary healthcare team, the Practitioner (self-disclosing a Concern) or a Covenant Health staff member conveying the Concern on behalf of another.  

What happens if a Concern is submitted about me?

If a Concern has been submitted about you, the Associate Vice President (AVP) or designate will review the Concern completing a Triggered Initial Assessment (TIA) Part A and determine if any further action  of a TIA-Part B (Triggered Review) is required. A TIA-Part B of a Concern is a process that respects natural justice to see if there is merit to the concern.  It may not be required if the concern itself has already reflected an acceptable outcome, if the concern on its face is not valid, if the issues can be best resolved through a collaborative review process or if another process would be the most appropriate way to address the concern.  See “Concerns” flowmap (page 3) .

Are Concerns made public?

Whether you are submitting a Concern or have had a Concern submitted about you, all information related to the Concern will be kept strictly confidential and will not be disclosed to anyone outside of the process unless agreed to, in writing, by all parties or required by law to ensure public and/or patient safety. 

What happens if a TIA Part B (Triggered Review) is felt to be necessary?

If a TIA-Part B is felt necessary to further investigate the concern, you will be contacted, provided with a copy of the Concern and requested to provide a response. Throughout this process, a consensual resolution is always an option.  Covenant Health AVP, or designate will then forward the findings and his recommendations identifying required actions to the Covenant Health Chief Medical Officer  (CMO).  The CMO will make the final decision and this will be communicated to stakeholders are required.  

Do all complaints go through the formal Bylaw process?

All formal Concerns will be reviewed by the Covenant Health CMO, or designate. There is a distinction between an isolated workplace incident and a Bylaw Concern. Covenant Health encourages Practitioners to informally resolve issues. If this is not possible, or the nature of the incident is considered severe enough by the individual(s) involved to warrant action, submitting a formal written Concern would be the next step.

Is the College informed of a Concern?

The Covenant Health CMO, or designate may refer the Concern to the relevant College based on the Concern’s potential to impact the Practitioner’s licensure. The disclosure must be agreed to in writing by the Practitioner, or determined (after a consultation with the CMO) that the referral is required by law to ensure patient and/or public safety. At any time, the individual who submitted the Concern may also choose to independently convey their issue(s) to the relevant College for their review. 

What do I do if I’m feeling intimidated or bullied?

Intimidation/bullying in the workplace is a legitimate issue, however you may not need to submit a Concern in writing. There are various conciliatory strategies you can attempt prior to initiating the Concern process. You can speak directly with the party responsible for the intimidation/bullying or you can address the issue with your leader. If you feel you are being intimidated/bullied by your leader, you can bring your concern to your leader’s superior. If the intimidation/bullying persists, the next step would be to submit a formal Concern to your Facility Chief, Site Medical Director or to Chief Medical Officer or designate.

What is Consensual Resolution?

Consensual Resolution is a collaborative process involving the Affected Practitioner, the relevant Covenant Health medical leader(s), and the Complainant. The point of Consensual Resolution is for all parties to review the initial Concern and any other relevant material together in an attempt to come to an agreed upon solution to the issue. At any time throughout the Concern process, the Affected Practitioner and/or the relevant Covenant Health medical administrative leader(s) may recommend a Consensual Resolution in order to avoid a Hearing.  

In what circumstance would a Concern warrant Immediate Action?

If there are reasonable grounds to believe that a Practitioner’s professional performance and/or conduct is putting the health or safety of any person, including themselves, at risk, Immediate Action can be taken by the CMO. Immediate Action may result in direct suspension of Appointment and Clinical Privileges. This is considered a last resort and only used when lesser measures cannot address the severity of the issue.

Do all Concerns go to a Hearing?

No. At any point during the resolution process, a Concern can be dismissed as unfounded by the Covenant Health CMO, or designate or the affected Practitioner can choose to seek a consensual resolution prior to a hearing. the CMO) that the referral is required by law to ensure patient and/or public safety. At any time, the individual who submitted the Concern may also choose to independently convey their issue(s) to the relevant College for their review.  

Who sits on the Hearing Committee?

Hearing Committee members are drawn from a provincial pool of designates representing a cross section of  specialties, geography, practice settings and clinical experience.