​Medical Staff Rules discuss about comprehensive review:

In circumstances where serious concerns arise from the medical staff member’s in-depth review, the Senior Medical Administrator will be informed, and a decision will be made in conjunction 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.
1. The Comprehensive Review Committee will undertake a further in-depth review, which will include all criteria outlined in item 2.3.2 d. i) and ii).
2. The Comprehensive Review Committee will report to the Department Head/Program Medical Director/Professional Practice Leader and the Senior Medical Administrator on the results of the In-Depth Review in accordance with the Medical Staff Bylaws Article 4.5 and 4.6, and will provide recommendations on the requirements for corrective action.
3. The MAC and subsequently the Board of Directors will be informed of the results of the comprehensive review of Medical Staff members.