scope:

Purpose. To establish policies and procedures per references (a) through (c) for adverse privileging actions, peer review panel procedures, and health care provider reporting. These provisions provide a fair and impartial process to resolve allegations of impairment or misconduct that may form the basis for the denial, reduction, suspension, or revocation of clinical privileges, or the termination of a professional staff appointment.

Applicability. This instruction applies to all military (active duty and Reserve) and civilian health care providers and clinical support staff (as defined in enclosure (1)) who are assigned to, employed by, contracted to, or under partnership agreements with Department of the Navy (DON) activities. The peer review panel procedures of this instruction do not apply to clinical support staff not required to obtain privileges per reference (c). Report clinical support staff, who are released due to physical impairment or disability or who commit misconduct as outlined in enclosure (2), to Bureau of Medicine and Surgery (BUMED) (MED-00L) for review and possible reporting to licensing or certification boards. Reference (d) governs trainees in Navy graduate medical education programs.