Professional Staff Credentialing Toolkit, 2012

Sample 23. Professional Staff Resignation/Retirement Policy[1]

1.Notice of Resignation/Retirement

In order to ensure adequate resolution of transfer of care issues, the hospital requires Professional Staff to provide an appropriate period of notice of resignation in writing to the Chief of Staff/Chair of the MAC (i.e., Generally two-three months. Hospitals may wish to vary depending on the unique circumstances.)

The notice should indicate whether the member intends to resign from the hospital and forfeit all privileges or whether some arrangement has been made for privileges to continue in some other capacity i.e., with Courtesy privileges).

it is important to recognize from time to time circumstances may arise where the member in unable to provide a shorter period of notice (for example, because of an emergency). Under these circumstances, the member and the Chief of Staff/Chair of the MAC have a mutual obligation to ensure there is a safe and orderly transfer of responsibilities and patient care and that it is conducted in a professional manner.

2.Obligations regarding Transfer of Patient Care

Regardless as to whether the member of the Professional Staff is leaving an inpatient or outpatient setting (or both), the member should meet with his/her Chief of Department and/or Head in order to review the plans for the disposition of his/her clinical responsibilities and patient load. This would include the member providing a list of his/her patients.

Depending on the setting, some patients may be transferred to home or community resources while others will be transferred to another member of the hospital’s Professional Staff. The Chief of Department/Head must be satisfied that the disposition plan meets the standard of care of the Department and hospital.

Patients should be notified of the transfer of care in a timely matter and this should be documented in the health record. Outpatients should be notified in writing by letter. Ideally, the member should take the opportunity to discuss the transfer of care with individual patients and introduce them to their new clinician.

The departing member must meet hospital standards for completion of a transfer note. This must be sufficiently detailed to enable a safe transition of care. In the case of patients who are being transferred to home or community resources, a detailed discharge summary including a plan of care must be provided to the community clinician and/or agency.

3.Administrative Duties

The departing member of the Professional Staff must coordinate the transfer of his/her administrative duties with their Chief/Head in an orderly and professional matter.

4.Record Completion

The departing member of the Professional Staff must complete and sign off all outstanding health records before his/her departure date. All paper-based health records must be returned to Health Records. Thereafter, any deficiencies become the responsibility of the Chief/Head.

5.Keys/ID, Parking Passes, Pagers, Cell Phones

The member of the Professional Staff should turn in their keys, hospital identification, and parking passes to the Division manager at the end of his/her last day. S/he should also turn in any equipment, pagers, lap tops, or cell phones that are the property of hospital. Hospitals are advised to use a standard check out list outlining the contents of the returned property. The member can sign off on the list to avoid any later disputes.

6.Notification to the Professional Staff Office – IT, Health Records/Admitting, Pharmacy

A copy of the letter of resignation (with the final date at the hospital) should be provided by the Chief of Department to the Professional Staff Office.

The Professional Staff Office will:

  • Request IT/Health Records/Admitting/Pharmacy access to be terminated as of the day after the member’s final day.
  • Ensure the member’s resignation is forwarded to the MAC and to the board.
  • If a physician, notify the Ministry regarding the change in the physician’s AFP status.
  • If applicable, notify the affiliated university of the member’s resignation.

Sample 23. Professional Staff Resignation/Retirement Policy 1

[1]Adapted from source: Centre for Addiction and Mental Health.