Ask the expert: Our quality department does have an incident report database, but we can't run reports on incidents by individual physicians. How can we gather data about complaints filed against a physician who exhibits disruptive behavior?

Although useful, it is not necessary to produce a rate of complaints or to benchmark the physician against other physicians in the department or hospital. Despite the limitations of your hospital's quality software, you should be able to gather evidence of a physician's inappropriate behavior and noncompliance with performance expectations by collecting incident reports and complaints filed against the physician.

Keep in mind that if your hospital has adopted a zero-tolerance policy in regard to disruptive behavior, evidence of deviation from that policy is sufficient. Incident reports may provide your credentials committee with enough evidence to take steps to obtain the physician's compliance with the conduct policy.