For Physicians

Medical Staff Health Policies

Members of the medical staff who conduct medical care activities must be in control of their manual dexterity and skills, mental faculties and judgment. Lack of such control, which is generally referred to as "impairment," has many causes, some of which may be preventable or subject to rehabilitation. The American Medical Association defines the impaired physician as "one who is unable to practice medicine with reasonable skill and safety to patients because of a physical or mental illness, including deterioration through the aging process or loss of motor skill, or excessive use or abuse of drugs, including alcohol."

Applicable provisions of the standards of the Joint Commission require the medical staff to implement a process to identify and manage matters of physician health that is separate from the medical staff disciplinary process. The intent of these provisions is to encourage medical staffs to design a process that provides education about physician health, addresses prevention of physical, psychiatric or emotional illness and facilitates diagnosis, treatment and rehabilitation of physicians who suffer from a potentially impairing condition.

The goals of this policy are to educate physicians/health care providers and prevent health problems if possible, to identify those who have health problems through self-referral or report by others, and to remediate and rehabilitate to the extent possible.

Ad Hoc Subcommittee of the Executive Committee

An ad hoc subcommittee of the executive committee of the medical staff is hereby established to implement this policy. The subcommittee shall be composed of the president of the medical staff, the immediate past president of the medical staff, the president-elect of the medical staff, the chair of the credentials committee, the medical director and an additional member of the medical staff appointed by the president of the medical staff.

Education

At the time of initial credentialing, each applicant shall receive a copy of this policy. At each recredentialing cycle, each member of the medical staff will be provided with information addressing medical staff health issues. The medical staff and the hospital may offer educational sessions from time to time regarding medical staff health issues.

Report and Investigation

If any individual working in the hospital has a reasonable suspicion that a physician appointed to the medical staff is impaired, the following steps should be taken:

1. The individual who suspects the physician of being impaired must give an oral or, preferably, written report to the medical staff president, the medical director or the administrator. The report must be factual and shall include a description of the incident(s) that led to the belief that the physician might be impaired. The individual making the report does not need to have proof of the impairment, but must state the facts that led to the suspicions.

2. If, after discussing the incident(s) with the individual who filed the report, the medical staff president, medical director or administrator believes there is enough information to warrant an investigation, the administrator shall request that an investigation be conducted and a report of its findings rendered by:

The medical staff president.
A standing committee of the medical staff.
An outside consultant.
Another individual or individuals appropriate under the circumstances.

3. If the investigation produces sufficient evidence that the physician is impaired, the medical director shall meet personally with that physician or designate another appropriate individual to do so. The physician shall be told that the results of an investigation indicate that the physician suffers from an impairment that affects his or her practice.

4. Depending upon the severity of the problem and the nature of the impairment, the hospital has the following options.

Require the physician to undertake a rehabilitation program as a condition of continued appointment and clinical privileges.
Impose appropriate restrictions on the physician's practice; or
Immediately suspend the physician's privileges in the hospital until rehabilitation has been accomplished, if the physician does not agree to discontinue practice voluntarily.

5. The hospital shall seek the advice of hospital legal counsel to determine whether any conduct must be reported to law enforcement authorities or other government agencies, and what further steps must be taken.

6. The original report and a description of the actions taken by the medical staff president, medical director or administrator will be included in the physician's medical staff file. If the investigation reveals that there is no merit to the report, the report shall be destroyed. If the investigation reveals that there may be some merit to the report, but not enough to warrant immediate action, the report shall be included in a confidential portion of the physician's personnel file and the physician's activities and practice shall be monitored until it can be established whether there is an impairment problem.

Rehabilitation

7. Hospital and medical staff leadership shall assist the physician in locating a suitable rehabilitation program. The hospital shall not reinstate a physician until it is established, to the hospital's satisfaction, that the physician has successfully completed a rehabilitation program in which the hospital has confidence.

Reinstatement

8. Upon sufficient proof that a physician who has been found to be suffering an impairment has successfully completed a rehabilitation program, the hospital may consider reinstating that physician to the medical staff.

9. When considering an impaired physician for reinstatement, the hospital and its medical staff leadership must consider patient care interests to be paramount.

10. The hospital must first obtain a letter from the physician director of the rehabilitation program where the physician was treated. The physician must authorize the release of this information. The letter from the director of the rehabilitation program shall state:

Whether the physician is participating in the program.
Whether the physician is in compliance with all of the terms of the program.
Whether the physician attends program meetings regularly (if appropriate).
To what extent the physician's behavior and conduct are monitored.
Whether, in the opinion of the rehabilitation program physicians, the physician is rehabilitated.
Whether an after-care program has been recommended to the physician and, if so, a description of the after-care program.
Whether, in the program director's opinion, the physician is capable of resuming medical practice and providing continuous, competent care to patients.

11. The physician must inform the hospital of the name and address of his or her primary care physician, and must authorize the physician to provide the hospital with information regarding his or her condition and treatment. The hospital has the right to require an opinion from other physician consultants of its choice.

12. The hospital shall request the primary care physician to provide information regarding the precise nature of the physician's condition, the course of treatment, and the answers to the questions posed above in 10 (e) and (g).

13. Assuming all information the hospital receives indicates that the physician is rehabilitated and capable of resuming patient care, the hospital must take the following additional precautions when restoring clinical privileges:

The physician must identify two physicians who are willing to assume responsibility for the care of his or her patients in the event that he or she is unable or unavailable to care for them.
The hospital shall require the physician to provide the hospital with periodic reports from his or her primary care physician—for a period of time specified by the medical director—stating that the physician is continuing treatment or therapy, as appropriate, and that his or her ability to treat and care for patients in the hospital is not impaired.

14. The medical director or a physician appointed by the medical director chair shall monitor the physician's exercise of clinical privileges in the hospital. The medical director shall determine the nature of that monitoring after reviewing all of the circumstances.

15. The physician must agree to submit to an alcohol or drug screening test (if appropriate to the impairment) at the request of the medical staff president, the medical director or the administrator.

16. All requests for information concerning the impaired physician shall be forwarded to the medical director for response.