MEDICAL STAFF
POLICY & PROCEDURE
TITLE:
Effective Date:
IMPAIRED PRACTITIONERS
3/01
MS-04
POLICY:
This policy provides guidance and direction when confronted with a potentially impaired practitioner.
PURPOSE:
In its obligation to protect patients from harm, the medical staff will plan and participate in a process that
addresses physician health; provides the education of licensed practitioners and other hospital staff about
illness and impairment recognition issues specific to independent practitioners; facilitates confidential
diagnosis, treatment, and rehabilitation of independent licensed practitioners who suffer from a potentially
impairing condition.
Exception: Exceptions to parts of this policy may include impairment due to age and irreversible medical
illness or other factors not subject to rehabilitation.
PROCEDURE:
A.
DEFINITION OF IMPAIRMENT/OVERSIGHT
Any time a practitioner is unable to safely perform the privileges he or she have been granted, the
matter will be forwarded to the Medical Executive Committee. The Medical Executive Committee
may delegate the investigation and oversight of rehabilitation to an ad hoc committee.
B.
REPORTING OF PROBLEMS
1. By Observer: When the conduct or performance of a practitioner or other physical or
behavioral manifestations while present on the Hospital grounds or other professional
situations appear to indicate that the practitioner is or may be impaired in the capacity to
perform the professional responsibilities safely, any practitioner or Hospital employee or
agent observing the incident should immediately report the circumstances to the Chief
Executive Officer, Vice President/Medical Affairs or designee on-site (charge nurse or shift
coordinator). The Vice President/Medical Affairs or his designee will also contact the
applicable Department Chair or other Medical Executive Committee member.
2. Self Reporting – An independent licensed practitioner may self-report by contacting a Medical
Staff Officer, Vice President/Medical Affairs, or Chief Executive Officer or administrator on
call.
C.
EVALUATING THE COMPLIANT, ALLEGATION, CONCERN, EVENT, REPORT
1. The Department Chair and Vice President/Medical Affairs or their designees will meet with
the practitioner involved to assess the situation and evaluate the credibility and impact of the
complaint, allegation, concern, event or report. The immediacy of the evaluation will be
based on patient safety. If in their opinion, any question of impairment and/or intoxication
exists, a urine sample, blood alcohol or other substance screening measurement will be
MEDICAL STAFF POLICY:
IMPAIRED PRACTITIONERS
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immediately obtained under direct supervision and evaluated for possible mood-altering
substances. If a medical problem is believed to be present, then an appropriate evaluation
will be recommended or requested.
After an evaluation of the complaint, allegation, concern, event or report, the Department
Chair or Vice President/Medical Affairs will inform the Medical Executive Committee and the
Chief Executive Officer of the conclusions and actions pursuant to this section.
a. Consequence Of Positive Test Results
If a urine or blood sample obtained under section C. is positive for a mood-altering
substance, the matter will be referred to the Medical Executive Committee, which, absent
a clear showing of mitigating circumstances, may recommend chemical dependency
evaluation and/or treatment. If a sample obtained under section C. is positive for a
mood-altering substance on a second occasion, the Medical Executive Committee will,
absent a showing of just cause, require chemical dependency evaluation and treatment
in an inpatient setting acceptable to the practitioner in question and the Medical
Executive Committee. The Vice President/Medical Affairs will also contact the Alabama
Physician Health Program (APHP) program of the Medical Association of the State of
Alabama in accordance with its regulations. The Medical Executive Committee will keep
the Chief Executive Officer informed of its actions pursuant to this section.
b. Failure To Comply
Failure of a practitioner to comply with a request under section C. to meet with the
Department Chair or Vice President/Medical Affairs for body fluid samples or other testing
or failure to comply with recommendations or requirements of the Medical Executive
Committee will result in the Medical Executive Committee considering the matter for such
disciplinary action as it deems appropriate pursuant to the Medical Staff Bylaws,
including, without limitation, suspension or revocation of Medical Staff membership.
c.
Report of Findings
Following investigation, the Vice President/Medical Affairs or administrator on call will
render a report of the findings to:
1.
the medical staff president;
2.
the chair of the appropriate department;
3.
individuals appropriate under the circumstances; or
4.
the Credentials and Medical Executive Committees.
d. Findings of Impairment or Inability to Provide Safe Care
If the investigation produces sufficient evidence that the practitioner is impaired or is
unable to provide safe care, the Vice President/Medical Affairs and the Department Chair
or other member of the Medical Executive Committee will meet personally with the
practitioner. The practitioner will be told the results of the investigation that indicate the
practitioner suffers from an impairment that may affect his/her care of hospital patients
and the practitioner may be summarily suspended until the Credentials Committee,
Medical Executive Committee and Houston County Healthcare Authority consider the
matter.
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IMPAIRED PRACTITIONERS
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Depending on the severity of the problem and the nature of the impairment, the Medical
Executive Committee, on recommendation of the Credentials Committee, may exercise
the following actions:
1. continuation of the summary suspension of the practitioner;
2. require the practitioner to undertake a rehabilitation program or undergo an
evaluation by an independent consultant at the choice of the hospital;
3. appoint a physician health ad hoc committee to oversee rehabilitation efforts;
4. comply with state statutes that apply to the practitioner’s conduct under
licensing statutes.
D. REHABILITATION, REINSTATEMENT AND MONITORING
The hospital and medical staff leadership will assist the practitioner in locating a suitable
rehabilitation program. The hospital will not reinstate a practitioner until it has been established
that the physician has successfully completed a rehabilitation program or medical regimen in
which the hospital has confidence.
1.
Upon sufficient proof that a practitioner who has been found to be suffering from
impairment has successfully completed a rehabilitation program, consideration may be
given to reinstatement, based on the following:
a.
patient care interest is paramount;
b.
The practitioner must authorize the director of the rehabilitation program to write a
letter to the Medical Executive Committee or physician health ad hoc committee
and the letter must state:
1.
whether the practitioner is participating in the program;
2.
whether the practitioner is in compliance with all the terms of the program;
3.
to what extent the practitioner’s behavior and conduct must be monitored;
4.
whether, in the opinion of the rehabilitation director, the practitioner has
been rehabilitated;
5.
whether an after-care program has been recommended to the practitioner,
and if so, a description of the aftercare;
6.
whether, in the program director’s opinion, the practitioner is capable of
resuming his/her privileges and providing competent care.
c.
The practitioner must inform the hospital of the name and address of his/her
primary care physician and authorize the physician to provide the hospital with
information regarding his/her condition or treatment. The hospital has the right to
require an opinion from other consultants of its choice.
d.
The hospital may request the primary care physician to provide the information
regarding the precise nature of the practitioner’s condition, course of treatment,
and the answers posed in section D.1.b.
e.
Assuming all information the hospital receives indicates that the practitioner is
rehabilitated and capable of resuming patient care duties, the Credentials
Committee or other appointed ad hoc physician health committee may take the
additional precautions before consideration and recommendation to the Medical
Executive Committee:
1.
Readiness of Another Practitioner to Assume Responsibility for Patients:
The practitioner must identify an appropriately privileged practitioner who is
willing to assume the responsibility for care of his/her patients in the event
that he/she is unwilling or unavailable to care for them.
2.
Periodic Reporting and Monitoring – A report may be required of the
primary care physician that the practitioner is continuing treatment or
therapy and his/her ability to care for patients in the hospital setting is not
MEDICAL STAFF POLICY:
IMPAIRED PRACTITIONERS
3.
E.
F.
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impaired. The practitioner may be required to submit to random drug or
alcohol screening.
Alcohol or Drug Screening –In addition to an initial drug screen, the
practitioner must agree to submit to an alcohol or drug screening test (if
appropriate to the impairment) at the request of a hospital manager,
physician or shift coordinator who suspects the practitioner is under the
influence of drugs or alcohol. If the individual does not agree, he/she will
be summarily suspended.
CONFIDENTIALITY
1.
Confidentiality will be maintained, except as limited by law, ethical obligation or when the
health or safety of a patient is threatened. This confidentiality applies to the practitioner, as
well as the informant. This confidentiality extends to the practitioner who self-refers.
2.
Throughout this process, all parties will avoid speculations, gossip, and any discussions of
this matter with anyone outside those described in this policy. The Vice President/Medical
Affairs or his/her designee will inform the individual who filed the report that follow-up action
was taken.
3.
The original report and description of all actions taken will be included in the physician’s
confidential risk management file.
4.
All requests for information concerning the impaired practitioner will be forwarded to the
Vice President/Medical Affairs or his/her designee for response.
CONFLICT
In the event there is an apparent or actual conflict between this policy and the bylaws, rules and
regulations or other policies of the hospital or medical staff, the provisions of this policy will
supersede such bylaws, rules, regulations or policies.
G.
EDUCATION
In addition to annual participation of hospital staff in a NetLearning module designed to educate
staff regarding identifying at risk criteria and the process for reporting concerns regarding whether
or not a practitioner can safely perform the privileges granted, a continuing medical education
program specifically addressing prevention of physical, psychiatric or emotional illness will be
scheduled.
Date adopted by the Medical Executive Committee:
Date adopted by the Houston County Healthcare Authority:
Revised/Reviewed:
March 13, 2001
March 27, 2001
January 20, 2003
February 11, 2003
December 13, 2005
March 13, 2007
January 13, 2009
January 28, 2010
March 17, 2011
September 13, 2011