Heritage Medical Group
POLICY AND PROCEDURE MANUAL
SECTION TITLE: / EFFECTIVE DATE: / POLICY #: / SECTION:Administrative/
Management / 1/1/2008 / A/M 15 / 1
SUBJECT: / REVISED: / REVIEWED: / PAGE:
Impaired Provider Policy / 1 - 32
POLICY: It is the policy of Heritage Medical Group to have as its core obligation the safe care of all who are patients at any one of its facilities. It is the policy of Heritage Medical Group to have as partners and to employ competent and licensed professionals who are mentally and physically capable, with or without reasonable accommodation, of providing medical and professional care to patients. In the event that a physician or a non-physician provider is either suspected of impairment or deemed impaired, that individual will be evaluated, monitored and assessed with regard to continued employment at the Heritage Medical Group. Heritage Medical Group shall maintain the option to either terminate the impaired physician or non-physician provider and report said incident to the Pennsylvania Board of Medicine, or to work with the Pennsylvania Physician Health Program in the rehabilitation of a physician or physician assistant and with the Voluntary Recovery Program for a certified registered nurse practitioner. In any event, the Executive Board shall principally be responsible for the decision to either terminate or retain said physician or non-physician provider. If the physician is a partner he/she may exercise his/her appeal option in the Partnership Agreement. For an employed physician or a non-physician provider the decision of the Executive Board shall be final and binding.
Our policy is to continue to support any impaired physicians and non-physician providers who have demonstrated willingness to rehabilitate and follow recommended, ongoing treatment plan; however, such assistance in the rehabilitation process is not a guarantee that said individual will be retained as a partner or an employed physician or non-physician provider. Willingness is demonstrated by one taking the initiative to come forward. Furthermore, termination or retention of the impaired physician or non-physician provider is at the sole discretion of Heritage Medical Group.
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PROCEDURE:
In the event that a circumstance suggesting a deterioration of a physician's or nonphysician provider’s level of physical or mental competence shall come to the attention of any physician, non-physician provider, or Heritage Medical Group staff member it shall be that person’s responsibility to report the matter to the Medical Director through the confidential reporting system in place at Heritage Medical Group. (See AttachmentA).
All reports received by the Medical Director concerning physical or mental competency shall be reviewed and discussed confidentially with the Heritage CEO. The Medical Director and the CEO shall jointly review the matter, and, if deemed necessary, the Medical Director shall conduct a full review of the individual's professional performance.
This review shall be conducted by the Heritage Medical Group Quality Assurance Peer Review Committee with the Medical Director serving as chair of this Committee. The Quality Assurance Peer Review Committee consists of the Medical Director and at least 3 physicians who are partners of Heritage Medical Group. Other physicians or non-physicians shall be assigned to the Quality Assurance Peer Review Committee for the Impairment Proceedings as deemed appropriate by the Medical Director.
The physician or non-physician provider has the right to appear before the Quality Assurance Peer Review Committee and present any pertinent information. Fact-finding will conclude as expeditiously as possible, normally it should be concluded within two weeks.
Should reasonable suspicion be found to the allegations, the physician or non-physician provider will be suspended from duty under authorization by the Medical Director until the matter is resolved. Reasonable suspicion shall be defined as a good faith question based upon objective facts and reasonable inferences drawn from investigation. The results of this initial investigation shall be reported promptly by the Medical Director to the Physician Health Program or the Voluntary Assistance Program for further guidance, intervention, and evaluation. Heritage Medical Group recognizes that the Physician Health Program and the Voluntary Assistance Program provide, as appropriate, evaluation, testing, monitoring, and treatment. The Medical Director will supply the Physician Health Program or the Voluntary Assistance Program with the name, address, and phone number of the affected physician or non-physician provider.
THE PROCEEDINGS SHALL BE, AS FAR AS POSSIBLE, CONFIDENTIAL AND FILING OF ALL IMPAIRMENT RECORDS RESTRICTED TO THE MEDICAL DIRECTOR’S OFFICE.
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At this stage the decision may be made to terminate the employment relationship, or pursue expulsion pursuant to the Partnership Agreement. If a recommendation for employment termination is made this decision will be final and the employee will not have a right of appeal. If a recommendation for expulsion of a partner is made the matter will be turned over to the Executive Board for disposition according to the terms of the Partnership Agreement.
If employment termination or expulsion from the partnership is not recommended by the Medical Director as a result of the investigation, the physician or non-physician provider under review shall be notified by the Medical Director that the Physician Health Program or the Voluntary Assistance Program has been contacted and that this Program will be directing further investigation and treatment recommendations for Heritage Medical Group.
The Medical Director shall work with the Physician Health Program or the Voluntary Assistance Program:
(1) To assess the physician's or non-physician provider’s ability to work,
(2) To assess and monitor the physician's or the non-physician provider’s compliance with the Physician Health Program or the Voluntary Assistance Program treatment plan, as well as
(3) To coordinate activities.
If the Physician Health Program or the Voluntary Assistance Program finds the physician or the non-physician provider not to be impaired, employment without limitations will resume, and the record will be so noted. The physician or non-physician provider deemed unable to work shall be placed on a leave of absence until such time as the Physician Health Program or the Voluntary Assistance Program certifies the physician's or non-physician provider’s readiness for work.
The physician or non-physician provider must comply with any and all Physician Health Program or Voluntary Assistance Program requirements, including signing any needed Physician Health Program or Voluntary Assistance Program consent statements, to facilitate necessary monitoring and treatment procedures, including but not restricted to on the job drug monitoring upon request for the duration of employment. Should the physician or non-physician provider fail to comply with referral mechanisms to the Physician Health Program or the Voluntary Assistance Program or if the Physician Health Program or the Voluntary Assistance Program notifies Heritage Medical Group of any physician or non-physician non-compliance with an established treatment plan, the Medical Director shall recommend termination of said physician or non-physician provider, and such action will be reported to the State Licensing Board.
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To reiterate, strict adherence to the counseling, rehabilitation, and treatment plan is mandatory. The physician or non-physician provider will be allowed to return to work at Heritage Medical Group providing specific terms and conditions of further contractual arrangements are met, which include:
- Receiving written confirmation from the Physician Health Program or the voluntary Assistance Program that the physician or non-physician provider is in stable recovery and is safe to return to his/her practice
- Remaining free of drug and chemical dependency
- Completion of the program recommended by the counselor/state committee, followed by prescribed ongoing therapy
- Making provision for automatic release of therapeutic information to the Medical Director
- Signing consent statements for ongoing monitoring on site and upon request of the Medical Director.
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ATTACHMENT A
CONFIDENTIAL
PEER REVIEW PROTECTED
QUALITY REPORTING FORM
FOR BOTH EXEMPLARY PERFORMANCE AND FOR CONCERNS
The Quality Assurance Peer Review Committee requires that this form be prepared for its use for the purpose of conducting its peer review functions, including evaluating and improving quality of care and patient safety provided by Heritage Medical Group physician practices.
Please use this form for reporting any events that you feel are noteworthy with regard to the professional performance or behavior of one of our physician or non-physician provider members. This report should provide sufficient information in order to notify the Quality Assurance Committee that it may need to evaluate, investigate, or recognize, where appropriate. To the extent possible, your personal anonymity will be protected during this process.
Please forward report to the Chairperson of the Quality Assurance Committee.
Date of Report:______
Name of Person Filing Report (please print):______
Please indicate whether you prefer to remain anonymous:
I would like to remain anonymous during this process, to the extent possible.
Please feel free to use my name during this process.
Signed:______
Date(s) of Incident:______
Nature of the Exemplary Performance or Concern (Please use additional paper, as needed. Please insure that your report is legible):
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