UNIVERSITYHOSPITAL

Medical Staff
Policy & Procedure
Policy Title: / Policy #: / Effective Dare:
Practitioner Wellness / MS-9 / 07/17/01
Pages:
2 / Reviewed/Revised:
02/05
04/06
03/07
Approved by:
______
Chief Medical Officer Date

POLICY:

The purpose of this policy is to establish a process to provide education, support and audience to a practitioner affected by any physical, emotional, psychiatric impairment, or potential impairment, involving, among other conditions, alcohol and drug abuse, psychiatric disability, physical impairment, problems of aging, sexual misconduct, and the distress of everyday medical practice. The process as herein described will provide assistance and monitoring to enable a practitioner to gain restoration of optimal functioning rather than initiating disciplinary action.

I.Practitioner Assistance Committee

  1. The Practitioner Assistance Committee, a standing committee of the Medical

Staff, shall consist of five members of the Active Medical Staff. One member shall be appointed chairman. The committee will provide assistance and, as appropriate, facilitate

diagnosis, treatment and rehabilitation for a practitioner as determined by the

committee in cooperation with the practitioner.

  1. The committee will act at all times in a manner consistent with the protection of patients from harm and will function separately from the disciplinary function as established in the Quality and Accountability Policy and peer review process.
  1. The committee will meet as needed.

II.Referral to Committee

  1. A practitioner may refer himself/herself to the committee.
  1. Any hospital personnel or physician concerned about a practitioner’s condition

and ability to function professionally may contact either the department chairman

of the appropriate department or the President of the medical staff for possible

referral to the committee. Referral from hospital personnel needs to be done

through appropriate supervisors.

  1. In cases other than self-referral, the committee shall evaluate the credibility of the concern and may interview the practitioner who is the subject of the concern as well as others who may have information concerning the practitioner’s condition.
  1. The committee may request that the practitioner refer himself/herself to internal or external resources for diagnosis and treatment. The practitioner will be responsible for arranging all services and must inform the committee of the status.
  1. The committee will not have the authority to compel a practitioner to take action. If the practitioner refuses to take action under the recommendation, the committee may refer the concern through the Quality and Accountability Process.

III.Education of Medical Staff , Allied Health Professionals and Hospital Personnel

  1. All members of the Medical Staff and other organization staff will be educated on awareness of the committee, the referral process and the illness and impairment issues specific to physicians under this policy.

B.The education will be conducted on a repetitive basis and through various methods, including but not limited to, orientation, newsletters, at reappointment, physician and hospital committee and departmental meetings.

C.The education process will be the responsibility of the committee with the assistance of the Medical Staff Office and Education Resources.

IV.Resources

  1. The committee will identify and maintain a list of external and internal resources to provide diagnosis, treatment, and rehabilitation for the conditions of physical, emotional, psychiatric impairment, or potential impairment, involving, among other conditions, alcohol and drug abuse, psychiatric disability, physical impairment, problems of aging, sexual misconduct, and the distress of everyday medical practice.
  1. The resources will be updated periodically to provide pertinent information to a practitioner coming to or referred to the committee.

V.Monitoring and Confidentiality

  1. The committee will establish and maintain appropriate monitoring procedures to cover all phases of the diagnosis and rehabilitative process until the rehabilitation process is complete and the practitioner no longer requires assistance.
  1. The matter is forwarded to the medical staff leadership for appropriate corrective action if the practitioner fails to complete the diagnosis, treatment, or rehabilitation process or at any time during the process it is determined that a practitioner is unable to perform the privileges he or she has been granted and the practitioner will not voluntarily relinquish the privileges. All such corrective actions will comply with current medical staff disciplinary procedures and include strict adherence to state and federally mandated reporting requirements.

C.Referrals to and proceedings of the committee will remain confidential within the committee and records maintained in a file separate from the credentials/quality files unless referral for corrective action is required.

APPROVAL:

Credentials Committee: 3/12/07

MEC: 3/20/07

Board:

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