The Impaired Physician or Staff Member

For purposes of this policy Staff will refer to any employee, 
professional staff members, (physician, dentist, podiatrist, 
etc) licensed independent practitioners (LIP) or contracted 
It is our policy that all Staff act in an ethical manner, 
dealing honestly with patients and colleagues, avoiding fraud 
and deception; this organization does not condone and will 
not allow any Staff to render patient care services or to be 
involved in decisions relating to patient care at any time 
that judgment and/or skills may be compromised by the 
influence of chemical substances, including alcohol, and/or 
by emotional, physical illness or distress.
If any Staff has reason to believe that another member of the 
Staff may be impaired or has illness, the Medical Director 
should be immediately notified. Staff must be educated in 
areas of concern or at risk criteria.  Self referral is 
encouraged, however if a Staff member expresses concerns 
regarding another Staff member, the referring Staff member 
will be kept in confidence.  Additionally any complaint will 
be immediately investigated and fact-finding immediately 
carried out pursuant to the medical staff bylaws or the 
personnel policies and procedures, as applicable.
The organization will provide referral to the Staff member 
needing diagnosis and treatment. However this shall be kept 
in confidence unless limited by law, ethical obligation or 
when the health and safety of a patient is threatened. 

The Medical Director may immediately suspend the employment 
status or medical staff status of any Staff who may present 
an imminent danger to personal health or safety or to the 
health or safety of a patient or other Staff member.  
Supervisory personnel in the chain of command, appropriate to 
the specific situation, shall be involved.
Should the Staff member continue to work whether on full or 
restricted duty during the time of treatment; monitoring will 
occur of the affected Staff member and the safety of patients 
until the rehabilitation or any disciplinary process is 
complete and periodically thereafter, if required.
The Medical Director/Governing board will call a focused or 
peer review if the Staff member was suspended from duty or if 
there was disciplinary action taken and the review will occur 
prior to the Staff member's return to duty.  The review panel 
will consist of the Staff member's peers, whether they be 
internal or external, the Medical Director and as necessary 
rehabilitative specialists, or other designees as the Medical 
Director sees fit. The Staff member that is being reviewed 
will participate in this focused review process.
The Medical Director will evaluate any Staff with clinical 
privileges whose performance is questioned as a result of the 
measurement and assessment activities.  The Medical Director 
will also communicate to the appropriate parties of the 
findings, conclusions, recommendations, and actions taken to 
change or improve the Staff member's performance.
Approved By Governing Board    
Control #50.0