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