March 30, 2017

QUESTION:        We received word through the grapevine that a Medical Staff member was arrested for driving under the influence of alcohol (“DUI”) last weekend.  Does our Medical Staff leadership need to take any action, or should we only act if we’ve observed problems in the hospital?

ANSWER:            A DUI may be a sign of a significant underlying problem, or it may reflect only a momentary lapse in judgment.  Given this uncertainty and the potential risks to patients and the practitioner, it makes sense to speak with the practitioner about the DUI, gather relevant information, and decide if any additional action is needed.  This approach protects both patients and the practitioner.

Gathering information about the DUI is consistent with the process followed by some state medical boards, which use a trained professional to interview physicians who are arrested for a DUI to determine if an additional assessment or intervention is required.

The hospital’s Credentials Policy and Practitioner Health Policy should help physician leaders to address these issues:

  • The Credentials Policy should make clear that applicants and members of the Medical Staff must notify the Medical Staff Office, the Chief of Staff, or the Chief Medical Officer of any change in information provided on their application form. In fact, the Credentials Policy could specifically state that physician leaders must be notified of any DUI or similar matter.
  • The Practitioner Health Policy should outline a non-punitive, supportive process for carefully obtaining a practitioner’s input, evaluating a potential health issue, and helping the individual resolve the issue.

For more information on how to handle these and other issues, join us May 4-6 in New Orleans (and enjoy Jazz Fest at the same time – responsibly!).

February 11, 2016

QUESTION:        Our hospital has never gotten around to adopting a Practitioner Health Policy. Instead, we just have our MEC deal with health issues as they arise. Is this ok?

ANSWER:            No. If your hospital is accredited by the Joint Commission, standard MS.11.01.01 requires the medical staff to implement a process to identify and manage practitioner health issues which is separate from the disciplinary process. The elements of performance for standard MS.11.01.01 describe what such a process must include. For example, the process must educate staff on impairment recognition, evaluate the credibility of a complaint regarding health, monitor practitioners until rehabilitation is complete, and maintain confidentiality. Having the MEC (which is the one committee that can “discipline” practitioners) handle health issues on an ad hoc basis, without a written policy, is inconsistent with these standards.

Even if your hospital is not accredited by the Joint Commission, we think a separate Practitioner Health Policy makes a lot of sense. Such a policy is your chance to make clear that the process for addressing health issues is not punitive, but is instead designed to help the practitioner recover while protecting patients. The policy can also set forth modern best practices for identifying and resolving health issues.

For more information on what should be in a Practitioner Health Policy and how it should be implemented, we hope you can attend The Peer Review Clinic in San Antonio, Texas on April 14-16, 2016.