House Staff Manual - Winthrop University Hospital

appropriate in every circumstance. Medical Staff leadership and Hospital leaders educate physicians aboutrecognizing physician health issues, and address prevention strategies for physical and emotional illness.REFERRAL MECHANISM FOR EVALUATION OF COMPLAINT, ALLEGATION, OR CONCERNIt is the obligation of anyone within the organization to report concerns if a physician is affected by acondition that creates the likelihood that unsafe patient treatment may be provided.1. Physician Self-ReferralPhysicians are encouraged to contact CPH to obtain confidential assistance for themselves and theircolleagues. Physicians and staff members observing signs and symptoms that may be indicative of apotentially impairing condition may make referrals confidentially to CPH. CPH clinical staff willassess the credibility of the referral and coordinate the intervention and risk assessment. If the referralis credible, CPH will arrange for a confidential clinical evaluation at the physician’s cost by aspecialist approved by the Medical Society. If the evaluation results in no diagnosis, no further actionwill be taken.If a condition is diagnosed, CPH staff will obtain the physician’s approval to contact appropriatemedical staff leaders, preferably the Chief Academic Officer, Medical Director and DepartmentalChairperson to maintain confidentiality. To promote assistance and rehabilitation rather thandiscipline, physicians requiring time away from the training program will be granted a medical leave ofabsence. Time may need to be made up as per respective Licensing Board.(See Section 10 – Family and Medical Leave – re impact of leave on training status and applicablespecial board requirements).2. Hospital Staff ReferralIf an individual working in the Hospital has reasonable suspicion that a clinician may be impaired, thefollowing steps should be taken:An oral or written report shall be given to the President and Chief Executive Officer, the MedicalDirector, the Vice President of Administration responsible for Medical Staff Affairs, or theChairperson of a clinical department. (In the case of House Staff, the Chief Academic Officer willalso be notified.) The report shall include a description of the incident(s) that led to the belief thatthe physician may be impaired. The report does not need to give proof of the impairment, butmust state the facts leading to the suspicion.If, after discussion with the individual who filed the report, there is enough information to warrantan investigation, the CEO or his designee shall direct that an investigation be instituted andappoint the Medical Director to form an investigative committee.If, after investigation, it is found that sufficient evidence does exist, the Medical Director andother members of the investigative committee, if warranted, shall meet with the physician. Thephysician shall be told that the results of the investigation indicate that the physician may sufferfrom an impairment, that affects, or may affect his/her practice and be encouraged to seektreatment.Depending on the severity of the problem and the nature of the impairment, the Hospital may takethe following actions:• Require that the physician undergo a rehabilitation program as a condition of continuedappointment or clinical privileges;• Impose appropriate restrictions on the physician’s practice;Rev. 1/08