House Staff Manual - Winthrop University Hospital

• Immediately suspend the physician’s privileges until rehabilitation has been accomplished ifthe physician does not agree to discontinue practice voluntarily.If the physician does not accept the suggestions and findings of the Medical Director, the mattermay be referred to the Executive Committee of the Medical Staff for appropriate disposition.Voluntary request for a leave of absence from the medical staff and acceptance of a plan of actionwould not require further reporting and is consistent with the confidential and supportive role ofthis program.If the matter cannot be handled internally, or jeopardizes the safety of the physician or others, theHospital may seek the advice of Hospital counsel to determine whether any conduct must bereported to law enforcement authorities or other governmental agencies.The original report and a description of the actions taken will be included in a confidentialpersonnel file. If the investigation reveals that there may be some merit to the report but notenough to warrant immediate action, the report shall be included in the confidential file and thephysician’s activities and practice shall be monitored until it can be established that there is, or isnot, an impairment problem.Throughout this process, all parties shall be reminded to avoid speculation, conclusions, gossipand nay discussions of the matter with anyone outside those described in this process.REHABILITATION AND REINSTATEMENT TO HOUSE STAFF DUTIESCPH will coordinate appropriate treatment and notify Hospital Administration, the Medical Director andthe Chief Academic Officer when the resident is medically cleared for duty and appropriate monitoring inplace. Upon request, CPH will conference with Hospital representatives to facilitate reentry into theworkplace. Once back on duty, CPH will monitor the physician to assure continued engagement intreatment and investment in recovery. The Hospital, at it’s discretion, may request periodic reports fromCPH and may institute it’s own monitoring as it deems necessary.Physicians determined incapable of safely performing their clinical privileges should be referred to GMEStaff leadership and Administration for action consistent with Public Health Law and GME Policies. CPHshall also be notified.HOUSESTAFF EDUCATIONAL PROGRAMMembers of the Housestaff shall be oriented to recognize indicators of impairment in physicians and otherhealth professionals and shall receive an educational brochure from the Medical Society of New YorkState’s Committee on Physician Health.Periodically, the CPH will present education programs on physician impairment, intervention andconfidential assessment to the Executive Committee of the Medical Staff, clinical and nursingdepartments and other interested departments in the Hospital.The Medical Director or his designee will present information about the Physician Health andWellness Process at the Annual Medical Staff Meeting.CONFIDENTIALITYPhysician health assessments are confidential medical records and will be maintained with restrictedaccess separate from discipline or credential files. To promote confidentiality during house staffreappointment, only designated medical staff and administrative representatives will review physicianhealth assessments.Rev. 1/08