SECTION

Carle Physician Group
Professional Staff Policies /

Policy#804

Subject: / Assistance for Impaired Employed Professional Staff Members
Category: / Performance Management
PolicyOwner: / Executive Director of Medical Staff Services
Reviewed By: / Medical Directors’ Group; Medical Director of Employee Health
Approval Signature: / Chief Medical Officer
Effective Date: / 4/1/10 / Review Dates:Triennially / Revision Dates:

Purpose: To assist any employed professional staff member that has been identified or referred for investigation as possibly impaired and to ensure that all practitioners maintain the ability to deliver competent patient care and perform administrative duties.

Scope: All employed professional staff members.

Statement of Policy:

1.Definition:

"Impaired" shall mean the inability to competently practice medicine or perform administrative duties, which may also include repeated absences from work, due to physical or mental disabilities. Such disabilities include, but are not limited to, deterioration through the aging process, loss of motor skills, psychiatric illness, or use of drugs or alcohol, of sufficient degree to diminish a practitioner's ability to deliver competent patient care or perform administrative duties.

2.Employed professional staff members who believe they have animpairment should report it to the Chief Medical Officer (or designee).

  1. If any individual working in the Carle Physician Group or Carle Foundation/Hospital has a concern that an employed professional staff member is impaired, it should be reported according to the procedure outlined below.

Procedure:

  1. Any employed professional staff member suspected to be impaired should be reported to the Medical Director or Chief Medical Officer immediately using Attachment I.If the Chief Medical Officer is suspected the report should be made to the Chief Executive Officer, Carle Physician Group. If the Chief Executive Officer, Carle Physician Group, is suspected the report should be made to the Chief Executive Officer, Carle Foundation Hospital. The report must be factual and shall include a description of the incident(s) that led to the report. The individual making the report does not need to have proof of the impairment, but must state the facts that led to the concern.
  1. If, after reviewing the report, the Chief Medical Officer (or designee) believes an investigation is warranted, the Chief Medical Officer (or designee) shall notify the Medical Director of Employee Health and request a fit for duty evaluation.
  1. The employed professional staff member shall be seen, a history and physical performed. Drug and alcohol testing will be performed.
  2. An opinion on fitness for duty will be rendered to the Chief Medical Officer.
  • Fit for Duty – return to full work
  • Not fit for duty (temporarily)
  • need additional information (e.g. IME, Drug, ETOH, Psyc/other consult set up
  • Needs rehabilitation program and re-evaluated at end of program
  • Not fit for duty (permanent)
  1. If additional information is needed, after this information is obtained a new recommendation will be rendered to the Chief Medical Officer from Employee Health Services.
  1. Once a rehabilitation program is completed, re-evaluation by Employee Health Services Medical Director will be performed and a recommendation with regard to “return to work” will be rendered to the Chief Medical Officer. The return to work recommendation may include contractual agreements (e.g. quality and/or drug and ETOH testing every two years, quarterly updates by psychiatrist every two years).
  1. Depending upon the severity of the problem and the nature of the impairment, the Carle Physician Groupleadership may take one or more of the following options:
  1. Require the employed professional staff member to undertake a rehabilitation program or other appropriate medical care. If Professional Staff member refuses, refer to Disciplinary Procedures Policy #802;
  1. Restrict the activities of the employed professional staff member, according to the report as rendered by the Independent Medical Evaluation;
  1. Suspend employed professional staff member in accordance with Disciplinary Procedures Policy #802.
  1. Relieve employed professional staff member from any administrative duties.
  1. Throughout this process, all parties shall consider this matter strictly confidential and shall avoid speculation, conclusions, gossip, and any discussions of this matter with anyone outside of those individuals described in this policy.
  1. Nothing in this Policy waives rights Carle may otherwise have arising under the Professional Services Employment Agreement between Carle and a professional staff member to take appropriate corrective or disciplinary action.

Electronic Approval on File

Kirk Moberg, M.D., Ph.D.

Chief Medical Officer

Attachment(s):

CONFIDENTIAL Documentation of Suspected Impaired Professional Staff Member

Attachment I

Policy #804

CONFIDENTIAL DOCUMENTATION OF SUSPECTED IMPAIRED EMPLOYED PROFESSIONAL STAFF MEMBER

Professional Staff Member Name______Date ______Time ______

OBSERVATION CHECKLIST:

Demeanor sleepy/lethargic giddy/laughing confused

 normal talkative crying threatening

 hostile excited violent/abusive

 quarrelsome anxious/nervous

Actions violent/abusive erratic threatening

 normal fighting hyperactive asleep/unconscious

 resisting sullen mood

Speech shouting/loud silent whispering

 normal slow rambling/incoherent

 slurred profane

Posture/Walking stumbling staggering falling

 normal swaying unsteady holding

Movements fumbling jerky slow

 normal nervous hyperactive

Eyes bloodshot watery closed

 normal glassy droopy difficulty tracking/focusing

Face

 normal flushed pale sweaty

Appearance dirty messy stains on clothing

 normal partially dressed

Breath/Hands/Hair alcohol odor marijuana odor faint alcohol odor

 normal odors masked by cologne/mints/tobacco/other

Other Observations:

______

______

______

______Signature Date

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