David Geffen School of Medicine at UCLA Graduate Medical Education
 
 
Policy Purpose and Objectives Definitions Procedure

Medical Staff Health Policy

Procedure
  1. Self-Reporting
    When a member staff member wishes to self-report his/her impairment, they may refer themselves to the Medical Staff Health Committee for assistance, in line with its charge under the Bylaws.

  2. Third-Party Reporting
    1. No Imminent Danger to Patients If a UCLAMedical Center employee or member of the medical staff (including House Staff) suspects that a medical staff member may be impaired, but is not thought to be an imminent danger to patients, he/she should complete a Report of Observed Behavior Form and submit it to the Chief of Staff or designee. The Chief of Staff will investigate and make a determination.
    2. Potential Imminent Danger to Patients If an observer suspects that a medical staff member may be practicing in an impaired state which may reasonably be thought to be an imminent risk to patients, the following procedure will be followed:
      • Observer will notify supervisor or department head.
      • Supervisor or department head will make an assessment of whether there is imminent danger to patients. If so, the supervisor will call the Chief of Staff and Administrator on Call.
      • The Chief or Staff or their physician designee will come to the unit and meet in a private location with the member who is suspected of being impaired. The Chief of Staff will make a determine regarding the allegation.
    3. Upon completion of the investigation one of the following decisions will be made concerning the allegation:
      1. No action required
      2. Initiate the Disruptive Physician Policy
      3. Refer the physician to the Medical Staff Health Committee
      4. Invoke immediate correction action pursuant the Medical staff Bylaws
    4. If the medical staff member is suspended:
      1. The member will be requested to sign a consent form for obtaining a sample of blood/urine and the collection of this sample will be supervised by the Chief of Staff or their designee. The sample will be transported to an outside reference lab for drug screening.
      2. Failure to give consent for this testing will be grounds for separation from the medical staff.
      3. The same day or next working day if after hours, after suspension, the member will be referred to the Medical Staff Health Committee, which will be requested to make a recommendation within 3 days.
    5. If the member is referred to the Medical Staff Health Committee without summary suspension, that Committee will recommend to the medical staff one of the following within 14 days. The Committee, in consultation with the Department Chair, may seek formal psychiatric or substance abuse consultation in order to assist them with their determination.
      1. No evidence of impairment, no further action required.
      2. Member impaired, not presently in treatment. Treatment recommended in order to maintain privileges.
      3. Member impaired, in diversion program or counseling, and should be allowed to continue to practice.
      4. Member impaired, in diversion program or counseling, and should not be allowed to practice until reevaluation during therapy.

  3. Report to the Diversion Program of the Medical Board of California
    This is only necessary when the physician will not voluntarily sign up with the Diversion Program when required by the Medical Staff Executive Committee on the recommendation of the Medical Staff Health Committee.

  4. Billing
    Medical costs related to the evaluation for fitness for duty are the responsibility of the Medical staff member.


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