Medical Staff Health Policy
Procedure
- 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.
- Third-Party Reporting
- 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.
- 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.
- Upon completion of the investigation one of
the following decisions will be made concerning
the allegation:
- No action required
- Initiate the Disruptive Physician Policy
- Refer the physician to the Medical Staff
Health Committee
- Invoke immediate correction action pursuant
the Medical staff Bylaws
- If the medical staff member is suspended:
- 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.
- Failure to give consent for this testing
will be grounds for separation from the
medical staff.
- 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.
- 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.
- No evidence of impairment, no further
action required.
- Member impaired, not presently in
treatment. Treatment recommended in
order to maintain privileges.
- Member impaired, in diversion program
or counseling, and should be allowed to
continue to practice.
- Member impaired, in diversion program
or counseling, and should not
be allowed to practice until reevaluation
during therapy.
- 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.
- Billing
Medical costs related to the evaluation for fitness
for duty are the responsibility of the Medical
staff member.
Back to Table of Contents
|