UCLA Health Impaired Physician Policy

PHYSICIAN HEALTH COMMITTEE (IMPAIRED OR COMPROMISED PHYSICIAN)

The Medical Staff supports the wellbeing and health of Medical Staff Members (hereinafter “member(s)”) with the aim of protecting patient welfare, advancing patient care, fostering a culture of safety, and improving member function by the existence of a Physician Health Committee that:

• Offers assistance to the Medical Staff by creating an environment and consultation mechanism that is conducive to self-referral and rehabilitation of members who may be suffering from a medical, psychiatric, behavioral, and/or substance-use related problem that poses a threat to patient care, self, and/or others;
• Promotes patient safety by establishing a mechanism to identify and offer treatment to impaired or compromised Medical Staff Members;
• Provides education to the Medical Staff and other members of the organization about how to recognize potential signs of impairment and compromise;
• Enhances the safety of patients, Medical Staff, housestaff, and employees;
• Provides oversight, treatment, and assistance for a potentially compromised Medical Staff member by:
  1. Reporting a potentially compromised Medical Staff member to the appropriate leadership as specified in this policy;
  2. Assessing the credibility of a complaint or allegation of possible impairment;
  3. Ensuring, to the extent possible, the confidentiality of all deliberations and documentation;
  4. Referring a potentially compromised Medical Staff member to appropriate internal or external resources for diagnosis, evaluation, treatment, and/or monitoring of a condition under the guidance of the Physician Health Committee;
  5. Monitoring the re-integration of a member into active Medical Staff status in accordance with any applicable Physician Health Committee Monitoring Agreement established between the Medical Staff member and the Physician Health Committee; and
  6. When deemed necessary, facilitating the safe removal of the compromised Medical Staff member from the Ronald Reagan UCLA Medical Center and other UCLA Health or UCLA Health affiliated buildings

POLICY

Because early identification is essential for successful rehabilitation and patient protection, it is the policy of the Medical Staff to identify compromised or impaired members as early as possible to facilitate confidential treatment and rehabilitation, and to monitor recovery activities.

The Physician Health Committee achieves this purpose through prevention, intervention, and facilitation of treatment for medical, psychiatric, behavioral, and/or substance-use related problems of members. The process utilizes assistance and rehabilitation, rather than discipline, to aid members in retaining professional function consistent with providing high quality and safe medical care.

The Physician Health Committee also provides education regarding physician health and wellbeing while addressing the prevention of conditions and behaviors that undermine a culture of safety.

DEFINITIONS

Impaired or Compromised Member

An “impaired or compromised member” is a member who is or may be experiencing a medical, psychiatric, behavioral, and/or substance-use related problem that affects or has the potential to affect their ability to treat patients safely or competently. Examples include, but are not limited to, emotional or physical distress, cognitive impairment due to medical or psychiatric etiology, exhibiting behavior that undermines a culture of safety, and use of alcohol or other mood-altering substances or medications having the potential to affect their performance.

Impairment or Compromise

“Impairment or compromise” refers to any condition or behavior, regardless of cause, which may interfere with the member’s ability to function as normally expected. Impairment or compromise may exist in one or multiple domains, including but not limited to, psychomotor activity and skills, conceptual or factual recall, abstract thought processes, judgment, attentiveness, demeanor, and attitudes as manifested in speech or actions. Major symptoms of impairment or compromise may include declining work performance as manifested by repeated behaviors including decreased concern for patient wellbeing, unavailability, missed appointments, unexplained absences, a pattern of incomplete medical records, poorly communicated medical orders, and withdrawal from hospital or other professional activities. Additional indications may include lapses in judgment, inappropriate relationships, boundary violations, signs or behavior related to intoxication, selfmedication, misuse of controlled substances, or misuse of alcohol. Change in character or personality, bizarre or unexplained behaviors, deteriorating personal hygiene, and mood swings are further accompaniments of potential impairment or compromise. Impairment or compromise may also include excessive unprofessionalism, such as the failure to return pages, repeated reports of poor or disrespectful communication, and harassing, disruptive, or aggressive behavior.

Observer

Anyone who suspects that a member may be impaired or compromised and who notifies the member’s Service Chief, and/or the Chief of Staff, or their respective designees.

Reviewer

Once notified of a suspicion, the Service Chief, Chief of Staff, or their respective designees, gather information, make a determination regarding the allegation, and can refer the matter to the Physician Health Committee via completed forms and any support documents (see attached Appendix A Referral to the Physician Health Committee).

External Medical Review Officer

A Medical Review Officer (“MRO”) is a licensed physician responsible for receiving and reviewing laboratory results generated by a drug and alcohol-testing program and evaluating medical explanations for certain drug test results. An external MRO is an MRO not affiliated with UCLA and as such, is less likely to have a potential conflict of interest.

Committee Coordinator(s)

The Physician Health Committee coordinator(s) will act as case manager. The Member is required to check-in with a Coordinator at regular weekly intervals, as has been determined by the Committee. The Coordinator(s) will speak regularly with the Member’s treatment provider(s) and worksite monitor. If the Member was referred to the Committee by their Service Chief or the Chief of Staff, the Coordinator will provide broad feedback to the referrer.

Workplace Monitor

A Workplace Monitor shall be appointed by the Service Chief or Chief of Staff and/or the Physician Health Committee to observe the Member on a regular basis to assess whether the Member may be impaired or unable to work safely. The Member will meet regularly with the Workplace Monitor in order to assess any ongoing or developing problems that might increase the likelihood for relapse, or might be a sign of continued substance abuse or impairment due to a mental, behavioral or physical health conditions. The Workplace Monitor shall immediately inform the Physician Health Committee if any unusual or concerning behavior is observed.

PROCEDURE

Referral to Physician Health Committee

1. Member Self-Referral
   When a member wishes to self-report their impaired or compromised state or an event of concern (e.g., a charge of driving under the influence (DUI)), the member may refer themselves to the Physician Health Committee for assistance consistent with Medical Staff Bylaws Article 11.7.4

2. Referral After Returning from Medical Leave for a Condition that May Affect Patient Care
   If there is concern that a member may be impaired or compromised in their ability to provide safe and competent patient care upon return from medical leave, the member may self-refer or be referred by their Service Chief, the Chief of Staff or their designee, for assessment by the Physician Health Committee.

3. Third-Party Reporting
   Any Observer who suspects that a member may be impaired or compromised, should follow the following procedure:

   1. The Observer should notify the member’s Service Chief and the Chief of Staff, or their respective designees (i.e., Reviewer).

   2. The Reviewer will assess whether the member may present an imminent danger to patient health or to a safe work environment. If the Reviewer determines that the member may present an imminent danger, the Reviewer will immediately remove the member from all patient care duties and alert the Chief of Staff if not yet notified, the Chief Medical Officer and the Administrator On Call.

   3. The Reviewer will gather relevant information, including interviewing the member, and make a determination regarding the allegation and determine if a referral to the Physician Health Committee is warranted.

   4. If it is determined that a referral to the Physician Health Committee is warranted, the Reviewer must compile all information from the Observer and complete the “Referral to the Medical Staff Health Committee” form. [APPENDIX A].

   5. The Reviewer shall alert the Chief of Staff and/or the Chief Medical Officer to the determination, for any further action by the Medical Staff.

Reasonable Suspicion Drug and Alcohol Testing

1. If a Service Chief or the Chief of Staff has a reasonable suspicion that a member is impaired or compromised, they, or their designee, may ask the member to submit to drug or alcohol testing. The Member will be asked to sign a consent form [APPENDIX C “Consent Form to Drug and Alcohol Testing”] for a drug and/or alcohol-screening test. The Service Chief, the Chief of Staff, or their designee, shall document the basis for this request and have the form co-signed by a second witness [APPENDIX B “Observation Checklist for Reasonable Suspicion Drug Testing”].

2. The Service Chief, the Chief of Staff, or their designee will follow the “Procedure for Reasonable Suspicion Drug and Alcohol Testing” as follows:
   • Contact the Chief of Staff to discuss the matter, if the Chief of Staff has not already been informed. The Chief of Staff or their designee will act as a witness for the checklist of symptoms.
   • Complete observation checklist of symptoms from Appendix B.
   • Contact the Physician Health Committee Team to oversee testing.
   • Have the member fill out and sign the “Consent for Reasonable Suspicion Drug Testing” form (Appendix C).
   • Inform the member that they are being removed from patient care duties and potentially other UCLA Health activities pending the results of the evaluation by the Physician Health Committee.
   • Ask for and take possession of the member’s employee ID and change paging status to unavailable. Restrict ID, Mednet and CareConnect access.
   • Inform the member that they are highly recommended not to drive. They should call a friend, family member, or a taxi. Security will give them the “Driving Recommendation: Acknowledgement and Release” (Appendix D) to sign.
   • The Physician Health Committee Chair or Coordinator will contact the drug/alcohol testing service to arrange testing. Testing can include, but is not limited to, the collection of urine, hair, nails, breath, or blood specimen.
3. If the results of the drug/alcohol test are negative, the Service Chief, the Chief of Staff, or their designee, will inform the member of such. The Physician Health Committee must receive verification of the negative test result before it will recommend that the member be permitted to return to the patient care setting.
4. If the member has a positive, external MRO verified or non-negative drug test result, or a confirmed test for alcohol, the Physician Health Committee will request the member to meet for a Physician Health Committee Review (see below).
5. The member has the option to refuse the drug/alcohol testing. If the member refuses, obstructs, or attempts to cause a delay in the collection of the specimen for the test, this will be considered the equivalent of a positive drug or alcohol test. The Physician Health Committee will recommend to the Service Chief and Chief of Staff that a member who engages in such behavior should not be permitted to return to patient care duties. The Medical Staff will separately determine whether the member should be summarily suspended under Article 7 of the Medical Staff Bylaws.

Physician Health Committee Review

When a member is referred to the Physician Health Committee, the Committee will assess and review the information provided by the Reviewer, meet with the member to evaluate the information, discuss the initial assessment, and make a recommendation. Such recommendations may include further evaluation, referral to an outside professional and/or facility for evaluation and/or treatment, professional coaching, education program and/or participation in a monitoring program, and/or regular toxicology screening. Any costs, fees, or expenses associated with any type of assessment, monitoring, evaluation, treatment, or program participation will be the sole responsibility of the member receiving such services.

Depending on the severity of the problem(s) and the nature and/or extent of the member's impairment or compromise, the Health Committee may take any, or all, of the following actions, in any order, after consultation with the Chief of Staff(s) and/or any member(s) of hospital leadership whose involvement is necessary to the circumstance:

1. Recommend to departmental and/or Medical Staff leadership that the member voluntarily take a leave of absence, during which time he or she would participate in a rehabilitation or treatment program to address and resolve the impairment.
2. Recommend to departmental and/or Medical Staff leadership that appropriate conditions or limitations be placed on the member’s practice.
3. Recommend to departmental and/or Medical Staff leadership that the member voluntarily agree to refrain from exercising some or all UCLA Health medical privileges until rehabilitation or treatment has been completed or an accommodation has been made to ensure that the member is able to practice safely and competently.
4. Recommend to departmental and/or Medical Staff leadership that some or all of the member’s UCLA Health medical privileges be suspended if the member does not voluntarily agree to refrain from practicing at UCLA Health facilities.

Evaluation

1. If the Committee is unable to make a determination as to the validity of the concern, further evaluation will be recommended.
2. The Physician Health Committee will provide the member with a list of several approved evaluators or evaluation programs.
3. The member will inform the Physician Health Committee of the evaluator that will be used, and will sign a release of information for the Physician Health Committee to speak with the evaluator.
4. Refusal to participate in the evaluation or sign the release of information will mean the Physician Health Committee is unable to form a recommendation and will report this to the member’s Service Chief and the Chief of Staff.
5. If the member undergoes an evaluation and the evaluator determines that additional information is needed from third parties—such as the member’s Service Chief, treatment providers, family members or significant others in order to make a recommendation— written permission shall first be obtained from the member to speak with such third parties regarding the member’s condition. If a member refuses to provide written permission, the member will be asked to acknowledge that refusal may hinder the evaluator and Physician Health Committee’s ability to obtain a thorough evaluation and make a recommendation.
6. For an evaluation to be considered complete, the member must agree to the evaluator carrying out all elements of an approved evaluation, which may include psychological testing, cognitive testing, drug/alcohol testing, collection of collateral information, and/or medical, neuropsychiatric, and psychiatric examination.
7. The evaluator will send the Physician Health Committee a report following the evaluation.
8. If the member decides that they do not want the evaluation sent to the Physician Health Committee, this will be considered the same as a member refusing to undergo an evaluation. The member may not request a second evaluation or an evaluation by a different evaluator to supplant the original. The member, however, may have a second evaluation done by a different vetted program, which the Physician Health Committee will consider in conjunction with the original evaluation.
9. The Physician Health Committee will use the evaluator’s report to form a recommendation regarding the member’s need for treatment and/or return to patient care.

Monitoring

1. A Monitoring Agreement will be created by the Physician Health Committee to address the member’s circumstances [See APPENDICES E and F “Monitoring Agreements”], their needs, and may specify the conditions under which the member could return to or remain in the patient care setting. All Monitoring Agreements for members with a documented psychiatric or substance use related problem will include a requirement that the member not travel without prior approval from the Physician Health Committee and their treatment provider in order to maintain continuity of treatment and testing.

2. Monitoring will be generally undertaken for a period of at least five years to be reviewed on an annual basis. If a member voluntarily resigns from the Medical Staff before the recommended period of monitoring is completed, the Physician Health Committee will assist the member in transition to any subsequent Physicians Health Program or Wellbeing Committee for monitoring, if applicable.
3. If the member declines to sign the Monitoring Agreement, the Physician Health Committee will immediately inform the Service Chief, the Chief of Staff, and the Governing Body of this decision. The Medical Staff will separately determine whether the member should be summarily suspended under Article 7 of the Medical Staff Bylaws and a report made to the Medical Board of California.

Treatment

1. The Physician Health Committee will inform the member of its recommendation for treatment, educational activities, or a coaching program.

2. The Physician Health Committee will work with the member to choose appropriate and vetted treatment, educational activities, or coaching options.
3. The Physician Health Committee will inform the member’s Service Chief and the Chief of Staff of the schedules of treatment, educational, or coaching programs, and of monitoring activities. The member may request accommodation for treatment if necessary.
4. The member will sign releases allowing the Physician Health Committee to speak to their treatment, education, or coaching provider. The Physician Health Committee will communicate regularly with the provider(s). These conversations will not include details of the content of the treatment or training and will primarily be to determine general progress.

Return to Work

If the Committee determines that it is safe for the member to continue working either during the period they is participating in a treatment, or educational, or coaching program, or following the member’s return to work, the following will occur:

1. The Committee will relay this information to the member’s Service Chief and/or the Chief of Staff. The final decision to maintain or reinstate a physician’s clinical privileges must be approved by Chief of Staff with final ratification by the Governing Body.

2. Upon approval by the member’s Service Chief and the Chief of Staff, the member’s Monitoring Agreement will be finalized and signed.

3. The member’s progress will be overseen via regular reports from the Workplace Monitor and from the treatment, coaching, or educational provider at the frequency outlined in the Monitoring Agreement.

4. The member will communicate regularly with the Physician Health Committee at the frequency outlined in the Monitoring Agreement.

5. The member’s progress will be reviewed by the Physician Health Committee on at least an annual basis. For substance use concerns, monitoring will continue for at least five years.

CONFIDENTIALITY

1. The Member’s personal health and other information obtained by the Committee under the terms of this policy (collectively referred to as “Confidential Information”), will be protected from disclosure except as may be required by law or as set forth in a Monitoring Agreement. The Committee shall release only the minimally necessary amount of Confidential Information to the Governing Body and the UCLA Health Chief Quality and Medical Officer or the Chief Medical Officer, as may be necessary for appropriate leadership oversight of quality of care in the patient environment. Such release of minimally necessary Confidential Information may be at the discretion of the Physician Health Committee, or upon the request of the Governing Body. In addition, the Committee shall release the minimally necessary amount of Confidential Information to the Chief of Staff, and to the Member’s Service Chief, as may be appropriate for health care operations and work place purposes, including but not limited to the member’s status in the Program and specifics concerning the member’s ability to work safely in a patient care environment. Confidential Information obtained by the Committee shall be maintained separate from the member’s employment and credentials files and from UCLA’s electronic medical record.

Non-Compliance

The medical staff believe that issues of impairment can best be dealt with by the Health Committee to the extent possible. If, however, a Member does not consent to be seen by a vetted evaluator, complete the evaluation, participate in a vetted treatment program, or adhere to treatment, rehabilitation and monitoring activities, the Committee will notify the Member’s Service Chief and the Chief of Staff that the Member has chosen not to follow the recommendations of the Committee. At this time, the Physician Health Committee will inform the Member, their Service Chief, the Chief of Staff and the Governing Body, that the Physician Health Committee will no longer monitor adherence to rehabilitation. The Medical Staff will separately determine whether the Member should be summarily suspended under Article 7 of the Medical Staff Bylaws and a report made to the Medical Board of California.

REFERENCES

1. California Medical Association: Guidelines for Hospital Medical Staff Wellbeing Committees

2. Federation of State Physician Health Programs: Physician Health Program Guidelines
3. Federation of State Medical Boards: Guidance on Physician Impairment
4. Joint Commission on Accreditation of Healthcare Organizations Medical Staff Standard, Physician Health, MS 4.8

APPENDICES

APPENDIX A: REFERRAL TO THE PHYSICIAN HEALTH COMMITTEE

APPENDIX B: OBSERVATION CHECKLIST FOR REASONABLE SUSPICION DRUG TESTING

APPENDIX C: CONSENT TO DRUG AND ALCOHOL TESTING

APPENDIX D: DRIVING RECOMMENDATION: ACKNOWLEDGEMENT AND RELEASE

APPENDIX E: MONITORING AGREEMENT FOR SUBSTANCE USE, MEDICAL OR MENTAL HEALTH CONCERNS

APPENDIX F: MONITORING AGREEMENT FOR BEHAVIOR THAT UNDERMINES A CULUTRE OF SAFETY

 

 

Physician Health Committee: May 13, 2021

Medical Staff Executive Committee: May 27, 2021

Governing Body: June 15, 2021