QUESTION:        Our hospital has never gotten around to adopting a Practitioner Health Policy. Instead, we just have our MEC deal with health issues as they arise. Is this ok?

ANSWER:            No. If your hospital is accredited by the Joint Commission, standard MS.11.01.01 requires the medical staff to implement a process to identify and manage practitioner health issues which is separate from the disciplinary process. The elements of performance for standard MS.11.01.01 describe what such a process must include. For example, the process must educate staff on impairment recognition, evaluate the credibility of a complaint regarding health, monitor practitioners until rehabilitation is complete, and maintain confidentiality. Having the MEC (which is the one committee that can “discipline” practitioners) handle health issues on an ad hoc basis, without a written policy, is inconsistent with these standards.

Even if your hospital is not accredited by the Joint Commission, we think a separate Practitioner Health Policy makes a lot of sense. Such a policy is your chance to make clear that the process for addressing health issues is not punitive, but is instead designed to help the practitioner recover while protecting patients. The policy can also set forth modern best practices for identifying and resolving health issues.

For more information on what should be in a Practitioner Health Policy and how it should be implemented, we hope you can attend The Peer Review Clinic in San Antonio, Texas on April 14-16, 2016.