Model TMA/THA/TMF-PHP Medical Staff Bylaw
JCAHO Wellness Committee Requirement

Introduction: Wellness Committee/Medical Staff Assistance Committees are not commonly mandated by state law, with the notable exception of California, where medical staff bylaws, rules, and regulations must provide for assisting medical staff members in obtaining rehabilitation for impairment by chemical dependency or mental illness.

The Joint Commission has recently added standard MS 2.6 which calls upon the medical staff to implement a process to identify and manage individual physician health matters separate and apart from the disciplinary process and to promote medical staff education on impairment and other physician health issues.

These Model Bylaws are intended to be a resource for hospital medical staffs when addressing Joint Commission standard MS 2.6. The sponsoring organizations believe it may be helpful to some medical staffs to have these Model Bylaws as a reference when existing bylaws are amended or new ones developed.

Medical staff assistance committees can serve invaluable purposes for every medical staff. Properly structured committees afford impaired medical staff members a non-punitive opportunity to recover while preserving their valuable skills through monitored practice. If the purview of the committee is sufficiently broad, it can be used to monitor the work of practitioners with infectious diseases if needed. Further, members whose limited ability to work well with others affects patient care can be helped through appropriate intervention and education provided by such a committee. A common mistake in medical staff bylaws is to refer to “physician assistance committees.” Not only does this reference suggest that only physicians are in need of assistance, it could be construed to exclude non-physician members of the medical staff unnecessarily.

[Ed. Note: The following sections are appropriate for larger hospitals with numbers of credentialed physicians sufficient to staff a Wellness Committee. §II details procedures for smaller hospitals. In either type of hospital, the Wellness Committee functions may be incorporated into another standing committee.]

Medical Staff Wellness Committee

1) Intent
The following sections concerning this hospital’s Medical Staff Wellness Committee involves the design of an ongoing process, under Tennessee’s Peer Review Law of 1967 (T.C.A. §63-6-219), by which the Committee: a.) provides the medical staff with education about physician health; b.) prevents physical, psychiatric, or emotional illness; and, c.) facilitates confidential diagnosis, treatment, and rehabilitation of physicians who suffer from a potentially impairing condition. The purpose of the process is assistance and rehabilitation, rather than discipline, to aid a physician in retaining or regaining optimal professional functioning, consistent with protection of patients. If at any time during the diagnosis, treatment, or rehabilitation phase of the process it is determined that a physician is unable to safely perform the privileges he or she had been granted, the Committee shall forward the matter to the Medical Executive Committee for appropriate corrective action that includes strict adherence to any state or federally mandated reporting requirements.

2) Composition
There is hereby established a Medical Staff Wellness Committee comprised of no less than [ ] Active Staff members appointed by the Chief of Staff, a majority of whom, including the chair, shall be physicians. Except for initial appointments, each member shall serve a term of [ ] years, and the terms shall be staggered as deemed appropriate by the Medical Executive Committee to achieve continuity. Insofar as possible, members of this committee shall not serve as active participants on other peer review or quality assurance committees while serving on this committee.

3) Duties
The Medical Staff Wellness Committee shall have as its purpose the improvement of the quality of care and the promotion of health and competence among Staff members. The committee may receive reports related to the health, well-being or impairment of medical staff members and, as it deems appropriate, may investigate such reports. The committee’s duties shall be:

a) To educate the Medical staff and other organization staff about illness and impairment recognition issues specific to physicians;

b) To develop a written impaired Staff member policy that addresses appropriate intervention, denial, revocation, or limitation of clinical privileges, follow-up assessments, and the reinstatement of clinical privileges for impaired applicants or Staff members upon their re-entry; to obtain the approval of the Medical Staff for such policy; and to implement such policy;

c) To receive self-referrals and any other report relating to the mental or physical health, well-being, or impairment of any applicant or Staff member, as relevant to such person’s ability to exercise the clinical privileges granted to, or requested by, such person;

d) To evaluate the credibility of, and investigate such reports to the extent necessary to protect the health, welfare, and safety of patients, other Staff members, and hospital personnel;

e) As it deems necessary, to provide such advice, counseling, and referral to the Tennessee Medical Foundation’s Physician Health Program, or other appropriate referral, for diagnosis and treatment of the condition or concern.

f) To maintain the confidentiality of the physician seeking referral or referred for assistance, except as limited by law, ethical obligation, or when the safety of a patient is threatened;

g) To consider, in conjunction with the Credentials and the Quality Assessment and Improvement Committee peer review, the results of any such tests or evaluations or the refusal to consent to such testing or evaluation; to implement any intervention or other action in accordance with the impaired member policy as adopted by the Staff; and to request corrective action in accordance with the provisions of Article XI when appropriate; and

h) To monitor the affected physician and the safety of patients until the rehabilitation or any disciplinary process is complete, or to delegate such monitoring, by agreement, to the Tennessee Medical Foundation’s Physician Health Program.

The activities of the Medical Staff Wellness Committee shall be confidential. The refusal to consent to such testing or evaluation as is requested by the Medical Staff Wellness Committee shall constitute grounds for denial of an application for Staff membership or clinical privileges or for immediate suspension or revocation of all or any portion of a member’s Staff membership or clinical privileges; however, any member against whom any action is taken with respect to Staff membership or clinical privileges as a result of the refusal to consent to testing or as a result of any test results shall have the right to a hearing and appellate review in accordance with Article XII.

4.) Meetings
The Medical Staff Wellness Committee shall meet as often as necessary as called by its chair, but at least [monthly/quarterly]. The Medical Staff Wellness Committee shall maintain such records of its proceedings and actions, as it deems advisable, but shall report its activities in their entirety to the Medical Executive Committee.

[Optional Section II]

Wellness Procedures for Smaller Hospitals

1.) Intent:
It is the intent of this hospital medical staff, in addition to its duty to ensure that patients receive quality health care, that its physician staff members remain unencumbered by any health condition which impairs their ability to deliver quality care to their patients. Towards this end, the Medical Staff has adopted the following processes to address health impairments related to the disease of chemical dependency (including alcohol and other drugs), or mental or emotional illness, or both.

The purpose of the process outlined herein is to facilitate referrals of impaired physicians to the Tennessee Medical Foundation Physician Health Program (or a similar program or process of treatment) for assistance and rehabilitation, rather than discipline, of the affected physicians in order to aid the physicians in retaining or regaining optimal professional functioning, consistent with protection of patients. If at any time during the diagnosis, treatment, rehabilitation or monitoring phases of such events by this Medical Staff, the Medical Wellness Subcommittee of the Medical Executive Committee determines that a physician is unable to safely perform the privileges he or she had been granted, the Subcommittee may, in its discretion, forward the matter to the remaining members of the Medical Executive Committee or a disciplinary peer review committee for appropriate corrective action that includes strict adherence to any state or federally mandated reporting requirements.

Finally, it is the policy of this hospital and Medical Staff to ensure that impaired physicians receive the treatment and rehabilitation services they need to enable them to return to safe and productive medical practice. It is acknowledged that this process is voluntary on the part of the affected physician, and further that, unless an impaired physician accepts the terms and conditions for assessment, treatment (if necessary) and referral to the TMF-PHP (or similar program or process), then this policy and procedure shall not apply. In such instances, the matter shall be reviewed in the ordinary course as a peer review and disciplinary matter.

2.) Composition
There is hereby created a Medical Staff Wellness Subcommittee of the Medical Executive Committee composed of no less than three physicians who are active Staff members. Insofar as possible, members of this subcommittee shall not serve as active participants on other peer review or quality assurance committees of this hospital while serving on this committee.

3.) Duties
a.) The Medical Staff Wellness Subcommittee, under Tennessee’s Peer Review Law of 1967 (T.C.A. §63-6-219), shall refer to the Tennessee Medical Foundation Physicians Health Program (or a similar program or entity) any physician who is suffering from the disease of chemical dependence or mental or emotional illness or both. Once such a referral is made, the Subcommittee shall monitor the progress and activity of the physician in the TMF-PHP’s aftercare system, including the results from any initial assessments or diagnosis(es) prior to the physician’s entry into treatment or TMF-PHP advocacy relationship. It is expected that physicians receiving such assistance shall, following treatment, have entered into a TMF-PHP aftercare contract, which normally runs for five years, and which includes regular and random drug screens, 12 Step meeting attendance, TMF-PHP Regional Aftercare Monitoring Team oversight, and regular contact with the TMF-PHP Medical Director and/or the Assistant Medical Director for this hospital’s region.

b.) The Subcommittee shall work with the TMF-PHP and, if available and as applicable, other entities and individuals, to:

i.) Provide the Medical Staff with education about illness and impairment recognition issues specific to physicians;

ii.) Provide Medical Staff members with opportunities for self-referral concerning their own potential impairment;

iii) Provide an avenue for the filing or referral of reports concerning the mental, emotional, or physical well-being or impairment of any applicant or Staff member, as relevant to such person’s ability to exercise the clinical privileges granted to, or requested by, such person;

iv.) Provide and maintain confidentiality of the physician seeking referral or who has been referred for assistance, except as limited by law, ethical obligation, or when the safety of a patient is threatened;

v.) Consult with the TMF-PHP (or similar entity) on an impaired Staff member policy (to be approved by the Medical Staff) that addresses appropriate intervention, denial, revocation, or limitation of clinical privileges, follow-up assessments, and the reinstatement of clinical privileges for impaired applicants or Staff members upon their re-entry;

vi.) Receive self-referrals and any other report relating to the mental or physical health, well-being, or impairment of any applicant or Staff member, as relevant to such person’s ability to exercise the clinical privileges granted to, or requested by, such person;

vii.) Evaluate the credibility of, and investigate such reports to the extent necessary to protect the health, welfare, and safety of patients, other Staff members, and hospital personnel.