Healthcare organizations must offer a program for responding to impaired healthcare workers. The threat to patient safety is high.
- Educate all levels of the organization about the policies and procedures for impairment.
- Ensure no retaliation occurs for reporting concerns about impairment.
- Be flexible in the options for helping someone overcome impairment with various accommodations and treatments.
Impaired healthcare workers (HCWs) can pose a serious threat to patient safety, but they must be handled carefully and with respect to their own health conditions. Risk managers must ensure their organizations are prepared to protect patient safety while also working to help impaired HCWs receive treatment and return to work.
Healthcare organizations always faced the problem of impaired professionals and workers, but the issue is receiving more attention now because of some high-profile cases, says Rebecca M. Lindstrom, JD, shareholder with Polsinelli in Chicago.
Lindstrom notes the most publicized case of an impaired physician is Christopher Duntsch, MD, PhD, who practiced medicine in Dallas for two years before becoming the first doctor in the United States to be sentenced to life in prison for his practice of medicine. (For more on the Duntsch case, see “‘Dr. Death’ Case Holds Lessons for Risk Managers, Hospitals” in the June 2021 Healthcare Risk Management.)
In another recent case, Robert Morris Levy, a former pathologist at Veterans Health Care System of the Ozarks in Fayetteville, AR, was sentenced to 20 years in prison. The hospital suspended him for being impaired at work, which the court found led to faulty diagnoses and three deaths.
“We’re becoming more aware of it, and people are feeling more empowered to speak out and report when they have concerns,” Lindstrom says. “With the #MeToo movement and everything else going on in the past year or so, people are more confident about speaking up about powerful people like physicians. The trend is more people raise a concern because we’re seeing what happens when you don’t call people out and you let things go on for too long.”
Risk managers should ensure education on impairment at all levels of the organization, starting with what defines impairment, Lindstrom says. For example, an HCW can experience a mental health issue while sober. The education also should include instruction on what to do when someone suspects impairment.
“When it comes to physician impairment, the people who are most likely to spot it are those staff who work with them closely behind the scenes — the nurses, scribes, and technicians. They need to know what to look for and how to report it,” Lindstrom explains. “They have to know there will not be any retaliation, that they will be protected if they report their concerns.”
Follow Through on Reports
The hospital or health system should be prepared to take all complaints seriously by conducting a prompt investigation, she says. Be proactive and refer the HCW to a wellness committee, a physician health program, or rehabilitation program.
One of the biggest mistakes healthcare organizations make with impaired physicians is to not take reports seriously or to only halfheartedly investigate, Lindstrom says. Each report must be fully investigated, rather than simply asking the physician or nurse if they are impaired and then accepting the denial.
“Don’t ever say that’s enough and you’ll just wait to see if anyone else complains, because surely if the professional really is impaired then someone else will report it, too,” Lindstrom says. “The risks are too high.”
The authors of a 2008 study found 78.7% of physicians were still licensed and working five years after completing a rehab program, compared with relapse rates of 40% to 60% in standard nonphysician programs.1
“When you identify an impaired physician and address the problem quickly, there is a high likelihood they are going to be rehabilitated. Focus on rehabilitation and make sure you have a fair process in place,” she says.
The organization must write an impaired physician policy that specifies what happens in case of suspected impairment, Lindstrom says. Specific policies and procedures must be in place, but remember some flexibility is required.
“What works for one might not work for another. Have some flexibility to provide reasonable accommodations, or have people work with a therapist, or go to an inpatient program,” Lindstrom says. “Don’t try to say, ‘This is how we do it with everyone,’ because with impairment it can be important to tailor the response and the improvement program to what that particular person needs.”
Licensing Boards Offer Best Practices
Best practices for impaired HCWs are clearly established through the professional practices board or licensing board in each state, notes Rich Jones, MA, MBA, LCAS, SAP, executive vice president and executive director of Heritage CARES, a confidential online recovery program for people and families struggling with substance use disorders, based in Coppell, TX.
Although there might be small levels of variability, most states hold the same expectations, he says. Mandated clinical treatment is used to stabilize the condition and might include detox, rehab, long-term residential, or intensive outpatient care. American Society of Addiction Medicine (ASAM) placement criteria are used to guide decision-making on this level of care recommendation. A qualified professional, such as a licensed counselor, psychiatrist, or a licensed drug and alcohol specialist, will conduct the ASAM level-of-care assessment.
Following clinical treatment and stabilization, the person will engage in long-term monitoring program, 12-step or other recovery groups, random urine drug screens, and ongoing clinical care as indicated. Law enforcement would initiate additional, case-by-case legal consequences in the event a crime has occurred.
“Note that having a substance use disorder is not a crime. However, doing certain things to support that disorder could be a crime. For example, diverting pills or writing illegal/fake scripts,” Jones explains. “The addiction is not a crime. But the behavior associated with the addiction is a crime and could be prosecuted accordingly.”
Jones underscores the need for flexibility when responding to impaired physicians.
“Do not fall into an automatic one-size-fits-all response. Some people will require detox and inpatient treatment while others may be able to be stabilized via community-based outpatient care,” he notes. “A truly individualized assessment should be conducted. Recovery group requirements should be taken into account for multiple pathways, and all avenues should be explored.”
Monitoring Periods Vary
Most human resources (HR) departments issue clear guidelines on how to respond to impairment among HCWs, Jones notes. There are limitations consistent with the Americans with Disabilities Act. For instance, substance use disorder is a disease and treatment and/or monitoring must be offered before termination. The professional practices board provides guardrails and guidelines for HR responses.
Monitoring periods vary from discipline to discipline. Physicians are the most intensely scrutinized and monitored.
“The physician monitoring programs are five years in length and have a stunning history of success, with 90-plus percent compliance and completion,” Jones says. “This is because physicians are highly motivated to retain their license. Nursing monitoring may be less intense in terms of length of time and requirements.”
Union factors must be considered, Jones notes. The collective bargaining agreement in any given system certainly will play into the response. However, all union contracts must comply with the professional practices board/licensing board expectations.
“Therefore, the union cannot protect the healthcare provider from the monitoring programs or board sanctions,” Jones says.
- McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008;337:a2038.
- Rich Jones, MA, MBA, LCAS, SAP, Executive Vice President, Executive Director, Heritage CARES, Coppell, TX. Phone: (469) 293-3175.
- Rebecca M. Lindstrom, JD, Shareholder, Polsinelli, Chicago. Phone: (312) 463-6217. Email: email@example.com.