Physician health committee policy and procedure

All medical staffs should have a process in place that addresses education about illness and impairment, describes a mechanism for self-referral or referral from other sources, and ensures confidentiality throughout the process. This is specifically required by The Joint Commission in MS.11.01.01. The accerditor also calls for medical staffs to have a process for evaluating the credibility of a complaint, a mechanism for reporting unsafe treatment to the medical staff, and an appropriate course of action for the medical staff to take—but again, this is a best practice for all hospitals, regardless of their accreditor. An excellent way to achieve this is to establish a physician health committee that is responsible for these matters. The following policy can help you establish such a committee.