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Impaired Residents: A Summary of Key Policies and Procedures (43.9)

Impaired Residents: A Summary of Key Policies and Procedures (43.9) - Policies, Administrative, UWHC, Department Specific, Graduate Medical Education (GME)

43.9





Effective Date:
2013-08-21

Administrative Manual

 Graduate Medical Education

Policy #: 43.9

Original
 Revision

Page 1
Of 5

Title: Impaired Residents: A Summary of Key
Policies and Procedures



Impaired Residents: A Summary of Key Policies and Procedures

UW Hospital and Clinics
Version: Revision
Effective Date: 2013-08-21
Manual: Graduate Medical Education
………………………………………………………………………………………………………
I.PURPOSE
To summarize the UWHC policies and procedures re: impaired employees and detail the step-by-step procedure to
follow in the case of suspected impairment.
II.POLICY
GME trainees are UWHC employees and should be treated as such for the purposes of addressing suspected
impairment. The UWHC policies that address impairment are summarized below. The full text of each policy can be
found on u-connect.
For purposes of the following policies and procedures, the Program Director will be considered equivalent to the
manager and the director of GME administration will function as the ELRC representative. The DIO would be
considered the administrator.

A. Drug-Free Workplace, Policy #9.05
UWHC has a no-tolerance policy regarding the unlawful manufacture, distribution, sale, purchase, dispensation,
possession or use of drugs and controlled substances, or unauthorized use, or being under the influence of
alcohol or drugs in the workplace. Violation of this policy will result in disciplinary action, up to and including
discharge, and may have legal consequences. UWHC recognizes drug and alcohol dependence as an illness
and major health problem and offers confidential assistance through the Employee Assistance Program (EAP).
An employee is required to report arrests or convictions for drug offenses to his/her immediate manager.

B. Pre-Employment Drug Testing for Safety Sensitive Positions, Policy #9.23
UWHC conducts pre-employment drug testing as a condition of employment for all prospective employees who
will be appointed to “safety sensitive” positions which includes all prospective GME trainees.

C. Fitness for Duty: Impaired Employee, Policy #9.34
UWHC employees are expected to report to report to work unimpaired in their ability to perform their duties at all
times. An employees taking prescribed medication which may compromise ability to perform assigned duties
must report this to his/her immediate manager. The use or being under the influence of any legally obtained drug
while at work, on or in UWHC property or vehicles, or during work hours is prohibited if such use or influence may
affect the safety of the employee, other employees, patients or member(s) of the public.

An employee who has reason to believe that the use of a legal drug may impair his/her job performance must
report such drug use to the employee’s manager or Employee Health Service (EHS). A fitness-for-duty
assessment may be required.

When conditions of impairment exist that may affect the ability of the employee to perform his/her job in a safe
and productive manner, the employee will be required to undergo a fitness-for-duty evaluation. An employee will
be subject to a fitness-for-duty evaluation when a manager, nursing supervisor, or individual in charge has reason
to believe the employee has impaired judgment or lacks physical or mental capacity to satisfactorily perform
regularly required job duties. If the employee does not consent to this evaluation, the employee will be suspended
without pay pending investigation by the employee’s manager and the Human Resources Department’s
Employee and Labor Relations Consultant (ELRC). When fitness-for-duty results become available, the





Effective Date:
2013-08-21

Administrative Manual

 Graduate Medical Education

Policy #: 43.9

Original
 Revision

Page 2
Of 5

Title: Impaired Residents: A Summary of Key
Policies and Procedures



employee’s manager and director, in consultation with the ELRC, determine appropriate levels of disciplinary
action and will make a referral to EAP (if positive result).

If a supervisor has information or belief that a professionally licensed employee has a problem with alcohol or
drug use that impairs the employee’s ability to perform his/her professional duties, the supervisor must notify
his/her administrator. The ranking licensed professional will report the impairment to the Wisconsin
Department of Regulation and Licensing and copy UWHC Human Resources, ELR.

D. Employee Assistance Program, Policy #9.15
UWHC, as a concerned and responsible healthcare provider, recognizes that employees’ physical, psychological
and/or emotional health can adversely affect their work. The Employee Assistance Program (EAP) offers all
employees and their family members/significant others in their households confidential and professional help with
alcohol and other drug use, and a host of other problems, e.g., legal concerns, financial difficulties, parenting,
depression.

The EAP is a good resource, but is not a substitute for appropriate corrective action. When an employee
accesses EAP, s/he is still expected to meet and maintain existing job performance standards and practices and
work rules. A referral to EAP does not prevent UWHC from taking appropriate managerial or corrective action.

E. Fitness for Duty: Health Service Clearance to Return to Work/Continue Work, Policy #9.22
Employee Health Service (EHS) will conduct a health assessment and provide return to work clearance for
employees. An absence from work of any duration due to signs or symptoms of alcohol use or impairment
requires a return to work clearance.
III.PERSONS AFFECTED GME Trainees in ACGME-accredited residency and fellowship programs.
IV.DEFINITIONS
A. Resident is intended to include all residents and fellows in ACGME accredited training programs.
B. Program(s) will refer to ACGME-accredited program(s).
V.PROCEDURES
Complete details are in the above referenced policies. This is only a summary to facilitate finding key steps for the
Program Director or other supervising faculty to use in the case of suspected on-the-job impairment (reasonable
cause). If time is not of the essence, please refer to the original policy.

Excerpted from UWHC Policy 9.34 Fitness for Duty: Impaired Employee. Wording has been adjusted to be relevant to
residents.
A. Program Director or Supervising Faculty Assessment (reasonable cause):
1. An employee will be subject to a fitness-for-duty evaluation when a Program Director or Supervising
Faculty, Nursing supervisor, or individual in charge has reason to believe the employee has impaired
judgment or lacks physical or mental capacity to satisfactorily perform the regularly required job
duties. This includes not only impairment due to suspected drug or alcohol use, but also non-drug
related impairments or conditions.
2. Whenever feasible, another individual in charge should also make an independent assessment based
on observations of the same factors. When making the assessment, the Program Director or
Supervising Faculty should use the Manager's Report of Reasonable Cause form, available on the
Intranet.





Effective Date:
2013-08-21

Administrative Manual

 Graduate Medical Education

Policy #: 43.9

Original
 Revision

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Title: Impaired Residents: A Summary of Key
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3. The Program Director or Supervising Faculty or individual in charge should look at the incident and
combinations of behaviors. The following is a reference list only and should not be considered an all-
inclusive list:
a. Physical Condition
i. Blank stares
ii. Bloodshot eyes
iii. Body odor
iv. Chronic runny nose
v. Constricted pupils
vi. Dilated pupils
vii. Dizziness/staggering
viii. Excessive sweating
ix. Flushed skin
x. Irregular breathing
xi. Odor of alcoholic beverages
xii. Poor depth perception
xiii. Slurred speech
xiv. Tremors/shakes
xv. Vomiting/nausea
xvi. Watery eyes
b. Work performance
i. Argumentative/threatening behavior
ii. Chronic/excessive lateness/absence
iii. Disoriented/confused
iv. Dozes/nods off
v. Fails to meet deadlines
vi. Forgetfulness
vii. Frequent accidents on or off the job
viii. High error rate
ix. Hyperactive/restless behavior
x. Leaves work station without notice
xi. Long or frequent breaks/meals
xii. Needs repeated instruction
xiii. Overreactions to criticism
xiv. Rapid/unpredictable mood swings
xv. Reckless/disregards procedures
xvi. Significant change in pace; job takes more time
xvii. Dramatic decline in work performance
c. Behaviors/observation
i. Avoidance of others
ii. Change in personal hygiene/appearance
iii. Frequent complaints from co-workers
iv. Increased patient/customer complaints
v. Outbursts - tears or anger
vi. Pattern of absences (e.g., before and after weekend or days off, etc.)
B. Fitness-for-Duty Evaluation:
1. A resident is required to report, when directed, to EHS (Monday through Friday from 8:00 a.m.
through 4:30 p.m.) or the Emergency Department (at all other times when EHS is not open) for a
fitness-for-duty evaluation, and will be accompanied by his/her Program Director or Supervising
Faculty or the individual in charge. This may occur when an employee reports for duty or in the
course of the work shift.





Effective Date:
2013-08-21

Administrative Manual

 Graduate Medical Education

Policy #: 43.9

Original
 Revision

Page 4
Of 5

Title: Impaired Residents: A Summary of Key
Policies and Procedures



2. The Program Director or Supervising Faculty (or person in charge) shall document on the "Manager's
Report of Reasonable Cause" form (Policy 9.34, Appendix A) their observations of the employee as
the reasons the Program Director or Supervising Faculty (or individual in charge) believes the
resident is unable to initiate or continue normal work duties and has been referred for a fitness-for-
duty evaluation. When a resident is presented for a fitness-for-duty evaluation, EHS or the
Emergency Department staff will conduct the evaluation based on the information provided on the
"Manager's Report of Reasonable Cause" form. EHS and UWHC will have access to any assessment
and test results conducted by the Emergency Department.
3. The resident signs the "Authorization for Release of Medical Information" form provided by EHS. A
resident who refuses to sign the "Authorization for Release of Medical Information" form will be
presumed to have tested positive for a drug(s) and/or alcohol.
4. Any medical/drug supplies (i.e., syringe, vial, pills, etc.) or other suspicious material observed near
the resident must be secured by Security, and these materials must be presented to EHS/Emergency
Department for referral to the laboratory for analysis. Suspicious material not needed for analysis,
may be given to University of Wisconsin (UW) Police (608/262-4524) as contraband and possible
physical evidence.
5. The fitness-for-duty evaluation will include a drug and alcohol screen, medical examination, and, as
appropriate, additional assessments may be recommended by EHS. A Chain of Custody form will be
completed and signed by the resident, authorizing the release of the results to UWHC.
6. EHS will release the results of the evaluation to the resident. UWHC shall maintain all
communications regarding the results of any drug or alcohol test conducted under this policy as
confidential except as otherwise provided herein. Residents who have tested positive for drugs or
alcohol under this policy may have access to test records upon written request to EHS. The pass or
fail results of any drug or alcohol screening will be released to the director of GME Administration )or
the DIO or the Senior Medical Director for GME) by EHS provided the Chain of Custody form has
been completed and signed by the resident. Any additional information, including non-drug related
conditions or impairments, may be shared with the GME office as appropriate.
C. Investigation:
1. A resident referred for a fitness-for-duty evaluation, or a resident suspected of being under the
influence of drug or alcohol who refuses to consent to a fitness for duty evaluation, will be suspended
with pay pending investigation by the resident’s Program Director (or individual in charge) in
conjunction with the director of GME Administration and the Human Resource department's
Employee and Labor Relations Consultant (ERLC). The resident will not return to work until after all
test results are available and reviewed by the Medical Review Officer (MRO).
2. If the results are negative and a resident returns to work, the resident will be reimbursed for any part
of a suspension that was unpaid.
3. If the results are positive, it is the responsibility of the employee's Program Director and the GME
director in consultation with the DIO, to determine appropriate levels of disciplinary action.
4. The ELRC may notify the UW Police at 608/262-4524 if its investigation suggests that criminal
conduct has occurred. If a supervisor has information or belief that criminal conduct requiring
immediate police response or investigation has occurred, he/she should contact the UW Police. The
supervisor must notify the ELRC whenever such a police referral is made. Criminal conduct includes
sale or use of controlled substances as well as diversion and/or theft of controlled substances.
D. Transportation to Home:
A resident who a Program Director or Supervising Faculty or individual in charge has reason to believe may be
under the influence of alcohol or drugs or suffering other impairment may be unfit to operate a motor vehicle.
Therefore, the Program Director or Supervising Faculty or individual in charge will arrange for the resident's
transportation home by some means other than the employee operating his/her personal vehicle, or contact
UWHC Police and Security if the employee refuses assistance.





Effective Date:
2013-08-21

Administrative Manual

 Graduate Medical Education

Policy #: 43.9

Original
 Revision

Page 5
Of 5

Title: Impaired Residents: A Summary of Key
Policies and Procedures



E. Employee Assistance Program:
1. Residents who are suspected to be unfit to work due to use of drugs and/or alcohol will be referred to
the Employee Assistance Program (EAP). See Hospital Administrative Policy 9.15. Referrals to the
EAP will be coordinated through the GME office. After an incident involving drugs and/or alcohol,
those individuals who return to work with the permission of their Program Director may do so under a
written agreement that may mandate regular appointments with EAP and random drug and alcohol
screenings. The term of a written agreement is normally one year. Violation of the terms of the
agreement will be reported to the resident's Program Director and discharge may result.
2. Residents who are deemed unfit-for-duty for reasons other than drug or alcohol use will, when
appropriate, also be referred to appropriate treatment from EAP. The EAP provider is National
Employee Assistance Services (NEAS). NEAS counselors can be contacted 24 hours per day, 7 days
per week by calling 1-800-634-6433.
3. In most instances, an resident's request for a leave of absence to obtain treatment for substance
abuse will be granted by UWHC, except the treatment will not delay a decision to discipline and/or
discharge a resident for policy or work rule violations. The terms of the resident's absence for
treatment will depend on the employee's eligibility for leave of absence, and will be determined in
consultation with the GME office.
VI.MODIFICATIONS
This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made for the
purpose of inducing any person to become or remain an employee of UWHC, and should not be considered
"promises" or as granting "property" rights. UWHC may add to, subtract from and/or modify this Policy at any time.
Nothing contained in this Policy impairs the right of a non-represented employee or UWHC to terminate the
employment relationship at-will. For represented employees, who are not at-will employees, this policy does not
supersede, limit nor grant any rights beyond those provided by the applicable collective bargaining agreement.
VII.REFERENCES
A. ACGME Institutional Requirements (www.acgme.org)
B. ACGME Policies and Procedures Manual (www.acgme.org)
C. UWHC Policy # 9.05: Drug-Free Workplace
D. UWHC Policy # 9.23: Pre-Employment Drug Testing for Safety Sensitive Positions
E. UWHC Policy # 9.34: Fitness for Duty: Impaired Employees
F. UWHC Policy # 9.15: Employee Assistance Program
G. UWHC Policy # 9.22: Fitness for Duty: Health Service Clearance to Return to Work/Continue Work
VIII.COORDINATION
Sr. Management Sponsor: Susan Goelzer, MD, Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Review/Approval Committee: Graduate Medical Education Oversight Committee, 8/21/13
SIGNED BY




Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Senior Medical Director for GME/Designated Institutional Official
Associate Dean for Graduate Medical Education