Guidelines for Making Formal Referrals to a Physician Health Program

Guidelines for Making Formal Referrals to a Physician Health Program (CPHP)

Effective management of physicians in the workplace necessitates a multi-dimensional and multi-systemic set of decisions and tasks. All systems involved (for example, medical staff office, administration, legal, colleagues, committees and CPHP) must work closely together for the most effective outcome. Intervention options may include:

"Counseling" the physician
Referral for an evaluation/assistance
Consequences/discipline/termination or
Any combination of 1, 2, and 3

Steps to making an effective referral:

I. IDENTIFICATION

Defining the problem(s)
Clarifying policy and/or employment contracts, credentialing by-laws, etc
Determine tried solutions

II. CONFRONTATION: MAKING A REFERRAL

Institutions/organizations/hospitals often find that employing a myriad of approaches to change a problematic situation, such as counseling, coaching, observation, and threat of consequences has not produced the desired results. In other cases, it may be determined that evaluation processes, such as ruling out illness as a root cause for the behavior, may be most beneficial as a place to start. In either situation, a referral to CPHP can serve as a helpful tool to the manager of the physician.
Setting the stage for the meeting: who should be present? Present prepared letter of documentation and referral at appropriate time and location.
Initial call to CPHP:
1. Make an initial call to CPHP and discuss the following:
  1. What are the specific performance issues and/or behaviors causing concern?
  2. How often and with what frequency are they occurring?
  3. How long have you worked with and/or known this physician?
  4. Is his/her performance or behavior different now than sometime before? How long has this been a problem?
  5. What has been tried to correct the problem(s)? How often? What has been documented? What is the physician’s response to attempts made to confront and resolve the problem(s)?
  6. Are you concerned about the physician’s safety with patients? Has the physician had patient complaints—particularly in specific reference to his/her performance or behavior?
  7. Describe the quality of working relationships the physician has with the staff. What types of specific feedback has been heard from staff or employees?
  8. Is the physician regarded as a top-performing physician whose medical knowledge/expertise is respected?
  9. Are you aware of any personal problems the physician is having?
  10. Have there been recent changes in the physician’s workload, level of responsibility, workplace structure, rules, culture, etc.?
  11. What are the consequences for the physician not following through with this referral? By what date does the physician need to contact CPHP? When are you meeting with the physician to refer him? What type of documentation is available for the physician? For CPHP?
  12. Do you feel prepared for such a confrontation? Who needs to be there? Would it be helpful for you to prepare and "walk through" your approach with someone else who is in the loop? It is recommended that more than one person meet with the physician being referred. Where are you going to conduct the meeting?
2. CPHP recommends to the workplace that a letter of referral be given to the physician in the meeting and include the following:
  1. History (dates/patterns) and specific description of the performance and/or behavioral problems;
  2. Summary of the steps that have been taken to remedy situation that resulted in little or no change;
  3. Formal referral to CPHP for evaluation;
  4. Define what specific questions you would like to see answered in the evaluation;
  5. Outline the structure:
    1. How long the physician is given to make contact (recommended 24 hours);
    2. State that you have contacted CPHP and discussed the referral and CPHP is expecting the physician’s call;
    3. Clarify expectations about the physician signing a consent form so CPHP may provide necessary report/feedback;
    4. Clarify what the consequences are if the physician elects to not follow through with the referral (be as specific as possible);
  6. Reference any of the questions as discussed in the referral call to CPHP in the letter. Much of this is helpful information to document to the physician being referred and;
  7. Carbon Copy CPHP on the letter of referral

III. FOLLOW UP

Outline a structure in which the workplace intends to follow up. For example, regularly scheduled meetings to review the physician’s progress and provide timely and specific feedback on how he/she is doing would be helpful and responsible management. The physician would realize that the matter is not going to be dropped and that he/she will hear feedback. The physician deserves consistent and timely feedback if performance/behaviors have improved or if problems are remaining. The physician should be told that colleagues, staff and/or employees would be followed up with as well, to solicit feedback.
Provide ongoing feedback to CPHP before, during and after the evaluation about the physician’s behavior so that CPHP may continue to work most effectively with the physician.
CPHP can provide ongoing feedback pertaining to client involvement, cooperation and progress at CPHP, upon request and with proper consent.
Consider a workplace meeting as a tool. The meeting can be held with workplace management/administration, CPHP personnel and the referred physician. These meetings can serve a variety of purposes. They can:
1. Enhance communication between physician and workplace;
2. Clarify expectations at the workplace (acceptable vs. unacceptable behaviors) and how feedback will be provided to the physician;
3. Explain how the physician’s behavior will be measured;
4. Listen to and/or document any concerns the physician has;
5. Clarify and act upon recommendations/progress reports by CPHP and;
6. Help reach agreements on behavior and conduct
Consider mentoring in the workplace. This would involve a physician to serve as a mentor to the referred physician on behavioral issues, coaching and supporting on desired behavioral change.

IV. CPHP SERVICES

Consultation Services
CPHP may provide consultation and support to managers and administrators regarding physicians in the workplace. CPHP is a “tool” in the manager’s tool bag for sorting out their perceptions, concerns, and interventions related to physicians.
Evaluation Services
CPHP evaluations of physicians typically include the following:
1. Identifying Data and Reasons for Referral
2. Interviewing Collateral Sources of Information
3. History Relayed by the Individual
4. Medical History
5. Legal and Financial History
6. Education and Employment History
7. Family and Social History
8. Mental Status Examination and Psychological Dynamics
9. Laboratory Results
10. Problem Definition and/or Diagnoses
11. Conclusions
12. Recommendations