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School of Medicine

Referrals

VCUHS Medical Staff Health Committee

The VCU Health System Medical Staff Health Committee provides education and awareness of mental and physical impairments as well as a mechanism to address concerns regarding potential mental or physical impairment of a practitioner in a timely, effective and confidential manner. The Committee is comprised of physicians within the Health System as well as representatives from Human Resources, GME and Employee Health.

Frequently Asked Questions


    • Who established the Medical Staff Health Committee and why?
      The Medical Staff Health Committee was established by the MCV Hospitals Medical Staff Executive Committee to create a mechanism to address concerns regarding possible impairment in an effective, confidential manner that protects patients as well as practitioners. The VCUHS Medical Staff Impairment Policy, approved by the Medical Staff Executive Committee, guides the investigation and evaluation process.

    • Which employees and practitioners are covered by the Medical Staff Impairment Policy?
      The policy applies to any practitioner who is privileged or credentialed by the VCU Health System.

    • What is impairment?
      Impairment is any physical or mental disability that substantially alters the ability of a practitioner to practice his or her profession with safety to his/her patients and the public.

    • What do you do if you suspect a member of the Medical Staff of being impaired?
      During the period of Monday-Friday, 8:00 a.m.–5:00 p.m., call or page either Dr. Ron Clark, Chief Medical Officer (804-828-4654), Employee Health (804-828-0584) or Human Resources Employee Relations Office (804-628-9433) for assistance. If the impairment is noted after these hours, page the clinical administrator for assistance on pager 6105. The appropriate division and/or department chair will be notified and a small team of individuals will be called to quickly assess the concern and determine what steps are needed to resolve the matter in a timely, safe and confidential manner. If the team determines that there is a reasonable chance that the practitioner is impaired or that substance use/abuse exists, the individual will be placed on administrative leave until a thorough assessment is completed. Concerns regarding potential impairment may also be relayed via a confidential hotline at 804-828-2200.

    • What happens after a report is made to the Medical Staff Health Committee?
      As noted above, the concern will be investigated by members of the Medical Staff Health Committee. If the concern is validated, the Committee will make recommendations for referral for further assessment and treatment as appropriate to the circumstances. If the practitioner refuses to accept the recommendation offered, further action, including possible withdrawal of privileges, will be considered.

    • If a report is made to the Medical Staff Health Committee, does it automatically get reported to the Board of Health Professions?
      No, only confirmed positive drug or alcohol tests, or admissions for substance abuse or mental health treatment where the individual or others could be at risk for harm requires mandatory Board reporting. In all other cases, the Committee will base the decision to report on the provisions of Virginia Code §54.1-2906-9.

    • Who do I contact if I have questions?
      Referrals may be made to the Medical Staff Health Committee by addressing written correspondence to:

      Medical Staff Health Committee
      Box 980510
      Richmond, Virginia 23298-0510
      Phone: 804-828-2200 [MSHC hotline]