EVALUATION, CORRECTIVE ACTION, AND DISCIPLINARY POLICY FOR RESIDENTS

VI. Reporting

A. Whenever the Director takes any action under Section IV, Performance Deficiencies, s/he shall notify the Assistant Dean for Graduate Medical Education, the Administrative Director of NYU House Staff Affairs, and all relevant Hospital Medical Directors of the action taken and the circumstances surrounding it, as well as the ultimate disposition of the matter. It shall be the responsibility of the Assistant Dean for Graduate Medical Education to advise the Graduate Medical Education Committee of all such actions.

B. Hospitals are required, under § 405.3 (e), Codes, Rules and Regulations of New York State, to report to the OPMC any denial, suspension, restriction, termination, or curtailment of training, employment, association, or professional privileges or the denial of certification of completion of training of any physician licensed or registered by the New York State Department of Education for reasons related in any way to any of the following:

1. Alleged mental or physical impairment, incompetence, malpractice, misconduct, or endangerment of patient safety or welfare;

2. Voluntary or involuntary resignation or withdrawal of association or of privileges with the Hospital to avoid the imposition of disciplinary measures; and

3. The receipt of information concerning a conviction of a misdemeanor or felony.

The report must be made in writing to OPMC, with a copy to the appropriate area administrator of the New York State Office of Health Systems Management, within 30 days after the taking of such action, and must include:

a. The name and address of the individual;

b. The profession and license number;

c. The date of the Hospital's action;

d. A description of the action taken; and

e. The reason for the Hospital's action or the nature of the action or conduct which led to the resignation or withdrawal and the date thereof.

C. In cases involving unlicensed physicians practicing under a limited permit or serving in a clinical fellowship or residency, the Hospital must report to the New York State Education Department Office of Professional Discipline.

D. All licensed health professionals, including physicians, are required by state law to report colleagues whom they suspect may be guilty of misconduct as defined in New York State law. Failure to report suspected instances of misconduct is, in itself, misconduct. For physicians and residents affiliated with a hospital, the report can be made to the hospital's professional practices committee, which must then inform OPMC; in the case of a resident, the report shall be made to the resident's Director, the Administrative Director for NYU House Staff Affairs, and all relevant Hospital Medical Directors. If the colleague is not affiliated with a hospital, a report can be made to the county medical society, which will be responsible for reporting to OPMC. If a health professional is uncertain whether specific actions or behaviors constitute misconduct, s/he may request advice from OPMC without revealing the name of the practitioner. Once advice is provided, the health professional who requested the advice is required to follow it.

E. Practitioners suspected of having problems with alcohol, drugs, or mental illness, but whose ability to practice is not impaired, may be reported to the Committee on Physicians' Health of the Medical Society of the State of New York (CPH). All calls are confidential. CPH identifies, refers to treatment and monitors impaired physicians. The program is voluntary and participation is confidential. The names of physicians participating in the program are not shared with OPMC without a participant's approval unless there is a failure to comply with treatment recommendations. A physician whose medical performance may be impaired, however, also must be reported to OPMC. The law does not exempt physicians from their duty to report colleagues practicing with a suspected impairment to OPMC because they have reported to CPH.

F. Nothing in this policy relieves the institution of its obligations to report incidents of possible professional misconduct under applicable laws and regulations. The results of drug or alcohol testing and matters related thereto shall be kept confidential except to the extent necessary to implement this policy.