Medical Staff Policy and Procedure

ATTACHMENT I Alfred I. duPont Hospital for Children Medical Staff Policy and Procedure Medical Staff Member Referral

Reasonable concern exists if facts and/or circumstances indicate that a Medical Staff Member is not performing his or her professional duties as expected. Concern may be based on, but not limited to, the following: Observed signs or behaviors from using or being under the influence of alcohol or drugs, erratic/bizarre behavior compared to expected behavior, inappropriate conduct, or illness affecting ability to exercise privileges. You are not responsible for identifying the cause of the problem. Medical Staff Member being referred:

For additional information, please have the Hospital Medical Director contact:

Date: Name: Telephone No.:  Disoriented  Disrespect for colleagues, staff, patients,  Thick, slurred speech guests and family members  Poor motor coordination  Rude or abusive conduct toward other  Sleepiness/drowsiness physicians, nurses, ancillary staff, support  Rounding at times atypical for the individual staff, or patients  Dilated pupils  Threatening behavior or physical assault  Flushed face, head or neck  Inappropriate comment to patients about other  Significant changes in personality physicians, nurses, support staff or the  Unexplained accidents or injuries to self patient’s treatment in the hospital  Hand tremor  Repeated unwelcome advances, requests for  Odor of alcohol on breath sexual favor or other verbal or physical  Hearing and/or seeing things conduct of a sexual nature  Extremely nervous  Belligerent or disrespectful conduct during  Unusually talkative committee or department meetings  Profuse sweating  Inappropriate comments in the patient medical  Uncoordinated gait record or other official documents  Poor perception of time and distance  Breach of patient confidentiality  Unable to perform usual routine tasks  Willfully destroying, misusing or damaging  Use of alcohol or illegal substances while on hospital property hospital premises  Unusual forgetfulness  Other: ______ Difficult to contact ______ Missed appointments/unexplained absences ______ Unkempt appearance ______ Mood changes ______ Inappropriate treatment of patients or dangerous orders Please forward this form to the Hospital Medical Director or call the Hospital Medical Director at 302-651-5829 any time to report a concern.

CONFIDENTIAL

Corresponding Medical Staff Policies: 57.46 Sexual Harassment 57.35 Identification, Investigation and Intervention Medical Staff Members with Suspected or Known Impairment 57.68 Medical Staff Code of Conduct updated 04/04/18