Health Care Professionals | MaineHealth Maine Medical Center

MaineHealth Provider Professionalism Committee

I. Definition and Authority

The Provider Professionalism Committee (PPC) is an operational committee of MaineHealth at each of its communities which reviews and addresses concerns about physician/APP conduct alleged to be at odds with the expectations and/or values of MaineHealth.

In cases where professionalism concerns are deemed credible, the PPC issues employment discipline for employed providers. As to Medical Staff intervention with respect to professionalism issues that come forward, the PPC and/or members thereof are authorized through the By-Laws to hear concerns raised and, if and as deemed appropriate, to issue particular levels of redress through its Chair and/or Co-Chairs and/or to otherwise refer professionalism issues to the Medical Executive Committee (“MEC”) of the Medical Staff for any actions deemed appropriate by the MEC in connection with a provider’s medical staff appointment and/or privileges.

II. Members

Members of the PPC for a MaineHealth community generally include the Chief Medical Officer and/or ACMO (the CMO and/or ACMO will Chair the PPC), the Medical Staff President, the VP of Physician & APP Services, certain Chiefs/Chairs/Senior Medical Leaders, APP(s) and other MaineHealth leaders and/or MaineHealth counsel (counsel is non-voting) as needed. The CMO and/or ACMO, in consultation with the VP of Physician & APP Services, shall select the applicable Chiefs/Chairs/Senior Medical Leaders and APP(s) to sit on the PPC, and the CMO and/or ACMO, in consultation with the VP of Physician & APP Services, may remove a PPC member from serving on the PPC at any time, for just cause determined within their discretion.

III. Goal & Process

The goal of the Provider Professionalism Committee is to resolve, as early as possible, any issues of professionalism raised about a physician/APP, and to discern whether concerns raised are credible following appropriate fact-finding including discussion with the provider involved. Where concerns are deemed not credible, this may be documented as such and retained in the PPC files.

1. Certain First Time Offenses: On occasion, a reported “first time alleged offense” of lack of professionalism by a provider may not rise to PPC level. This may be, for example, an occasion where a provider is alleged – for the first time – to be rude, dismissive, demeaning, or to have used profanity, angry expressions of frustration etc., all of which conduct does not align with MaineHealth expectations and/or values. Such first time offenses may be handled through a collegial conversation with the provider’s Department Chair/Service Line Chief/Division Chief/Senior Medical Director/Medical Director/Associate Medical Director as long as all of the following requirements are met:
   1. Leaders first review any reported alleged professionalism issue with the VP of Physician & APP Services and VP of HR or (if delegated) Director of HR to determine if appropriate for non-PPC, collegial conversation treatment; and
   2. The nature of the first-time offense does not involve alleged harassment, discrimination, retaliation, safety violation/concerns, particularly offensive and/or egregious behavior and/or any behavior falling outside of “zero tolerance” policies of MaineHealth. The VP of HR or (if delegated) Director of HR and VP of Physician & APP Services will be helpful in making such assessments; and
   3. the collegial conversation is subsequently documented in writing by appropriate leadership, with copy of the document then forwarded to the Chair of the PPC and to HR.
2. All other Professionalism Concerns - Required Reporting to PPC: Alleged inappropriate conduct must be reported to the PPC when:
   1. It is not a first time offense or allegation, regardless of nature of offense; and/or
   2. The nature of the first time offense involves alleged harassment, discrimination, retaliation, safety violation/concerns, particularly offensive and/or egregious behavior and/or any behavior falling outside of “zero tolerance” policies of MaineHealth.

Once a physician/APP is within the PPC process, they may also offered support as appropriate to help identify underlying causes for troubling behavior and/or to help identify successful pathways forward. All PPC proceedings are confidential, with any medical staff related matters (including referrals to MEC) protected by peer review. Documentation of PPC matters is maintained in the CMO/ACMO Office and/or within HR (for employed providers) and in a Medical Staff Member’s medical staff file if/as appropriate.

IV. Inputs

Concerns about physician/APP conduct may come from a variety of sources, including but not limited to: a verbal report, e-mail or other issued complaint from staff or coworkers, the Safety Reporting System (ie. Safety Net), a patient complaint, or a complaint issued by a third party (visitor, licensing Board, community member). All concerns related to professionalism regardless of nature or source should be reported to the VP of Physician & APP Services, VP of HR (and/or their Director of HR delegate) and PPC Chair, who will engage other applicable leadership as appropriate. It is anticipated that the Chair of the requisite Department and/or Service Line Chief be informed and knowledgeable about conduct concerns set for PPC review. The PPC process entails appropriate fact-finding inclusive of appropriate leadership and HR for employed workforce. Inquiry steps may involve the community CMO/ACMO, VP of Physician and App Services, and/or other clinical, administrative and/or medical staff leaders appropriate to the circumstance. Witnesses may be interviewed and relevant documents collected, and the physician/APP involved will be a key component of process. Any notes and/or documentation of the fact- finding will be retained and provided/accessible to the PPC.

Non-PPC Matters: Concerns related to Provider impairment and/or Provider Privacy Violations will not be handled by the PPC. Untimely documentation matters are also generally handled outside of the PPC and in accordance with an applicable MHMG documentation policy. At times, certain conduct may also fall so outside the values of MaineHealth and expectations for employment that, while there may be a professionalism component, the conduct rises to level of immediate separation. Such conduct may be reviewed by MaineHealth outside of the PPC process related to such immediate action. Examples may include, but not be limited to, fraud, theft, inappropriate manipulation or falsification of documentation including patient record(s), or material insubordination of leadership including but not limited to in a pattern of such behavior. An applicable employment agreement may also dictate a particular outcome for a matter. Matters outside of the PPC will be handled by HR, MaineHealth leadership and/or community Medical Staff as appropriate and in accordance with applicable employment agreement(s), policies, practices and laws.

V. Progressive Discipline Steps Where Conduct is Found Credible

Collegial Conversation Step – not referred to PPC (pre-PPC step)

• Step 1: Collegial Intervention Action & Letter*
• Step 2: Verbal, Documented Warning (for employed providers) and/or Letter of Guidance* (independent providers)
• Step 3: Written Warning (employed providers) and Referral to MEC for all providers (employed & independent) for Medical Staff review/action
• Step 4: Final Warning (employed providers) and Referral to MEC for all providers (employed + independent) for Medical Staff review/action
• Step 5: Separation of Employment (employed providers) and referral to MEC for independent providers.

*In connection with the above actions, for both employed Providers and independent providers, collegial Interventions and letters of guidance are also informal medical staff steps under the Bylaws for resolving professional conduct concerns, so Steps 1 and 2 serve a dual process. For any Provider who is at the Written Warning, Final Warning, or Separation Stages set forth above, the PPC will also refer the Provider (whether employed or not – essentially providers who have come before the Committee for the 3, 4 or 5th time or equivalent based on nature of conduct) to the MEC for review and deliberation under the Medical Staff Bylaws as related to their Medical Staff appointment and/or privileges.

Importantly, while the PPC encourages and supports progressive steps as set forth above, the PPC reserves the discretion and right at all times to issue the level of action deemed warranted given the nature of, and/or pattern of, behavior. The PPC may also consider the extent of any gaps in time between corrective steps. In these manners, the PPC may, for example, issue a final warning or Separation on a first occurrence, or repeat a certain corrective step if substantial time has passed between concerns raised without a pattern and in consideration of a provider’s sustained pattern of improvement.

VI. Support Options Available to Physicians/APPs

• Referral to DocExecutive or Similar Resource if/as available
• Outside Physician/APP Course, Coach or Program (ie. Professional Renewal Center)
• Referral to the Peer Support Program (Internal – Led by Chief Wellness Officer)
• FPPE through Med Staff/Departmental Process
• State of Maine Medical Professionals Health Program
• Other as deemed appropriate by PPC/MEC/Department Chair