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Joint Commission Requirement - MS.11.01.01

Effective January 1, 2001, the Joint Commission requires that hospital organizations have their medical staff implement a process to identify and manage matters of individual licensed independent practitioner (LIP), which is separate from actions taken for disciplinary purposes.

The intent of the Joint Commission requirement is to assist physicians and other LIPs with health concerns and therefore provide protections to patients.

In this regard, Joint Commission requires medical staff and organization leaders to:

  • Design a process that provides education about LIP health;
  • Addresses prevention of physical, psychiatric, or emotional illness;
  • Facilitates confidential diagnosis, treatment, and rehabilitation of LIPs who suffer a potentially impairing condition

As the Joint Commission provides, the purpose of the process is to facilitate rehabilitation, rather than discipline, by assisting a practitioner to retain and or regain optimal professional functioning that is consistent with protection of patients. If at any time during the diagnosis, treatment, or rehabilitation phase of the process it is determined that a practitioner is unable to safely perform the privileges he or she has been granted, the matter is forwarded for appropriate corrective action that includes strict adherence to any state or federally mandated reporting requirements.

The process design should include:

  • Education of LIPs and other organization staff about illness and impairment recognition issues specific to LIPs;
  • Self-referral by an LIP;
  • Referral by others and maintaining informant confidentiality;
  • Referral of the affected LIP to the appropriate professional internal or external resources for evaluation, diagnosis and treatment of the condition or concern;
  • Maintenance of confidentiality of the LIP seeking referral or referred for assistance, except as limited by applicable law, ethical obligation, or when the safety of a patient is threatened;
  • Evaluation of the credibility of a complaint, allegation or concern;
  • Monitoring of the LIP and the safety of patients until the rehabilitation  is complete and periodically thereafter, if required;
  • Reporting to the organized medical staff leadership instances in which an LIP is providing unsafe treatment.


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