How to Establish Hospital and HMO Physician Health Committees - PHS

The medical staff bylaws should be reviewed to ascertain if there is a provision for a committee to address physician health matters. Such a bylaw may determine the composition, policies, and procedures of the committee. If there is no existing bylaw, PHS suggests the following guidelines in developing a committee. Legal counsel should be consulted to determine if an amendment to hospital medical staff bylaws is appropriate and, if so, to draft language for a new bylaw.


It is generally recommended that three to seven physicians serve on the committee. All members must be members of the medical staff to be sure that the committee constitutes a medical peer review committee under Massachusetts law. Members should have an interest and expertise in chemical dependency, mental illness, and aging/cognitive problems. It is often helpful to include both men and women with a mix of ages and specialties. Members with a history of chemical dependency should be in recovery for at least two years prior to membership on such a committee.

Conflict of Interest

Members of the physician health committee should avoid membership on other hospital or HMO committees that may conflict with their responsibilities as committee members. Executive or credentials committees are examples of committees that may pose such conflicts. Inclusion of physicians in positions of authority such as the CEO or president of the medical staff may have the effect of discouraging referrals to the committee. It is important that the physician health committee be regarded as a resource for assistance and not as a disciplinary entity.


The committee should publicize its existence to the hospital medical staff. Specific contact people should be identified so that referrals can be facilitated. All members of the medical staff and hospital employees should feel encouraged to contact the committee directly with their concerns.

The committee should sponsor educational programs to acquaint the medical staff with the nature of physician health issues and the purpose of the committee. Physician Health Services is available to provide speakers for such programs.

Peer Review Protections

The committee should be identified and function as a medical peer review committee. A hospital or HMO medical peer review committee is a committee of the medical staff of the hospital or HMO in which the medical staff operates under the bylaws approved by the hospital's or HMO's governing board. Massachusetts General Law chapter 111, section 1, includes a definition of medical peer review committees. It specifically identifies the "evaluation and assistance of health care providers impaired or allegedly impaired by reason of alcohol, drugs, physical disability, mental instability, or otherwise."

The status of the medical peer review committee provides confidentiality and immunity protections under Massachusetts law. The reports, records, and proceedings of the committee are confidential with the following exceptions:

  • Proceedings held by the boards of registration in medicine, social work, and psychology
  • Documents, incident reports, and records otherwise available from original sources
  • In an action against a committee member for bad faith or unreasonable action
  • Testimony where information is known to an individual independently of committee proceedings

Immunity protections from civil liability are available for committee members for actions that are reasonable and taken in good faith. The same immunity protections are also available to individuals and entities who provide information or services to the committee as long as the information or services are provided in good faith and are reasonable. Thus, colleagues will be encouraged to come forward with their concerns if they feel that the matter will be handled with discretion and with minimal risk of liability to themselves.

Liaison With Physician Health Services

Ideally, one committee member should be designated to be a liaison with Physician Health Services. It is essential that the committee be familiar with the operations and resources available from PHS. This will help the committee avoid duplicating resources that PHS can provide. It will also ensure that the committee benefits from the experience and expertise of PHS in handling physician health matters.

The communications between the hospital or HMO physician health committee and PHS are confidential peer review communications. In addition to confidentiality under Massachusetts law, the PHS records of physicians with chemical dependency are protected under federal regulation 42 CFR, part 2.

Download the full "Guidelines for Establishing Hospital and HMO Physician Health Committees" (.pdf, 22 KB).

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