Hospital and Medical Practice Governance: Understanding the Medical Executive Committee (MEC)
We represent many physicians at hospitals such as John Muir Health (Walnut Creek/Concord) where the actual management structure and role of the MEC is unclear. Hopefully this blog which applies state wide will help. View our Peer Review Defense Page
The bylaws of hospitals, legal corporations, and practice groups outline the governance rules for these entities. However, hospitals typically cannot self-govern entirely. They have structures in place to prevent the corporate practice of medicine. Key among these structures are the physicians themselves, who organize and largely self-govern through a Medical Executive Committee (MEC).
The federal regulations at 42 CFR § 482.22 require that:
"(b) Standard: Medical staff organization and accountability. The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to patients."
It explicitly puts the medical staff under the supervision of the governing board:
"(1) The medical staff must be organized in a manner approved by the governing body."
Subsection (b)(2) of 482.22 defines the MEC composition this way:
"(2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy."
That part is simple. So, in sum, there must be an organized medical staff, and if it has an executive committee, that committee must be a majority MD or DO. For a detailed analysis of MEC rules, you can look at real-world examples such as the Stanford Medical Staff Bylaws.
What is a Medical Executive Committee (MEC)?
A Medical Executive Committee (MEC) is a governing body within a hospital or healthcare organization that consists of physicians and other key medical staff members. The MEC serves as a representative body for the medical staff and is responsible for making decisions related to patient care, clinical policies, and physician performance.
The specific composition and structure of a Medical Executive Committee can vary depending on the healthcare organization. Typically, the MEC includes elected or appointed physicians who hold leadership positions within the medical staff, such as the Chief of Staff, Vice Chief of Staff, department chairs, and other relevant roles.
In the standard tiered approach, the CEO team and the Medical Staff are usually equal, and above them is the governing Board of the Hospital. The MEC is consulted by the executive level team, and ultimate authority rests with the board of directors. There are other models of co-equals, but these are less common.
[ Governing Board of the Hospital ]
/ \
/ \
[ Hospital CEO / Executive Team ] <---> [ Organized Medical Staff ]
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[ Medical Executive Committee (MEC) ]
The allocations of responsibility and the independence of the Medical Staff and its MEC are critical to effective hospital management. In general, we have seen the role of the Medical Staff diminished and the CEOs running the ship. In practice, most boards are rubber stamps for corporate executives. The MEC is theoretically independent, but the overlap with management can call that independence into question.
The MEC represents the medical staff but acts primarily as an independent entity, much like Congress represents the public – or not. Issues such as scope of services (what a hospital offers) are important decisions, and the Medical Staff and CEO should be consulted before the Hospital Board makes a decision. In a recent case against John Muir Hospital in Walnut Creek, we are contending that a specialized surgery should not have been performed at the facility and that the Medical Staff should have been consulted before the surgery went forward.
What Does a Medical Executive Committee (MEC) Do?
A Medical Executive Committee (MEC) is responsible for making important medical and clinical decisions, overseeing medical staff, and addressing various healthcare-related issues within the organization. A good webpage for seeing the structure of the MEC as it oversees operations is the Stanford Website, which shows how the MEC structurally works with the other physician-led entities.
The primary functions of a Medical Executive Committee, which (again) is formed from the Medical Staff, may vary depending on the healthcare organization’s structure and policies as well as state law, but common functions include:
Governance and Leadership: The MEC plays a key role in setting the strategic direction and policies related to patient care, medical staff, and clinical services.
Credentialing and Privileging: The MEC reviews, evaluates, and approves the qualifications and privileges of physicians and other healthcare providers seeking to practice within the organization. This process ensures that healthcare providers meet the necessary requirements to deliver safe and high-quality care, granting authority to provide patient care only to qualified professionals.
Peer Review and Quality Improvement: The MEC oversees the peer review process, which involves evaluating the quality of medical care provided by physicians, addressing concerns or complaints, and implementing strategies for continuous quality improvement. This may involve reviewing adverse events, complications, and patient outcomes to identify areas for improvement, enhance patient safety, and promote evidence-based practices.
Policy Development and Implementation: The MEC collaborates with hospital administration to develop and implement clinical and administrative policies and protocols that govern the medical staff’s activities, ensuring that the medical staff follows best practices and evidence-based guidelines. These policies may cover areas such as patient safety, medical ethics, and compliance with regulatory requirements.
Collaboration and Communication (Liaison with Administration): The MEC serves as a liaison and a bridge between the medical staff and hospital administration, facilitating effective communication, cooperation, and collaboration between the two groups. The committee ensures that the perspectives and concerns of the medical staff are represented in decision-making processes.
Strategic Planning and Alignment: The MEC works with hospital leadership to align the medical staff’s activities with the organization’s strategic goals and objectives. This includes participating in strategic planning, resource allocation, and performance evaluation.
Compliance and Ethics: The committee may have a role in ensuring that medical staff members adhere to ethical standards and comply with relevant laws, regulations, and organizational policies.
By fulfilling these responsibilities, the Medical Executive Committee plays a vital role in ensuring the delivery of quality patient care, maintaining professional standards, and fostering a collaborative and effective healthcare environment within the organization.
Composition of the Medical Executive Committee
Members of the Medical Executive Committee (MEC) are typically elected or appointed based on their professional qualifications and experience. The committee often includes key figures such as the Chief Medical Officer (CMO), the Medical Director, department chairs, and representatives from various medical specialties. This diverse composition ensures comprehensive oversight and governance of medical practices within the organization.
Common roles and job titles for those involved in running a Medical Executive Committee include:
Chief Medical Officer (CMO): The CMO is the top of the executive and board side of the governing structure. The CMO is often a high-ranking physician within the organization and typically serves as the chairperson of the MEC. They provide leadership and guidance to the committee and represent the medical staff to the hospital administration. The CMO will often not have hospital privileges, although in smaller institutions a person may be both a member of medical staff and part of executive management.
Medical Staff President / Chief of Medical Staff: The Chief of Staff is simply the head doctor at the top of organized medical staff. In some organizations, the president of the medical staff, who is typically elected by the medical staff members, may lead the MEC or serve as a key member. This role varies depending on the hospital’s bylaws. Ultimately, this person is charged with patient safety and coordinates with the hospital and the executive level (especially the CMO) to ensure that patient safety needs are addressed. The Chief of Staff operates under the written bylaws supplemented by rules and regulations and policies. The actual role and power of the Chief of Staff is often ambiguous, and the ability of the Chief of Staff to operate is usually subordinate to the Medical Executive Committee. Medical discipline, credentialing, and privilege-related issues can be addressed by the Chief of Staff, but generally the MEC and other specialized committees will have primary responsibility.
Hospital CEO/Administrator: The hospital’s chief executive officer or administrator may be a member of the MEC or attend MEC meetings to provide input from the administrative perspective.
Other Medical Staff Leaders: The MEC may include other medical staff leaders, such as the Vice President of the Medical Staff or department chairs, who help coordinate and lead the committee’s activities.
Medical Staff Members: The MEC often includes elected representatives from various medical departments or specialties within the hospital. These representatives bring the concerns and perspectives of their respective departments to the committee.
Quality and Safety Officers: Individuals responsible for quality and patient safety within the organization may also be part of the MEC to ensure that clinical standards and patient care are closely monitored.
Legal and Compliance Advisors: Some MECs may have legal counsel and compliance officers to provide guidance on legal and regulatory matters related to medical staff affairs.
In a best-case scenario, the Medical Executive Committee and hospital administration have a level of tension, ensuring real checks and balances. In reality, the hospital administration drives customers, reimbursements, and advertising, so MEC committee members who represent and act on behalf of medical staff will have personal interests that are exploited by management to help control and drive their decisions.
What Laws Require a Medical Executive Committee (MEC) to Exist?
The Medical Executive Committee (MEC) plays a crucial role in ensuring the delivery of high-quality medical care and promoting effective collaboration among medical staff, administration, and other stakeholders within the healthcare organization.
In California, the MEC is defined and regulated under Cal. Code Regs. title 22 § 71503. This section states:
(a) Each hospital shall have an organized medical staff responsible to the governing body for the fitness, adequacy, and quality of the care rendered to patients.
(b) Medical staff membership: (1) The medical staff shall be composed of physicians and, where dental or podiatric services are provided, dentists or podiatrists. (2) As required by section 1316.5 of the Health and Safety Code: (A) Where clinical psychological services are provided by clinical psychologists in a health facility owned and operated by the state, the facility shall establish rules and medical staff bylaws that include provisions for medical staff membership and clinical privileges for clinical psychologists within the scope of their licensure as psychologists. (B) Where clinical psychological services are provided by clinical psychologists in a health facility not owned or operated by the state, the facility may enable the appointment of clinical psychologists to the medical staff.
(c) The medical staff, by vote of the members and with the approval of the governing body, shall adopt written bylaws which provide formal procedures for the evaluation of staff applications and credentials, appointments, reappointments, assignment of clinical privileges, appeals mechanisms, and other subjects or conditions deemed appropriate. The medical staff shall abide by and establish a means of enforcement of its bylaws. Medical staff bylaws, rules, and regulations shall not deny or restrict, within the scope of their licensure, the voting rights of staff members or assign staff members to any special class or category of staff membership based on whether such staff members hold an M.D., D.O., D.P.M. degree, or clinical psychology license.
(d) The medical staff shall meet regularly. Minutes of each meeting shall be retained and filed at the hospital.
(e) The medical staff bylaws, rules, and regulations shall include provisions for the performance of the following functions: executive review, credentialing, medical records, tissue review, utilization review, infection control, pharmacy and therapeutics, and assisting medical staff members impaired by chemical dependency and/or mental illness to obtain necessary rehabilitation services. These functions may be performed by individual committees, or when appropriate, all functions or more than one function may be performed by a single committee. Reports of activities and recommendations relating to these functions shall be made to the executive committee and the governing body as frequently as necessary and at least quarterly.
(f) The medical staff shall provide in its bylaws, rules, and regulations for appropriate practices and procedures to be observed in the various departments of the hospital. The practice of division of fees, under any guise whatsoever, shall be prohibited and any such division of fees shall be cause for exclusion from the staff.
(g) The medical staff shall provide for the availability of a staff physician or psychologist for emergencies among the in-hospital population in the event that the attending physician or psychologist or their alternate is not available.
(h) The medical staff shall participate in a continuing program of professional education. The results of retrospective medical care evaluation shall be used to determine the continuing education needs. Evidence of participation in such programs shall be available.
For more detailed information, you can refer to the California Code of Regulations and the Health and Safety Code.
THE JOINT COMMISSION Standards
The Joint Commission sets standards for the governance and operation of Medical Executive Committees (MECs) within healthcare organizations. While the Joint Commission does not have specific rules solely for MECs, it provides comprehensive guidelines that impact their functions. Here are some key points:
Governance and Leadership: The Joint Commission emphasizes the importance of effective governance and leadership within healthcare organizations. This includes ensuring that the MEC plays a crucial role in setting strategic directions and policies related to patient care, medical staff, and clinical services.
Credentialing and Privileging: The MEC is responsible for the credentialing and privileging of medical staff. The Joint Commission requires that healthcare organizations have a thorough process for evaluating and approving the credentials and privileges of physicians and other healthcare providers.
Peer Review: The MEC oversees the peer review process to ensure the quality of medical care provided by the medical staff. This involves reviewing adverse events, complications, and patient outcomes to identify areas for improvement.
Compliance and Ethics: The Joint Commission mandates that the MEC ensures medical staff members adhere to ethical standards and comply with relevant laws, regulations, and organizational policies.
Quality Improvement: The MEC collaborates with other hospital committees to implement quality improvement initiatives, enhance patient safety, and promote evidence-based practices.
Liaison with Administration: The MEC serves as a bridge between the medical staff and the hospital administration, fostering communication and cooperation between the two groups.
Remember that the hospital governing board is ultimately responsible for hospital safety and credentialing. The Medicare COPs make it very clear that the Board of Directors is above the MEC.
Powers of the Medical Executive Committee (MEC)
When a physician seeks employment with a group or credentials with a hospital, the Medical Executive Committee (MEC) takes tremendous control over the MD’s life. A summary suspension over 14 days is state reportable to the medical board (in California) and 30 days is reported to the National Practitioner Data Bank. These are removed if the physician later prevails, but the career-threatening power of the MEC should not be underestimated.
Before joining an organization, know who controls the MEC. Most MECs are controlled on paper by the medical staff but in reality by management. Power cliques can wrest control of the MEC from less political but more medically oriented physicians, changing the direction of the hospital and the conditions of your employment.
At times, the MEC can target a physician with unjustified suspensions, investigations, and reporting. (See our article titled "Physicians Have Less Rights than Criminals"). When a committee targets a physician with an unfair MEC investigation, legal representation is necessary. Rarely do hostile actions resolve without the intervention of an attorney and, in truth, even then the lack of physician rights makes the path difficult.
The Eight Unnamed Physicians Case (MEC Gone Haywire)
To understand how the Medical Executive Committee (MEC) can morph into a Frankenstein, consider the case of Eight Unnamed Physicians v. Medical Executive Committee. This case involves physicians who were eight of 11 members of a medical group that had, for years, arranged to provide all necessary anesthesia services at the hospital in return for a virtually exclusive opportunity to do so.
On Saturday, November 20, 2004, the hospital was informed that the physicians would be transferring their practices to a different hospital on the upcoming Monday, November 22. The Medical Executive Committee (MEC) aimed to individually discipline the physicians for this abrupt cessation of services, which purportedly could have endangered patient safety and eroded public trust in the hospital. The physicians refuted the allegations, asserting that they had made arrangements for adequate coverage.
The rest of this published case outlines the battle. The key point is that a business dispute put a gun in the hand of the MEC, and the MEC used the discipline process as a litigation substitute. The case is too long and detailed to discuss here, but the spoiler is that the physicians had far fewer options than you would think.
Can You Sue the MEC?
Our physician clients often ask whether an MEC can be sued. Usually, they are sued not for money but to force them to take action in a fair manner. Perhaps if that request is granted a second suit for money can be filed. The bottom line is that if you can sue organized medical staff as an entity, you can also sue the subgroup within that organization - the MEC.
One effective strategy used by good law firms is to align their work with existing frameworks used by large organizations. Generally, courts favor large entities (such as county organizations) and uphold their rules, enforcing them in a balanced manner. If your attorney is setting up bylaws for a smaller group, mirroring the practices of larger entities can provide an additional layer of protection. However, more often than not, the courts are highly deferential to the MEC.
Here are examples of major cases illustrating how courts handle actions involving an MEC:
Miller v. Eisenhower Medical Center, 27 Cal.3d 614 (1980)
In Miller v. Eisenhower Medical Center, the California Supreme Court addressed a suit challenging the MEC's denial of a physician's application for staff membership. The MEC had denied the application based on negative reference letters, and the physician sued contending the denial lacked a fair basis.
The court examined whether the MEC's decision-making process comported with fair procedure requirements under California common law, illustrating that MEC privilege decisions are subject to judicial review when fair process is alleged to have been denied.
In this case, the doctor was faced with letters that described him as a disruptive physician having trouble working well with other doctors. The doctor argued that this was not enough to deny him staff membership. The court found that:
“It is quite true, of course, that certain forms of disruptive or noncooperative conduct may have an adverse effect upon the level of patient care; we find ourselves in full accord with language to this effect in Huffaker and certain other cases” Miller v. Eisenhower Medical Center (1980) 27 Cal.3d 614, 629.
The disruptive physician challenge is a growing industry with experts who will twist every heated interaction into a disruption, so the Miller v. Eisenhower case has gained increasing importance over 45 years after it was decided!
However, citing an earlier case, the court also noted that:
“(i)n asserting their views as to proper treatment and hospital practices, many physicians will become involved in a certain amount of dispute and friction, and a determination that such common occurrences have more than their usual significance and show temperamental unsuitability for hospital practice of one of the doctors is of necessity highly conjectural.” (58 Cal.2d at p. 598, 25 Cal.Rptr. at p. 555, 376 P.2d at p. 435.) The subject bylaw, if interpreted in the manner suggested by defendant, would permit exclusion of an otherwise qualified physician on just such “conjectural” grounds" Miller v. Eisenhower Medical Center (1980) 27 Cal.3d 614, 629–630.
The court then ruled for the doctor saying:
"We believe that the instant case is one in which the principle of “real doubt” should properly be applied. As we have indicated, the dominant focus of these proceedings was drastically blurred by a failure of the deliberative bodies involved and indeed the parties and their counsel as well to properly understand and apply the hospital's own standards for admission to staff membership insofar as they concerned an applicant's ability to “work with” others. Although evidence was also presented on other matters, our reading of the record as a whole raises a significant and real doubt in our minds as to whether the deliberative bodies involved, had they been faced with only such other evidence, would have reached the result that they did. In any case it is clear that the misconception concerning the proper content of the hospital's standards for admission resulted in a severe misapprehension of the kind and quality of plaintiff's qualifications for admission. In these circumstances, we think the proper course is to return the matter to defendant in order that it may undertake further administrative proceedings directed to the assessment of plaintiff's qualifications for admission to its medical staff in light of a proper interpretation of its standards." Miller v. Eisenhower Medical Center (1980) 27 Cal.3d 614, 635–636.
Bichai v. Dignity Health, 61 Cal.App.5th 869 (2021)
More often the courts are deferential to the MEC. In Bichai v. Dignity Health, a physician sued the hospital alleging unfair competition and conspiracy to retaliate after the MEC recommended denial of his reapplication for staff membership.
The court noted that the MEC is part of the medical staff, which functions as a separate legal entity from the hospital itself. This led the court to rule that claims were not yet ripe because the hospital had not yet made a final decision on the MEC's recommendation.
This emphasizes how the administrative process must be fully used (in most cases) before a doctor can petition a court for relief. As the peer review process can take years, this can force a doctor to endure great hardship before he gets a fair hearing in the Superior Court.
