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What is Medical Staff, Organized Medical Staff & the MEC

Contra Costa County Physician Lawyer Daniel Horowitz in suit



CCR 22 § 71503 is the main but not only source of rules for the establishment and duties of a hospital’s “organized medical staff”. The core requirement is that each hospital have a “medical staff” and that this medical staff is responsible NOT to the CEO or administration but “to the governing body”.

There are three categories of responsibility to patients:

A. Fitness
B. Adequacy
C. Quality

Fitness is the least well defined area and it includes the scope of services that a hospital is fit to provide. It also addresses fitness of particular staff members to perform particular services.

The Joint Commission also has rules governing the conduct of the medical staff.
The requirements for medical staff are found at MS.01.01.01 EPs 5–7. These rules mix medical staff duties with governing body compliance and enforcement. In other words the two groups are intertwined. In reality, captive boards of directors often rubber stamp CEO decisions and medical staff responds more to the CEO level than to the governing body.

The Joint Commission lists some examples of policies may include:

A. Required elements of a medical history;

B. Detailed steps for credentialing and re-credentialing;

C. Responsibilities for oversight of professional graduate education program participants;

D. Medical staff health screening requirements (which includes mental health);

E. On-call coverage requirements (an area which can lead to peer review actions when
coverage is inadequate, delayed or non-existent);

The Medical Executive Committee (MEC)

At MS.02.01.01 the Joint Commission requires that there is a medical staff executive
committee. It is organized medical staff and the Medical Executive Committee that has the right adopt and amend medical staff documents but this is subject to the approval of the governing body. In many facilities changes are accomplished with less than optimal formality and with either no governing body approval or rubber stamp approval. This can be a problem as rules and rule changes are quasi-official and unevenly enforced.   Organized medical staff and the elected MEC are the interface and official representatives of medical staff.  These groups often operate informally but their roles are both important and require clear documentation of decisions and actions so that rules are enforced consistently.

Documents that Outline Medical Staff Rules

Few physicians know what documents internal to the hospital, outline the rules and responsibilities of medical staff. The Joint Commission, state and federal law require “By-Laws” and every hospital has them for medical staff although few physicians actually keep a copy. Two other documents often exist but are not required. These are medical staff rules and regulations and medical staff policies.

The medical staff rules and regulations are the fine points and details for implementing the by-laws themselves. There may also be procedures to address patient care issues including specific procedures and policies. The rules and regulations overlap “policies” which can contain specific procedures for specific tasks such as appointment, reappointment, privileging, hearing and appeal procedures.

It is important for physicians to understand what written policies govern their practice at a hospital. It may be tedious but each hospital has a different structure and a failure to adhere to written rules can expose the physician to peer review and MEC imposed discipline.

The Horowitz Physician Medical Lawyers are expert in navigating the rules and regulations that may lead to discipline, license restrictions and medical board or NPDB reporting. Call us if you need help.