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What is Organized Medical Staff and How Does it work with the Medical Executive Committee?

The terms Organized Medical Staff and Medical Executive Committee (MEC) are familiar to physicians but the actual distribution of responsibility and power is often hidden.   Some hospitals such as Stanford Children’s Health are highly transparent and their website is a good starting point in understanding how a well run medical community operates.

Stanford's transparency is important because it promotes consistency of care and consistency in procedures at a hospital.  If the rules are well known, easily accessible and developed collaborating there will be greater consistency in keeping medical records in a consistent format, putting into true day to day practice new treatment protocols (e.g. perioperative glycemic control protocols and other infection prevention procedures).

Organized Medical Staff information is defined broadly by the Joint Commission which defines three classes of documents that convey the procedures and policies of Medical Staff.

“Types of Medical Staff Documents

As you learn about MS standards, you may see the terms bylaws, rules and regulations, and
policies used to describe medical staff documents. Outside the standards, the term bylaws
may be used to refer to all these documents. But within the standards, these terms can’t be
used interchangeably.” (Medical Staff ESSENTIALS | Your Go-To Guide)

Medical Staff Committees

Stanford Children’s lists seven medical staff committees. These are:

Care Improvement Committee
Credentials Committee
Ethics Committee
Health Information Management Committee
Medical Executive Committee
Pharmacy and Therapeutics Committee
Well-Being of Physicians and Physicians-in-Training Committee

The Medical Executive Committee (MEC) is the Most Powerful

The Medical Executive Committee (MEC) is by far the most powerful of the committees. In most hospitals this committee essentially runs medical staff. It is the committee that most regularly meets with executive management and the “governing board” (usually the Board of Directors) This means that conflicts can arise between the medical staff in general and between the medical executive committee and other committees. The Joint Commission at MS.01.01.01,  EPs 10 and 11 describes how the organized medical staff has to manage those conflicts.

AMA Ethics Rule - Patient Safety First

The governing principle is detailed in the AMA Code of Ethics which states:

“The organized medical staff performs essential hospital functions even though it may often consist primarily of independent practicing physicians who are not hospital employees. The core responsibilities of the organized medical staff are the promotion of patient safety and the quality of care.”
(9.5.1 Organized Medical Staff)

When physicians are disciplined by medical staff / the Medical Executive Committee a core focus of both the persons/entity bringing the allegations and the physician presenting the defense is articulated in the second paragraph of 9.5.1 which reads:

Members of the organized medical staff may choose to act as a group for the purpose of communicating and dealing with the governing board and others with respect to matters that concerns the interest of the organized medical staff and its members. This is ethical so long as there is no adverse effect on patient safety and the quality of care
(9.5.1 Organized Medical Staff)

A Peer Review Defense for Physicians

Depending on the facts and issues, the doctor can argue that his/her practices were patient safety oriented and that medical staff was acting in favor of profit, expediency or to protect the careers or business interests of factions within the community.

Drugs, Alcohol, Mental Illness & Well Being Committees

Stanford’s Well Being committee performs a critical task by allowing physicians to confidentially obtain support and treatment for mental health issues that can also include drug or alcohol issues. A review of the Medical Board of California’s annual report shows that after Gross Negligence, drug, alcohol and DUI arrest matters are a major factor in the filing of Accusations. Likely the Gross Negligence filings also include physicians with undiscovered or unprovable drug and alcohol/mental health issues. If there is minimal patient harm, the Medical Board is rather forgiving to physicians who admit and obtain treatment for drug/alcohol and mental health issues.

Other entities such as John Muir Health do not make their By-Laws and other documents as easily accessible. (Try a web search on “John Muir Health” “by-laws” and see what you do or don’t get). There is an argument to be made that some hospitals involve medical staff to a greater degree than other hospitals. An open an public discussion of Medical Staff committees and rules/procedures promotes such cooperation.

Scope of Responsibility - An Important Distinction (Example)

One key point that is often overlooked is that Organized Medical Staff and NOT the MEC are responsible to oversee clinical care and medical staff performance.

MEC Conduct has Broad Legal Protections (and this can lead to abuse)

Another important point arises in the context of MEC inquires, investigations and actions. MEC peer review is protected under the Healthcare Quality Improvement Act and in California (and many other states) by the anti-SLAPP lawsuit protection statutes. The same issues handled solely as an employment issue may not have the same protections. This means that hospitals tend to refer even routine contract disputes to the MEC so that hospital administration can pressure the doctor with a lessened level of lawsuit exposure. It is in these situations that the composition of Organized Medical Staff and the Medical Executive Committee become critical. How independent are the individuals in these groups? How focused are they on the health of the hospital vs. the genuine needs of the patients as well as “right and wrong”?

Horowitz Medical Attorneys

The Horowitz medical attorneys defend physician licenses against improper MEC restrictions, Performance Improvement Plans and other interim remedies that often lead to a “captive physician” and future more severe discipline. If a peer review hearing is necessary we are expert trial lawyers with literally thousands of hearings and trials on our resume(s). We are always aware of potential medical board, DEA and even criminal adjuncts and we proceed with a 360 degree awareness of the implications of the actions being taken against our doctors. Early intervention is best. Call our lawyers as soon as you perceive a threat to your license.