Medical Executive Council Policies

Question:

Do you have a list of policies which need to be reviewed by a Medical Executive Council or Medical Executive leadership?

Answer:

Listed below are the specific standards that require medical staff to review/approve policies – it is a fairly limited list. In short, all official hospital policies that involve patient care should have medical staff approval. 

There might be different committees of the medical staff doing the analysis and wording, then have those committees work approved by MEC.  Standard MM.04.01.01 specifies that standing orders, protocols and order sets need medical staff approval.  

Here are some summarized medical staff standards that state the medical staff has to approve bylaws, rules and regs, as well as a process to resolve conflict between medical staff and the MEC.  The medical staff approves the privileging process/policies and the fair hearing process.  There is also a leadership standard that states the medical staff needs to review the quality of the clinical contracts, while not a policy, they have approval needs. 

MM.04.01.01: Medication orders are clear

EP 15 The medical staff and the hospital’s nursing and pharmacy leadership review and approval of standing orders and protocols

MS.06.01.05: Privileging

The medical staff plans and implements a privileging process.

MS.10.01.01: Appeal

EP 1 The medical staff has an appeal process addressing quality of care issues 

LD.04.03.09: Clinical Contracts

EP 1 Clinical leaders and medical staff have input into clinical services to be provided through contractual agreement.