Medical Executive Committee Reporting Requirements

What are the Medical Executive Committee reporting requirements? Which committees or teams are required to report to them?

What Are The Medical Executive Committee Reporting Requirements?

The Joint Commission medical executive committee reporting requirements permit maximum flexibility. This includes how you assign responsibility for medical staff functions to committees and how these committees report to medical staff leadership. There are no standards that say various committees must report to the MEC. But, there are many responsibilities assigned to the medical staff and most hospitals use them as the flexibly available medical staff leadership group for approval of and oversight of these functions. MS.01.01.01, details many medical staff functions that should be described in writing. That writing usually involves actions or approval from the MEC or entire medical staff. Issues are described in the MS chapter which includes:

• Bylaws
• Rules and regulations or policy changes
• Design of the privileging process
• Oversight of PI analysis and specifically the quality of histories and physicals
• Patient satisfaction
• Policies on emergency services at off-site locations that may not have an ED
• Oversight of emergency management services
• Supervision of GME
• Resource evaluation prior to awarding new privileges
• Approval of the qualifications of the radiology and nuclear medicine staff

The LD chapter has additional responsibilities including conflict resolution, feedback to the governing body by medical staff leadership. In the MM chapter they describe the formulary process and analysis of medication errors and adverse drug reactions. This is usually done through committees that include medical staff leaders and report to the MEC. 

The key thing to think of is when you obtain medical staff representation on different hospital committees, you usually want to ensure that those representatives speak for the medical staff. Having a feedback loop from that unique committee to the MEC for approval of actions ensures that agreement from the medical staff, not just your committee representative.

Patton Healthcare Consulting

Patton Healthcare Consulting provides a complete range of Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.

We serve more than 350 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.