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Chapter 10 Medical Staff Organization and Malpractice Medical Staff Organization

▸ MEDICAL STAFF ORGANIZATION The medical staff is formally organized with officers, committees, and bylaws. At

regular intervals, the various committees of the medical staff review and analyze

their responsibilities, clinical experiences, and opportunities for improvement. The

responsibilities of a variety of medical staff committees are described here.

Executive Committee. The executive committee oversees the activities of the

medical staff. It is responsible for recommending to the governing body such

things as medical staff structure, a process for reviewing credentials and

appointing members to the medical staff, a process for delineating clinical

privileges, a mechanism for the participation of the medical staff in performance

improvement activities, a process for peer review, a mechanism by which medical

staff membership may be terminated, and a mechanism for fair hearing

procedures. The executive committee reviews and acts on the reports of medical

staff departmental chairpersons and designated medical staff committees.

Actions requiring approval of the governing body are forwarded to the governing

body for approval. Executive committee members generally include the chief of

staff, medical staff officers, and department chairs. The chief executive and chief

nursing officers are generally nonvoting members of the committee.

Bylaws Committee. The functioning of the medical staff is described in its bylaws,

rules, and regulations, which must be reviewed and approved by the

organization’s governing body. Bylaws must be kept current, and the governing

body must approve recommended changes. The bylaws describe the various

membership categories of the medical staff (e.g., active, courtesy, consultative,

and allied professional staff) as well as the process for obtaining privileges.

Blood and Transfusion Committee. The blood and transfusion committee

develops blood usage policies and procedures. It is responsible for monitoring

transfusion services and reviewing indications for transfusions, blood ordering

practices, each transfusion episode, and transfusion reactions. The committee

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reports its findings and recommendations to the medical staff executive

committee.

Credentials Committee. The credentials committee oversees the application

process for medical staff applicants, requests for clinical privileges, and

reappointments to the medical staff. The committee makes its recommendations

to the medical executive committee.

Infection Control Committee. The infection control committee is generally

responsible for the development of policies and procedures for investigating,

controlling, and preventing infections.

Medical Records Committee. The medical records committee develops policies

and procedures as they pertain to the management of medical records, including

release, security, and storage. The committee determines the format of complete

medical records and reviews medical records for accuracy, completeness,

legibility, and timely completion. Medical records also are reviewed for clinical

pertinence. The committee ensures that medical records reflect the condition

and progress of the patient, including the results of all tests and therapy given,

and makes recommendations for disciplinary action as necessary.

Pharmacy and Therapeutics Committee. The pharmacy and therapeutics

committee is generally charged with developing policies and procedures relating

to the selection, procurement, distribution, handling, use, and safe

administration of drugs, biologicals, and diagnostic testing material. The

committee oversees the development and maintenance of a drug formulary. The

committee also evaluates and approves protocols for the use of investigational

or experimental drugs. The committee oversees the tracking of medication

errors and adverse drug reactions; the management, control, and effective and

safe use of medications through monitoring and evaluation; and the monitoring

of problem-prone, high-risk, and high-volume medications, utilizing parameters

such as appropriateness, safety, effectiveness, medication errors, food–drug

interactions, drug–drug interactions, drug–disease interactions, and adverse drug

reactions. The committee also performs other activities that may be delegated to

it by the medical executive committee.

Quality Improvement Council. The quality improvement council functions as a

patient care assessment and improvement committee. The council generally

consists of representatives from the organization’s administration, governing

body, medical staff, and nursing.

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Tissue Committee. The tissue committee reviews all surgical procedures. Surgical

case reviews address the justification and indications for surgical procedures.

Representation on the tissue committee should include the departments of

surgery, anesthesiology, pathology, nursing, risk management, and

administration.

Utilization Review Committee. The utilization review committee monitors and

evaluates utilization issues such as medical necessity and appropriateness of

admission and continued stay, as well as delay in the provision of diagnostic,

therapeutic, and supportive services. The utilization review committee ensures

that each patient is treated at an appropriate level of care. Objectives of the

committee include timely transfer of patients requiring alternate levels of care;

promotion of the efficient and effective use of the organization’s resources;

adherence to quality utilization standards of third-party payers; maintenance of

high-quality, cost-effective care; and identification of opportunities for

improvement.