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Medical Staff MeetingJune 25, 2008
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Purpose of the Medical Staff Organization
Assuring Quality Care
For All Patients
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Assuring Quality Care through . .
Effective Self Governance
Advising the Hospital on matters affecting quality.
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Issues Raised by Medical StaffMeetings are dominated by “dog and pony” shows; not physician
driven.Many meetings are poorly attended / not effective.Effective Meetings = Specialty- or Issue-specific.Too long to move an issue through the current structure. High potential to lose track of an issue.Many opportunities for change involve more than one specialty to
address.
To continue Medical Staff influence in the hospital, we need a structure that is more effective in
decision-making.
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Rebuilding an Influential Medical Staff
COMMUNICATION
MEDICAL STAFF FUNCTION & FORM
(i.e. Organization)
LEADERSHIP DEVELOPMENT
COMMUNICATION
PEER REVIEW
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Board of Directors
(Joint Commission Required)
Bylaws/Credentials Committee
QRC
DIVISIONS of the MEDICAL STAFF
Surgeons & Interventionalists
Hospital Based
Medicine CommunityMedicine
Medical Executive Committee
(Joint Commission Required
SPECIALTIES OF THE MEDICAL STAFF
Allergy Emerg Med General Surg Nephrology Ophth Pediatrics Rad Oncology
Anesth Endocrin Hospitalists Neonatology Oral Surg Plastic Surg Radiology
Card ENT Infect Dis Neurology Ortho Podiatry Rehab
Dental Family Med Internal Med NeuroSurg Pain Med Psychiatry Rheumatology
Derm Gastro Med Onc OB/GYN Pathology Pulm/CritCr Thoracic Surg
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DIVISIONS of the MEDICAL STAFF
Surg & Intervent.Est. 76
Hospital BasedEst. 48
MedicineEst. 61
Community Medicine
Est. 56
SPECIALTIES of the MEDICAL STAFFAnesth Dentists
OMSEmerg FamMed FamMed
Allergy
Gastro Card
Derm
Endocrin
MedOncHospitalists
IDIM
NephNeuro
PMRPsych
Pulm/CC
Rad Onc
Rheum
Neo
OB/GYN
Path
Peds
GenSurg
OrthoNeuroSurg
OphthENT
Plastic Pod
Thoracic
UrologyPain Med
Radiology
Ophth
IM
Card
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FeedbackSupport for trying something new.Appreciation for flexibility and less formality.Requests to better understand how issues are
managed and resolved in this proposed structure.Request for assurance that Voice by Specialty or
by Individual could be lost.Why does Community Medicine division have as
much representation on MEC as divisions with greater hospital involvement?
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Changes Made IncludeChanges made to Division leadership roles.Changes made to MEC membership.Changed division assignments to “by President with member input”.Changed Division name to “Surgeons and Interventionalists”Stressed that any combination of Specialties can meet as desired.Stressed that one goal is elimination of formality – Meet wherever and
whenever and report in.Clarified that the activity is focused on Specialties. Divisions meet as needed.Elected Division Leadership serve as facilitators and communicators.Clarified that Provider Support Services will continue to coordinate and
document as needed.
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Medical Executive Committee
Voting members include:
President, President-Elect, and Secretary-Treasurer Division Chief from all 4 Divisions
Vice Chief from Hospital-Based, Surgeons & Interventionalists, and Medicine Divisions
Total of 10
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Medical Executive Committee• Business includes:
• Performing the required regulatory duties of the medical staff;
• Acting on the recommendations coming up through the structure;
• Resolving issues only if they cannot be otherwise resolved.• Ensuring effective and efficient decision-making leading to
continued medical staff influence in the hospital.
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Division Leadership: Division members elect Chief, Vice Chief, &
Member at LargeChief , Vice Chief & Member at Large cannot
be from same specialty within a Division Chief and Vice Chief serve on MEC (Chief
only from Community Medicine)Member at Large responsible for overseeing
peer review for Division and serves on QRCVice Chief responsible for overseeing
credentialing and serves on Bylaws/Credentials.
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SPECIALTIES
Hospital Based Surgs/Intervents Medicine Community Med
• Responsible for consulting specialties and members of each division for patient care initiatives, problem solving, etc. • Collaboration As Needed. Attend meetings as interested.• Drawn together by like types of care and how practitioners work together to provide that care.• Shared interests, reflecting many existing cross- specialty activities. DIVISIONS of the MEDICAL STAFF
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SPECIALTIES
• Grassroots Structure• Identifies and Drives Issues up through the Structure• Flexible; Avoid Regulatory Requirements• Physician-Driven Agendas• Meet when/how/where/for what; no required content or minutes• Meet in any combination with other Specialties as desired.• Utilize any type of communication to conduct business• PSS always available to coordinate, document, etc.• Each Specialty elects a Representative
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Specialty’s VoiceMore even balance between Divisions; More
opportunity for all specialties to participate.Free to address own affairs w/o regulatory
constraints.Multiple ways for members to participate (meetings,
blogs, emails, faxes).Accountability to participate if want to have
influence. Responsibility to Trust elected Leaders & support
decisions.
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Individual Voice
Any medical staff member may: • Contact any medical staff leader to voice a concern;• Contact any medical staff officer to elevate a concern.• Attend MEC to elevate a concern.• Any medical staff member may attend at the invitation of their Division Chief attend MEC to voice a concern and vote on that matter.• Participate regularly and timely in providing input into
recommendations as they are considered via multiple channels (meetings, blogs, email, ballots)
• Vote on matters within Specialty, Division and Medical Staff as a Whole.
• Even after policy decisions are made, a petition process for reconsideration exists.
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Form Follows FunctionHow do we want to function?
Empower Physician Driven Agendas Technology to give us options other than meetings, when
appropriate
Right People – Right Place – Right Time
Remove regulatory-induced formality Work effectively despite % of medical staff disinterested or
too busy Empowered core of leadership to ensure efficient decision-
making and continued influence in the hospital
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Two Way CommunicationLeadership is accountable to ensure information is in
weekly or special newsletters and on electronic bulletin board. Future: Interactive Website
Leadership is accountable to adequately notify constituents using technology or traditional methods regarding issues & opportunities.
Members are accountable to receive information using these focused sources to stay informed.
Members are accountable to provide input in a timely manner.
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Patients count on the Medical Staff to counsel the Hospital effectively
regarding things that impact Quality of Care.
In order to promotethe influence of the Medical Staff
with the Board and Administration,
the Medical Staff must function effectively.
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Where do we go from here?Is this structure perfect? No Is it an individualized model similar to that
working for other medical staffs? YesIs it a well-thought out alternative with a high
probability of success? YesWill we modify it over time as we learn? Yes
Please