Review key MEC members and responsibilities
The medical executive committee (MEC) is the only medical staff committee that The Joint Commission requires accredited hospitals to have. CMS regulations state that if an MEC exists, its primary membership should be made up of MDs and DOs. Other members of the medical staff may be asked to serve on the committee, and the chief executive officer (CEO) is also required to sit on the committee and is often ex officio in status.
Most MECs consist of the chief of staff, vice chief of staff, immediate past chief, department chairpersons, and CEO. Other members of hospital administration and management may serve on the committee but do not hold voting rights.
Duties of the MEC include the following:
- Represent and act on behalf of the medical staff in all matters in between meetings of the medical staff
- Coordinate the activities and general policies of the various services
- Receive and act upon committee reports and make recommendations concerning them to the CEO and the board
- Serve as a liaison among medical staff, the CEO, and the board
- Recommend action to the CEO on matters of a medico-administrative and hospital management nature
- Ensure that the medical staff is kept abreast of the accreditation program (e.g., DNV GL, The Joint Commission, HFAP, etc.) and informed of the hospital’s accreditation status
- Take all reasonable steps to ensure professionally ethical conduct and the enforcement of hospital and medical staff rules
- Make recommendations to the board on actions affecting medical staff appointees, reappointments, clinical privileges, and any medical staff practitioner actions, as described in the credentialing policy
- Discharge the medical staff’s accountability to the board for the medical care rendered to patients in the hospital
The process for removing an MEC member and for removing authority of the MEC must also be included in the bylaws.