Is a medical executive committee required?
An executive committee, a medical board, or a similar structure exists in virtually every U.S. hospital. But is it true that a medical executive committee (MEC) is required?
There is no requirement in the CMS Conditions of Participation (CoP) for an MEC. In fact, the only requirement is that there be an “organized” medical staff that operates under by-laws approved by the governing body and is responsible to that body for the quality of medical care predominantly provided by individuals granted privileges. If an executive committee exists, then the CoP require that a majority of the members should be doctors of medicine or osteopathy. The only requirement is for a utilization management committee, which can either be an actual medical staff committee defined in the bylaws or a hospital committee with appropriate physician representation. The other accreditation agencies with “deeming authority” may have different requirements.
The answer to whether an MEC is required truly is, “It depends!” It depends on what state you are in, whether you use just the CMS CoP, or what “deemed status” accreditation agency you use.