Every surgery center and hospital surgical department has committees. As laborious as dealing with these committees can be, perhaps none is more important or overlooked as the Medical Executive Committee (MEC).

Rarely do individual hospital and surgery center personnel fully understand the role of this committee and the tremendous contribution it plays in safety and successful management of a quality facility. The MEC includes elected or “volunteered” surgeons from each specialty the facility performs, including anesthesia, the medical director of the facility, the administrator, and nurse manager of the hospital department or ASC.

The committee makes recommendations on matters that affect quality of care, including staffing, equipment, space planning, credentialing, medical staff appointment and reappointment, and clinical privileges. Further, the MEC helps ensure the ethical conduct and competent performance on the part of all members of the medical staff.

Few understand this powerful committee; if they did, more surgeons would want to be included. Although this is not a complete list, it does help explain the role of the MEC and might help everyone understand it better:

  • To represent and act on behalf of the medical staff subject to such limitations as may be imposed by the medical director;
  • To report to management peer group recommendations, proceeding from the MEC to the board of managers;
  • To receive and act on committee/administrative reports;
  • To implement and enforce policies/procedures of the medical staff;
  • To recommend actions to the medical director;
  • To make recommendations on the management of the facility and for membership on medical staff subcommittees;
  • To study peer review activities, including but not limited to clinical competence, adherence to policies and procedures, quality assurance, utilization management and risk management, and corrective action recommendations;
  • To take all reasonable steps to ensure professionally ethical conduct and competent clinical performance on the part of members of the medical staff;
  • To provide input into and approve as necessary patient care policies, procedures, and standards;
  • To review medical staff applications and supporting documentation on appointment and reappointment, including delineation of privileges and make recommendations to the governing board;
  • To perform medical staff functions relating to medical records, infection control, tissue, and tissue review;
  • To participate on ad hoc committees to carry out the work of the MEC, such as peer review, continuous quality improvement, risk management, and others (as may be indicated).

While not required, I often invite employees to sit in as a guest on some MEC meetings so they may witness how the committee functions. Most facilities will allow this but ask the guest to leave when the MEC goes into what they call “executive session.” This is where the board can deal with legal, personnel, contractual, and similar facility issues that board members are legally permitted to discuss in a private session.

The more you know about how your facility functions, the better you will understand what happens in the background and how it can affect you and your position.

(Earnhart & Associates is a consulting firm specializing in all aspects of outpatient surgery development and management. Earnhart & Associates can be reached at 5114 Balcones Woods Drive, Suite 307-203, Austin, TX, 78759. Phone: (512) 297-7575. Fax: (512) 233-2979. Email: searnhart@earnhart.com. Web: www.earnhart.com. Instagram: Earnhart.associates.)