Medical Staff Departmental Organization

What Can Medical Staff Departments Do for You?

Do you want to propose a change within your section or department? Medical staff departments were created to allow for change and decision making to happen at the section and department level. Some of the issues discussed at the section and department level include order set changes, call schedule problems, evidence-based medicine, and privilege changes/proposals among many other things. Get in contact with the section of your department if you need anything.

Who is on the Committee?

The medical staff departments consist of four departments and their sections. The four departments are family medicine, internal medicine, surgery, and women’s and children’s. Each department has its own sections with section chairs (as shown below).

Committee Duties and Responsibilities

  1. Serve as a forum for the exchange of clinical information regarding services provided by Department members.
  2. Provide recommendations to the Department Chairperson and/or the Medical Executive Committee with regard to the development of clinical practice guidelines related to care and services provided by Department members.
  3. Ensure that patients receive appropriate and medically necessary care from a member of the Medical Staff during the entire length of stay with the Hospital.
  4. Ensure that the same level of quality of patient care is provided by all individuals with delineated clinical privileges, within the Department, across Departments, and between members and non-members of the Medical Staff with clinical privileges.
  5. Ensure effective mechanisms for the clinical supervision of Advanced Practice Professionals, and House-staff Practitioners, if any.
  6. Provide information and/or recommendations to the Department Chairperson with regard to the criteria for granting clinical privileges within the Department.
  7. Provide information and/or recommendations to the Department Chairperson and/or the Medical Executive Committee with regard to Medical Staff policies and procedures.
  8. Provide recommendations to the Department Chairperson and/or the Medical Executive Committee with regard to ensuring appropriate call coverage by Department members.
  9. Perform peer review and quality assessment activities relative to the performance of individuals with clinical privileges in the Department and report such activities to the Medical Executive Committee on a regular basis.
  10. Provide leadership for activities related to patient safety, including proactive risk assessments, root cause analysis in response to an unanticipated adverse event, addressing patient safety alerts, and implementing procedures to comply with patient safety goals.
  11. Receive reports regarding Hospital performance improvement results that are applicable to the performance of the Department and its members, and integrate the Department’s performance improvement activities.
  12. Recommend medical educational programs to meet the needs of Department members, based on the scope of services provided by the Department, changes in medical practice or technology, and the results of Departmental performance improvement activities.

Departments