Medical Staff Governance

MEDICAL STAFF GOVERNANCE

Saint Vincent Health Center is a non-profit corporation organized under the laws of the Commonwealth of Pennsylvania. Its purpose is to provide patient care and appropriate educational and health-related programs for the community. The health center’s board of trustees delivers patient care, education and health-related programs through its medical staff.

Because the board is focused on organizational strategic direction, it assigns responsibilities for monitoring and improving the quality of care to the Saint Vincent medical staff and administration. Both administration, through the CEO, and the medical staff through the medical staff president of the health center, report to the board of trustees.

The governing body for the medical staff is the Saint Vincent Medical Executive Committee (MEC). The MEC, with input from the medical staff, formalizes meeting requirement and voting rules, appointment and reappointment criteria and quality improvement initiatives. Saint Vincent administration recognizes two significant spheres of medical staff responsibilities for performance improvement. A very important one is the sphere of control, i.e., individual physician performance improvement. The second sphere is that of influence as demonstrated through partnering with Saint Vincent administration on quality assurance, evidenced-based performance improvement and lean six sigma projects.When the findings of quality assessment processes are relevant to an individual staff member’s performance, the medical staff must determine their use in peer review and ongoing evaluations of a practitioner’s competence in accordance with the clinical privilege renewal/revision standards.

Medical staff leadership positions are voluntary. Medical staff leaders are elected for two-year terms. The leadership of the medical staff is voluntary and elected for two-year terms. Saint Vincent recognizes the valuable contribution of its physicians through the presence of three medical staff members on its board of trustees. One position is filled by the president of the medical staff, the othersare elected by the active medical staff. The latter two are three-year terms which may be renewed once for a total of six consecutive years. This continuity affords superlative representation from elected representatives from the medical staff to the board of trustees. The mission of the medical staff is comprised of the following five functions:

  • Quality Assessment and Improvement
    The Saint Vincent Medical Staff is not responsible for all aspects of quality at the hospital. It is responsible for the quality of care primarily dependent on the members of the medical staff and those allied health professionals that are privileged through the medical staff oversight.
  • Credentialing and Privileging
    The MEC is responsible for recommending criteria for medical staffmembership and privileges as well as the membership and privileges for individual applicants.
  • Governance
    The medical staff is organized democratically. The medical staff bylaws, decisions about who can vote, and who can hold office, and the responsibility of the medical staff are all elements of governance. The bylaws are presented in the Medical Staff Handbook and are broken down into seven chapters, including Medical Staff Bylaws, Fair Hearing Plan, Credentials, Medical Staff Organization and Functions, Rules and Regulations and Allied Health Professionals. In addition, the medical staff adheres to a code of ethics.
  • Administration
    The MEC oversees meeting management and how the medical staff is organized through committees and departments.
  • Communication
    The medical staff at Saint Vincent Health Center disseminates policies, discusses system changes, gathers physician input and effectively communicates with other departments, particularly the patient care services personnel. Communication is one of the most important functions of the organized medical staff.