Medical Staff MeetingJune 25, 2008

Purpose of the Medical Staff Organization

Assuring Quality Care

For All Patients

Assuring Quality Care through . .

Effective Self Governance

Advising the Hospital on matters affecting quality.

Issues Raised by Medical StaffMeetings are dominated by “dog and pony” shows; not physician

driven.Many meetings are poorly attended / not effective.Effective Meetings = Specialty- or Issue-specific.Too long to move an issue through the current structure. High potential to lose track of an issue.Many opportunities for change involve more than one specialty to

address.

To continue Medical Staff influence in the hospital, we need a structure that is more effective in

decision-making.

Rebuilding an Influential Medical Staff

COMMUNICATION

MEDICAL STAFF FUNCTION & FORM

(i.e. Organization)

LEADERSHIP DEVELOPMENT

COMMUNICATION

PEER REVIEW

Board of Directors

(Joint Commission Required)

Bylaws/Credentials Committee

QRC

DIVISIONS of the MEDICAL STAFF

Surgeons & Interventionalists

Hospital Based

Medicine CommunityMedicine

Medical Executive Committee

(Joint Commission Required

SPECIALTIES OF THE MEDICAL STAFF

Allergy Emerg Med General Surg Nephrology Ophth Pediatrics Rad Oncology

Anesth Endocrin Hospitalists Neonatology Oral Surg Plastic Surg Radiology

Card ENT Infect Dis Neurology Ortho Podiatry Rehab

Dental Family Med Internal Med NeuroSurg Pain Med Psychiatry Rheumatology

Derm Gastro Med Onc OB/GYN Pathology Pulm/CritCr Thoracic Surg

DIVISIONS of the MEDICAL STAFF

Surg & Intervent.Est. 76

Hospital BasedEst. 48

MedicineEst. 61

Community Medicine

Est. 56

SPECIALTIES of the MEDICAL STAFFAnesth Dentists

OMSEmerg FamMed FamMed

Allergy

Gastro Card

Derm

Endocrin

MedOncHospitalists

IDIM

NephNeuro

PMRPsych

Pulm/CC

Rad Onc

Rheum

Neo

OB/GYN

Path

Peds

GenSurg

OrthoNeuroSurg

OphthENT

Plastic Pod

Thoracic

UrologyPain Med

Radiology

Ophth

IM

Card

FeedbackSupport for trying something new.Appreciation for flexibility and less formality.Requests to better understand how issues are

managed and resolved in this proposed structure.Request for assurance that Voice by Specialty or

by Individual could be lost.Why does Community Medicine division have as

much representation on MEC as divisions with greater hospital involvement?

Changes Made IncludeChanges made to Division leadership roles.Changes made to MEC membership.Changed division assignments to “by President with member input”.Changed Division name to “Surgeons and Interventionalists”Stressed that any combination of Specialties can meet as desired.Stressed that one goal is elimination of formality – Meet wherever and

whenever and report in.Clarified that the activity is focused on Specialties. Divisions meet as needed.Elected Division Leadership serve as facilitators and communicators.Clarified that Provider Support Services will continue to coordinate and

document as needed.

Medical Executive Committee

Voting members include:

President, President-Elect, and Secretary-Treasurer Division Chief from all 4 Divisions

Vice Chief from Hospital-Based, Surgeons & Interventionalists, and Medicine Divisions

Total of 10

Medical Executive Committee• Business includes:

• Performing the required regulatory duties of the medical staff;

• Acting on the recommendations coming up through the structure;

• Resolving issues only if they cannot be otherwise resolved.• Ensuring effective and efficient decision-making leading to

continued medical staff influence in the hospital.

Division Leadership: Division members elect Chief, Vice Chief, &

Member at LargeChief , Vice Chief & Member at Large cannot

be from same specialty within a Division Chief and Vice Chief serve on MEC (Chief

only from Community Medicine)Member at Large responsible for overseeing

peer review for Division and serves on QRCVice Chief responsible for overseeing

credentialing and serves on Bylaws/Credentials.

SPECIALTIES

Hospital Based Surgs/Intervents Medicine Community Med

• Responsible for consulting specialties and members of each division for patient care initiatives, problem solving, etc. • Collaboration As Needed. Attend meetings as interested.• Drawn together by like types of care and how practitioners work together to provide that care.• Shared interests, reflecting many existing cross- specialty activities. DIVISIONS of the MEDICAL STAFF

SPECIALTIES

• Grassroots Structure• Identifies and Drives Issues up through the Structure• Flexible; Avoid Regulatory Requirements• Physician-Driven Agendas• Meet when/how/where/for what; no required content or minutes• Meet in any combination with other Specialties as desired.• Utilize any type of communication to conduct business• PSS always available to coordinate, document, etc.• Each Specialty elects a Representative

Specialty’s VoiceMore even balance between Divisions; More

opportunity for all specialties to participate.Free to address own affairs w/o regulatory

constraints.Multiple ways for members to participate (meetings,

blogs, emails, faxes).Accountability to participate if want to have

influence. Responsibility to Trust elected Leaders & support

decisions.

Individual Voice

Any medical staff member may: • Contact any medical staff leader to voice a concern;• Contact any medical staff officer to elevate a concern.• Attend MEC to elevate a concern.• Any medical staff member may attend at the invitation of their Division Chief attend MEC to voice a concern and vote on that matter.• Participate regularly and timely in providing input into

recommendations as they are considered via multiple channels (meetings, blogs, email, ballots)

• Vote on matters within Specialty, Division and Medical Staff as a Whole.

• Even after policy decisions are made, a petition process for reconsideration exists.

Form Follows FunctionHow do we want to function?

Empower Physician Driven Agendas Technology to give us options other than meetings, when

appropriate

Right People – Right Place – Right Time

Remove regulatory-induced formality Work effectively despite % of medical staff disinterested or

too busy Empowered core of leadership to ensure efficient decision-

making and continued influence in the hospital

Two Way CommunicationLeadership is accountable to ensure information is in

weekly or special newsletters and on electronic bulletin board. Future: Interactive Website

Leadership is accountable to adequately notify constituents using technology or traditional methods regarding issues & opportunities.

Members are accountable to receive information using these focused sources to stay informed.

Members are accountable to provide input in a timely manner.

Patients count on the Medical Staff to counsel the Hospital effectively

regarding things that impact Quality of Care.

In order to promotethe influence of the Medical Staff

with the Board and Administration,

the Medical Staff must function effectively.

Where do we go from here?Is this structure perfect? No Is it an individualized model similar to that

working for other medical staffs? YesIs it a well-thought out alternative with a high

probability of success? YesWill we modify it over time as we learn? Yes

Please