Section 107.25. Medical staff executive committee

(a) In a departmentalized hospital, there shall be an executive committee, or its equivalent, which represents the medical staff, which has responsibility for the effectiveness of all medical activities of the staff, and which acts for the medical staff.

(b) The executive committee, or its equivalent, shall:

(1) receive and act upon the reports of other medical staff committees;

(2) consider and recommend action to the chief executive officer on all matters of a medical administrative nature;

(3) implement the policies of the medical staff;

(4) make recommendations to the governing body and chief executive officer concerning hospital operations, problems, and procedures.

(5) take reasonable steps to ensure ethical professional conduct on the part of all members of the medical staff, and initiate such prescribed disciplinary measures as are indicated;

(6) be held accountable to the governing body, as representative of the medical staff, for the medical care rendered to the patients of the hospital;

(7) ensure that the medical staff is kept abreast of the approved accreditation program and informed of the accreditation status of the hospital;

(8) meet as necessary, but at least ten times a year, and maintain a per- manent record of each meeting and of any actions taken. The record of each executive committee meeting shall be submitted in full or in summary form to the governing body prior to the next meeting of the governing body; and

(9) fulfill such other responsibilities as are assigned to it by the medical staff bylaws.

Notation

Cross References

This section cited in 28 Pa. Code § 107.12 (relating to content of bylaws, rules and regulations).