Hospital Executive Committee
Purpose of the committee
- Governance of Patient Care
Functions of the committee
- To represent and act on behalf of the Medical staff in all matters
- To coordinate the activities and general policies of the hospital
- To receive and to act upon reports of the hospital standing committees, and other assigned groups as specified in the by-laws of
the hospital, and make recommendations to the administration.
- To implement policies of the hospital in collaboration with the administration.
- To enforce hospital and staff rules in the best interest of patient care and of the hospital, with regard to all persons who hold
appointment to the Medical Staff of the hospital
- To review the bylaws, policies, rules and regulations and associated documents of the Medical Staff as needed and recommend such
changes as may be necessary or desirable.
- To review and approve the credentials of all applicants for Medical Staff appointment, reappointment, and clinical privileges and to
approve criteria for clinical privileges.
- To monitor and evaluate medical care on a retrospective concurrent and prospective basis in all major clinical activities including the
routine collection of information about important aspects of patients cares provided and about the clinical performance of health care providers and periodic assessment of this information to identify opportunities to improve the car and to identify important problems inpatient care.
- To recommend, objective criteria that reflect current knowledge and clinical experience. These criteria shall be used by the Medical
Staff or by the hospital’s performance improvement program in the measurement and improvement of patient care. When important problems in patient care and clinical performance or opportunities to improve care are identified, the Medical Staff shall document the actions taken and evaluate the effectiveness of such actions.
- To continuously assess and improve the quality of care, treatment and services and the maintenance of quality control programs as appropriate.
- To report and recommend to hospital management when necessary with respect to matters affecting patient care, including personnel,
supplies, space, and other resources, special regulations, standing orders, and techniques.
- Measure, assess and improve the care provided in and develop a clinical policy for special care areas, patient care support services
- Conduct or coordinate the measurement assessment and improvement activities, including, but not limited to medical assessment and treatment, use of medications, use of blood and blood components, the performance of operative and other procedures, patient safety, and sentinel events, patient satisfaction, education of patients and family, appropriateness of clinical practice patterns, and significant departures from established patterns of clinical practice
- Conduct or coordinate medical record review activities including accurate, timely and legible completion of patient’s medical records
- Monitor the Hospital’s Infection control program and to Investigate and address healthcare-associated infections
- Coordinate the care provided by members of the Medical Staff with the care provided by the nursing service and with the activities of other Hospital patient care and administrative services.