1.2.1 Governance, direction, coordination, and action: a.
b.
c.
d.
e.
f.
Receive, coordinate, and act upon, as necessary, the reports and recommendations from Departments, committees, other groups, and officers concerning the functions assigned to them and the discharge of their delegated administrative responsibilities;
Account to the Board and to the staff with written recommendations for the overall quality and efficiency of patient care at the Hospital;
Take reasonable steps to maintain professional and ethical conduct and initiate investigations, and pursue corrective action of practitioners with privileges when warranted;
Make recommendations on medical, administrative, and Hospital clinical and operational matters;
Inform the medical staff of the accreditation and state licensure status of the Hospital;
Act on all matters of medical staff business, and fulfill any state and federal reporting requirements;
g. Oversee, develop, and plan continuing medical education( CME) plans, programs, and activities that are designed to keep the staff informed of significant new developments and new skills in medicine that are related to the findings of performance improvement activities; h.
Provide education on current ethical issues, recommend ethics policies and procedures, develop criteria and guidelines for the consideration of cases having ethical implications, and arrange for consultation with concerned physicians when ethical conflicts occur in order to facilitate and provide a process for conflict resolution;
i. Provide oversight concerning the quality of care provided by students, interns, residents, and fellows, and ensure that the same act within approved guidelines established by the medical staff and governing body; and j.
Ensure effective, timely, and adequate comprehensive communication between the members of the medical staff and medical staff leaders as well as between medical staff leaders and Hospital administration and the board.
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