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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