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Medical Staff: Leadership and Committees
Medical Staff Committees
The Bylaws Committee is a committee that conducts annual review of the Medical Staff bylaws and present recommended revisions to Medical Executive Committee. The Vice Chief of Staff will serve as Chair of this committee.
The purpose of the Care Improvement Committee is to provide a forum for the Medical Staff to assess the quality, appropriateness, and efficacy of treatment services. The committee will review the quality and appropriateness of treatment services provided by members of the healthcare team. The goal of the peer review process is to continuously improve treatment services within the system. The peer review process highlights the challenges that enhance or impede treatment providers as they strive to provide quality services. The Committee shall be responsible for overseeing the Peer Review Process for the Medical Staff.
The Cath Angio Medical Committee (CAMC) of SHC is the governing body for the Catheterization and Angiography Laboratories, and is responsible for providing oversight and taking action on issues related to the delivery of safe patient care, treatment and services in the Cath-Angio Region including the cath lab procedure rooms in the main hospital, the Cath Angio Pre-Procedure and Recovery (CAPR) and the Advanced Medicine Center labs. The committee recommends policies, procedures, and process improvements for appropriate delivery of high quality patient services for Adult and Pediatric Electrophysiology, Pediatric Cardiology, Interventional Adult Cardiology, Interventional Radiology, Vascular Surgery, Interventional Neuroradiology/Neurosurgery, and Pulmonary Hypertension evaluations.
The Committee serves as a focus of expertise and as a resource for monitoring and improving the professional behavior of our Medical Staff, both individually and collectively. It is hoped that the Committee on Professionalism members will develop a level of expertise and of respect from their peers such that the institutional response to disruptive behavior will be better informed, better received, more timely and more effective.
The Credentials and Privileges Committee reviews the credentials of providers applying for initial appointment or reappointment to the Medical Staff at SHC, and makes recommendations for membership and delineation of privileges in compliance with the Medical Staff Bylaws, Credentialing Policies and Procedures, and Clinical Service requirements; reviews and approves new or revised credentials and privileges, forms and processes; reviews and approves credentialing policies and procedures.
In addition, the Credentials and Privileges Committee reviews and acts upon reports from the Interdisciplinary Practice Committee (IDPC) of appointment and evaluations of Advanced Practice Providers. The IDPC is a subcommittee of the Credentials and Privileges Committee and is accountable to the Medical Executive Committee and the Governing Body.
Medical Staff Coordinator
The purpose of the Ethics Committee is to provide advice, consultation, guidance and education about the ethical aspects of the provision of medical treatment.
Medical Staff Committee Coordinator
The purpose of the HIM Committee is to provide physician-based oversight to the acquisition, implementation, and use of Information Technology and Management Services, especially in regards to improving the overall quality of patient care, treatment, and services at SHC. The Committee is accountable to the Medical Executive Committee, through the QIPSC, and serves as a forum to identify important health information management and technology issues and develop plans and actions to address these concerns. The Committee shall operate by authorizing a set of working sub-committees which will focus on specific areas of concern. These sub-committees will report to the HIM Committee on a regular basis.
The purpose of this Committee is to improve the quality of care, treatment and services for Stanford Health Care's patients, to provide a forum for SHC Medical Staff and employees and to provide oversight and take action on issues related to the critical care services to patients in the intensive care units, cardiac care units, and trauma units. In addition, the committee is charged with recommending policies, procedures, and process improvements for appropriate delivery of critical care services including oversight and evaluation of the code blue process throughout the hospital. The Committee is accountable to the Medical Executive Committee, through the QIPSC, and its scope includes the care provided in the East and North Intensive Care Units and in the Coronary Care Unit. Important problems and issues relating to care in these units will be evaluated and solutions identified.
To ensure that there is an active, effective, institution-wide infection control program that develops effective measures to prevent, identify, and control infections acquired in the Hospital or brought into the Hospital from the community.
The Interdisciplinary Practice Committee (IDPC) reviews and recommends approval of new or revised credentials and privileges, forms and processes relating to Advanced Practice Providers (APPs); reviews and recommends approval of job descriptions, standardized protocols/standardized procedures and other policies and procedures relating to APPs.
APPs include Physician Assistants (PA), Nurse Practitioners (NP), Certified Registered Nurse Anesthetists (CRNA), Clinical Nurse Specialists (CNS) and Certified Nurse Midwives (CNM).
The IDPC is a subcommittee of the Credentials and Privileges Committee and is accountable to the Medical Executive Committee and the Governing Body.
To function as the Executive Committee of the Medical Staff of Stanford Health Care, in accordance with the requirements and provisions of the Medical Staff Bylaws and Rules and Regulations.
The Operating Room Medical Committee ("ORMC") of SHC is the governing body of Operating Room Services, and is responsible for providing oversight and taking action on issues related to the delivery of safe patient care, treatment, services, and surgical services in the operating room region including the main operating rooms, the ambulatory surgical center, and surgical procedure areas; and recommending policies, procedures, and process improvements for appropriate delivery of surgical services.
The purpose of the Pharmacy and Therapeutics Committee is to provide oversight and take action on issues related to the medication use process. To formulate and review policies and procedures related to the medication management process including selection, regulation, compliance, distribution, storage, administration and safe use of drugs within SHC.
The Quality Patient Safety & Effectiveness Committee (QPSEC) is responsible for overseeing performance improvement activities. This committee provides guidance and support for hospital-wide performance improvement and patient safety efforts.
The purpose of this committee is to provide a forum focusing on (1) the matter of the impaired physician or physician-in-training in the Hospital and (2) disruptive or other inappropriate behavior of Medical Staff members.
The SHC medical staff is committed to supporting the well-being of our physicians and physicians-in-training. If you are concerned that you or a colleague may be struggling with alcohol, drugs, or behavioral problems, confidential help is available 24 hours a day through the Well-Being of Physicians and Physicians-in-Training Committee.
The principles of caring, confidentiality, and cooperation guide the Well-Being Committee's work.
The Committee's work is based upon a genuine concern for, and desire to, assist in the physical, emotional, and spiritual well-being of the medical staff and physicians-in-training.
Regardless of how an individual is brought to the attention of the Well-Being Committee, the Committee is committed to support and protect the confidentiality of the individual involved.
The program's success depends on cooperation between the individual being assisted and the Committee. In all instances, the Committee's goal is to support the individual in his/her recovery. Only by doing so effectively and confidentially will the Committee accomplish its dual purpose of aiding practitioner well-being and improving patient care and Medical Staff functioning.
Getting help for yourself or a colleague:
You may refer yourself, a medical staff colleague, or a physician-in-training for help. Additionally, any physician-in-training or hospital staff member may also make an anonymous referral to the Well-Being Committee:
How do I refer myself?
- Call or page the Chair or any committee member at any time to initiate the process
How do I refer someone else?
- Call or page the Chair or any member of the Well Being Committee to discuss the referral
- Documentation of the event that triggers the referral is important
- PLEASE NOTE: Your name will remain anonymous
Click here for more information about the Well Being Process
Medical Staff Committee Coordinator
The Wellness Committee is a new committee intended to encourage and support Medical Staff members and trainees in their efforts to maintain their own physical and mental well-being in the face of the many stresses of modern medical practice. The committee believes that the wellness of our caregivers is critical to the provision of high quality medical care. We intend to periodically assess the professional satisfaction, well-being and wellness needs of our practitioners, provide wellness resources and referrals, and promote a culture which respects wellness and "health seeking behavior" as essential elements of a complete physician.
The purpose of the Graduate Medical Education Review Committee (GMEC) is to coordinate and review all aspects of residency and fellowship education.
The purpose of the Patient Safety Committee is to establish, support, and provide oversight for an integrated interdisciplinary patient safety program.
The purpose of Medical Procedure Unit Committee (MPUC) of SHC is responsible for providing oversight and adjudicating issues related to the delivery of safe patient care and efficient practice for the procedural rooms (Endoscopy Unit) on the SHC campus sites; and recommending policies, procedures, and process improvements to achieve and ensure the highest quality procedure unit services including adherence to regulatory requirements.
The purpose of the Tissue Committee is to provide oversight of surgical cases in which tissue is submitted for review, and to investigate any discrepancies between pre-operative and post-operative diagnoses.