Mercy Hospital Medical Staff Bylaws - Mercy Health

11 COMMITTEESAdditional OfficersComplaint Procedure11.1 Committees, Generally6.3.1.1.1.(1) Perform such department functions as assigned by thedepartment director consistent with the department rulesand this CodeThe Board of Trustees may, after considering the advice andrecommendations of the Staff Executive Committee,establish other medico-administrative positions to performsuch duties as prescribed by the Board, or as defined byamendment to this Code. To the extent that any such officerperforms any clinical function, he must become and remaina member of the staff. In all events he must be subject tothis Code and to the other policies of the Hospital.If any member of the staff has a complaint with respect to anyofficer or other official of the staff, he may submit thecomplaint to the Senior Vice President, who may refer thematter to the President of the Medical Staff, the StaffExecutive Committee, or the appropriate hospitaladministrative officer for resolution.The standing committees of the Medical Staff are is the MEC which may and theCredentials Committee, and the Cancer Committee (Ethics Committee, InfectionControl Committee, Medical Record Committee, Regulations Committee). TheMEC (President of the Medical Staff) may establish additional committees (eitherstanding committees or ad hoc committees) as necessary to carry out Medical Staffresponsibilities. (There shall be a Medical Staff Executive Committee and suchother standing and special committees of the staff responsible to the ExecutiveCommittee as may from time to time be necessary and desirable to perform thestaff functions listed in Section 12.3, and elsewhere in this Code. The StaffExecutive Committee may, by resolution, and upon approval by the Board ofTrustees, establish a staff committee to perform one or more of the required stafffunctions. Those functions requiring participation of, rather than direct oversightby the staff may be discharged by medical staff representation on such managementcommittees of the Hospital as are established to perform such functions.). MedicalStaff Members from all MHP Medical Staffs comprise standing RegionalCommittees, which include Physicians Council, Bylaws, JRC and the SystemwideCredentials Oversight Committee. The composition, responsibilities and functionsof all committees other than the MEC, the JRC and the Bylaws Committee are setforth in the Medical Staff Committee Manual. To the extent that any Medical Staffcommittee performs as a Professional Review Body, the proceedings and records ofthat committee shall be confidential and shall be regarded as Peer Review Matterwithin the meaning of these Bylaws. All tangible Peer Review Matter must besecurely stored in the Medical Staff Office.- 47 -