There is a medical staff executive committee.

(1)

The structure and function of the medical staff executive committee conforms to the medical staff bylaws.

(2)

The chief executive officer (CEO) of the hospital or their designee attends each medical staff executive committee meeting on an ex-officio basis, with or without a vote.

(3)

The majority of voting medical staff executive committee members are fully licensed doctors of medicine or osteopathy actively practicing in the hospital. Note: All members of the organized medical staff, of any discipline or specialty, are eligible for membership on the medical staff executive committee.

(4)

The medical staff executive committee makes recommendations, as defined in the medical staff bylaws, directly to the governing body on all of the following, at a minimum: - Organized medical staff's structure - Process used to review credentials and delineate privileges - Executive committee's review of and actions on reports of medical staff committees, departments, and other assigned activity groups