The Medical Executive Committee Manual

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The Medical Executive Committee Manual

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The Medical Executive Committee Manual

Mary J. Hoppa; William F. Mills

Your resource to build and support an effective medical executive committee

Physician leaders are pressed for time. Give them the knowledge and tools to confidently and effectively carry out their MEC responsibilities and comply with accreditors’ standards.

This book will help MEC members understand their role in important medical staff functions, such as credentialing and privileging; competence assessment and peer review; physician contracts and alignment; and quality and patient safety. This book also helps MEC members understand their relationship to the medical staff, other committees, administrators, and the governing board.


This book will serve as a guide and reference manual for how the MEC can effectively and efficiently carry out its duties, including:

  • Methods for providing leadership that is fair, honest, and consistent
  • Maximizing members’ leadership skills and minimizing time spent in meetings
  • The MEC’s role in OPPE, FPPE, and peer review
  • The MEC’s role in physician contracting, physician-hospital alignment, and hospital strategies
  • Communicating with the governing board and hospital administrators

Published: October 2013

Table of Contents

Chapter 1: Roles and Responsibilities of the Medical Staff, Management, and Board

    • Quality and Safety
    • Board Responsibilities
    • Organizational Charts
    • Medical Staff Responsibilities
    • Management Responsibilities
    • Understanding Influence

Chapter 2: The Power of the Pyramid:  How to Achieve Great Physician Performance

    • Appoint Excellent Physicians
    • Set, Communicate, and Achieve Buy-In to Expectations
    • Measure Performance Against Expectations
    • Provide Periodic Feedback
    • Manage Poor Performance
    • Take Corrective Action

Chapter 3: Appoint Excellent Physicians

    • Guiding Principles

Chapter 4: Set, Communicate, and Achieve Buy-In to Expectations

    • How to Develop Great Expectations
    • Sample Performance Expectations

Chapter 5: Measure Performance Against Expectations

    • Peer Review
    • Special Circumstances in Peer Review

Chapter 6: Provide Periodic Feedback

    • Ten-Step Process for Creating Physician Performance Reports
    • Gaining Physician Buy-In to Reports

Chapter 7: Manage Poor Performance

Chapter 8: Take Corrective Action

Chapter 9: Medical Staff Bylaws and Rules and Regulations: The MEC’s Role

    • Composition of the MEC
    • Attendance Requirements
    • Code of Conduct
    • Confidentiality
    • Conflicts of Interest
    • The “Minority Report”
    • Implementing Change
    • Bylaws, Rules and Regulations, Policies and Procedures

Chapter 10: Medical Staff Functions: The MEC’s Role

    • Regulatory Requirements
    • Medical Staff Functions
    • Information Flow

Chapter 11: Credentialing and Privileging: The MEC’s Role

    • Are Credentialing and Privileging the Same?
    • Four-Step Process
    • Expedited Credentialing
    • Policy in Action
    • Essential Credentialing and Privileging Policies

Chapter 12: Peer Review, Quality, and Patient Safety: The MEC’s Role

    • Terms to Know          
    • Peer Review
    • Managing Loose vs. Managing Tight
    • Managing System Performance
    • Four Components of Patient Safety
    • Organizational Performance Improvement
    • What the MEC Can Do

Chapter 13: FPPE and OPPE: The MEC’s Role

    • What Is FPPE?
    • What Is OPPE?
    • The Six Core Competencies
    • Performance Improvement Plan Oversight

Chapter 14: Managing Professional Conduct: The MEC’s Role

    • Protecting a Culture of Safety
    • Medical Staff Code of Conduct Policy
    • Legal and Regulatory Obligation to Address Conduct Issues
    • Performance Pyramid to Address Conduct

Chapter 15: Physician Contracts: The MEC’s Role

    • Clinical Services Contracts
    • Quality Oversight
    • Annual Contract Review

Chapter 16: Strategic Collaboration With the Hospital: The MEC’s Role

    • The Right Number
    • The Right Type of Physician
    • The Right Quality
    • The Right Relationship to the Hospital
    • The Right Medical Staff Culture
    • The Right Structure and Processes
    • The Right Leadership

Chapter 17: Physician and Hospital Alignment: The MEC’s Role

    • What Is Alignment?
    • Physician and Hospital Success
    • Clinical Integration
    • Economic Integration
    • Cultural Integration

Chapter 18: Physician Leadership

    • Identify Potential Leaders
    • Recruit Leaders
    • Develop and Educate Leaders
    • Reward Leaders
    • Apply the Pyramid
    • Am I a Leader?

Chapter 19: Physician Leadership Tool Kit

    • Communication
    • Influence
    • Managing Personalities
    • Polarity Management

Chapter 20: Effective MEC Meetings

    • Assess Physician Leaders’ Management Style
    • Planning Effective Meetings
    • Developing the Agenda
    • Running Effective Meetings
    • Encouraging Cooperation of Meeting Participants
    • Decision Making Guidelines for Physician Leaders

Chapter 21: Your Turn: Implement and Improve

    • Final Thoughts
    • Your Turn

About the Authors

William F. Mills, MD, MMM, CPE, FACPE, FAAFP, is currently the senior vice president of quality and professional affairs for Upper Allegheny Health System, which consists of Olean (NY) General Hospital and Bradford (Pa.) Regional Medical Center. He is certified by the American Board of Family Medicine, is a certified physician executive from the Certifying Commission in Medical Management, and is a fellow in both the American Academy of Family Physicians and the American College of Physician Executives.

Mary J. Hoppa, MD, MBA is a senior consultant with The Greeley Company, in Danvers, MA. She brings more than 25 years of healthcare leadership and management experience to her work with physicians, hospitals, and healthcare organizations across the country. Hoppa’s roles in hospital administration and medical staff leadership in academic and community hospital settings make her uniquely qualified to assist physicians and medical centers in developing effective solutions to their most significant challenges. She has experience in credentialing and privileging, peer review and quality, medical staff education, conflict resolution, and is the leader of The Greeley Company’s bylaws division. She brings this experience into the accreditation practice.