Synergy - September/October 2013 - 27

namss focus

Removal of
MEC Members:
1.	 	f	a	member		of	the	MEC	does	not	
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attend	at	least	60%	of	all	meetings	in	
the	calendar	year,	the	elected	Officers	
of	the	Medical	Staff,	may	remove	the	
member	and	appoint	a	new	member	
until	the	next	election	of	the	organized	
Medical	Staff	if	an	officer	or	appropriate	
Department	if	a	Department	Chair.
2.	 	 EC	members	may	be	removed	from	
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office	for	cause,	by	a	two-thirds	vote	of	
the	MEC	members.
3.	 	 uch	stated	causes	include	and	should	
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not	be	limited	to:
a.	 	nvolvement	and	discipline	through	
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the	Code	of	Conduct	policy,	or;
b.	Dereliction	of	duties.
4.	 	 utomatic	removal	from	the	MEC	and	
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the	role	held	by	the	member	will	occur	
due	to:
a.	 	 oss	of	a	valid	State	of	Alaska	
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Medical	or	Dental	license
b.	 	 oss	of	Medical	Staff	membership	at	
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Providence	Alaska	Medical	Center
c.	 	nvoluntary	loss	of	privileges	at	
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Providence	Alaska	Medical	Center

Conflict Resolution Process for the
MEC and the Medical Staff:
1.	 	 hould	there	be	issues	of	conflict	
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between	the	medical	staff	and	the	
MEC	on	issues	including,	but	not	
limited	to,	proposals	to	adopt	a	
rule,	regulation,	or	policy	or	an	
amendment	thereto,	the	process	
outlined	below	will	be	followed.	
Nothing	in	the	foregoing	is	intended	
to	prevent	the	medical	staff	members	
from	communicating	with	the	
governing	body	on	a	rule,	regulation,	
manual	or	policy	adopted	by	the	
organized	medical	staff	or	the	MEC.	
The	governing	body	determines	the	
method	of	communication.
a.	 	 	Conflict	Resolution	Committee	
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(CRC)	shall	be	formed.	The	
committee	shall	be	composed	of	
5	MEC	members	(3	of	which	must	
be	the	current	chief	of	staff	and	at	
least	2	of	the	members	at	large),	and	
at	least	6	members	on	the	general	
medical	staff	that	do	not	currently	
serve	in	a	leadership	position	at	
PAMC	(at	least	one	representative	
from	Internal	Medicine	and	Surgery	
must	be	included	as	the	largest	

Our bylaws now reference every policy and manual
and the physician now knows exactly where to
look for what and we did it without having to have
to roll everything back into the bylaws.
and	receive	some	great	comments.	We	often	
take	policies	back	to	Bylaws	Committee	with	
the	medical	staff	input.	By	following	this	
process,	we	have	found	doctors	that	truly	
review	our	policies	and	value	the	process.	
Doctors	also	have	more	buy	in	now	to	the	
policies,	because	they	review	them	annually.	
With	today’s	technology,	it	is	not	too	hard	
to	accomplish.	We’ve	even	found	a	few	new	
members	for	our	Bylaws	Committee	based	
on	their	excellent	suggestions.	

The	other	big	challenge	we	faced	was	
the	removal	of	a	Medical	Executive	
Committee	member	as	well	as	the	
arbitration	committee	for	MEC	and	
the	medical	staff.	It	was	one	of	the	few	
times	in	my	career	that	I	actually	had	to	
“reinvent	the	wheel”	with	this	process.	
I	reviewed	the	process	for	our	joint	
conference	committee	with	the	board	
and	was	able	to	tailor	it	to	this	other	
environment.	What	did	we	come	up	with?

departments	of	the	PAMC	Medical	
Staff).	Whenever	possible,	attempts	
to	include	a	representative	from	
each	of	the	recognized	medical	staff	
departments	should	be	made.	The	
chair	of	the	CRC	will	be	the	chief	
of	staff.	All	eleven	members	will	
be	voting	members,	including	the	
CRC	chair.
b.	 	 	collegial	resolution	is	the	goal	
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of	the	CRC.	However,	if	such	a	
result	cannot	be	found	the	majority	
vote	shall	be	the	final	ruling	of	
the	CRC.	The	decision	of	the	
CRC	will	go	to	the	board	for	their	
approval.	If	an	approval	cannot	be	
granted,	the	similar	committee	at	
the	board	level	called	the	“Joint	
Conference	Committee	(JCC)”	shall	
convene.	The	detail	of	the	JCC	
shall	be	outlined	in	Medical	Staff	
Policy	(MS	980-100)	“Investigation,	
Hearing	and	Appeals”.

I	really	liked	this	change	to	the	review	
process	for	policies.	Our	bylaws	now	
reference	every	policy	and	manual	and	the	
physician	now	knows	exactly	where	to	look	
for	what	and	we	did	it	without	having	to	
have	to	roll	everything	back	into	the	bylaws.	
It’s	a	very	positive	change.
As	far	as	all	the	other	points	within	MS	
01.01.01,	we	reviewed	them	one	by	one,	
ensuring	all	the	appropriate	references	
to	policies	were	placed	in	the	bylaws,	
with	a	brief	explanation	of	the	policy,	
it’s	number	and	the	name	for	reference	
making	it	much	easier	to	find	what	you	
are	looking	for.	
I	am	happy	to	share	our	work.	Our	bylaws	
have	been	an	example	in	our	health	system	
and	have	been	shared	with	many.	I	hope	
you	all	survived!	■
September/Oct Ober 2013 SYNERGY

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Synergy - September/October 2013

Table of Contents for the Digital Edition of Synergy - September/October 2013
