Medical Staff Governance

A medical staff organization has two major purposes.

  • It establishes mechanisms for controlling the quality of care rendered by medical staff members and other practitioners granted clinical privileges.
  • It provides a structure whereby physicians have input into decision-making within the institution.

An organized medical staff is a legal entity with its own existence, bylaws, powers, privileges, and responsibilities.

Organized Medical Staff Functions

• Establish professional standards
• Provide for continuous surveillance to see that standards are met
• Take a leadership role in performance improvement and patient safety
• Make regular reports to the Governing Body on the quality of medical care
• Make recommendations to the governing body on appointments, reappointments, and clinical privileges
• Ensure compliance with UCSF Medical Staff Bylaws, Rules and Regulations, policies and procedures
• Take disciplinary actions (enforcement of professional standards) when necessary
• Participating in hospital and strategic planning