Legal Pointers

How to Navigate - Hospital Medical Executive Committees, Peer Reviews, Investigations, and Bylaws

Posted by Ben Mirza | Mar 14, 2023

There are committees in every surgical department and surgery center. Notwithstanding how tiresome it can be to work with these committees, the Medical Executive Committee (MEC), may be the most crucial or frequently neglected. 

It is uncommon for individual hospital and surgical center personnel to fully comprehend the role of this committee and the enormous contribution it makes to safety and the effective management of a quality facility. The MEC is comprised of elected or "volunteer" surgeons from each specialty the facility offer, including anesthesia, as well as the facility's medical director, administrator, and nurse manager of the hospital department. 

The committee offers recommendations on a variety of issues that have an impact on the standard of care, such as clinical privileges, staffing, facilities planning, equipment, the appointment and reappointment of medical staff, and credentialing. Additionally, the MEC works to guarantee that all medical staff members act ethically and perform competently. 

Few surgeons are familiar with this influential committee; if they were, more would want to be a part of it. 

How to Protect Against A Medical Executive Committee Peer Review Investigation 

There are many ways to protect yourself against a Medical Executive Committee complaint. 

There are typically three potential categories of reasons as to what the investigation is about: (i)Physical or Mental Impairment, (ii) Disruptive Behavior or (iii) Clinical Competence has come under question.  Start by looking at Florida Statute – Chapter 395.0193, which provides guidance on hospital licenses and the statutory peer review requirement. That combined with Chapter 458.337 (Medical Practice) and 459.016 (Osteopathic Medicine).  The pitfall to watchout for is that the event or occurs must be reported within 30 days of an adverse finding to the Division of Health Quality Assurance, regardless of the pendency of an appeal.  Federal Regulation, 42 C.F.R Section 482.12 and 482.22 require that there be a fair hearing process for all Medicare Conditions of Participation.  

Important - If there is a MEC meeting or a hearing, it is extremely important to watch what you say and what you put in writing, for anything that you say can and will be held against you, and at times it is taken completely out of context and used to push the physician out of the hospital.     

Once it is reported, and the state notifies all other institutions that staff privileges have been revoked or terminated, and all others are then required to respond accordingly, and it can be in unison. This also means that the peer review actions must be reported to the National Practitioner Data Bank (NPDB).  It is possible for the physician to make countering statements on to the NPDB report, but those too have to be carefully crafted to quell any fears the next employer may have. These are severe and extreme consequences for many physicians that get tangled in such MEC's web.  So, what can you do to prevent or address a MEC investigation?


If you would like to attend a seminar on this topic, please register through this zoom link: 

Title: How to Navigate - Hospital Medical Executive Committees, Peer Reviews, Investigations, and Bylaws 

Date and Time: Tuesday, March 21, 2023 

Registration Link: 


To learn more on How to Protect Against A Medical Executive Committee Peer Review Investigation, please click this link:

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Email: [email protected], Initial consults are at no charge  

Ben Assad Mirza 




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