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Medical Staff Affairs

The Medical Staff Affairs Office provides comprehensive services to support the membership of the Medical Staff of Mercy Medical Center.


  • To provide continuous performance improvement control mechanisms concerning patient care and to ensure that the interests and safety of the patients of the hospital are accorded the highest priority.
  • To promote a high level of professional performance in the Medical Center through the appropriate delineation of the clinical privileges that each practitioner may exercise in the Medical Center and through an ongoing review and evaluation of each practitioner's performance in the medical center.
  • To conduct an on-going assessment and re-evaluation of each practitioner's performance in the hospital.
  • To develop, maintain, adopt, and enforce the By-Laws, Rules and Regulations of the Medical Staff for the self-governance of medical staff activities so as to maintain accountability to the Governing Body.
  • To provide a means whereby issues concerning the Medical Staff and the Medical Center may be discussed by the Medical Staff with the Governing Body, the Chief Executive Officer and the Vice President of Medical Affairs.


  • Initial credentialing of new applicants to the Medical Center
  • Re-credentialing of the current membership of the Medical Staff
  • Maintenance of Credentialing and Quality files, which includes collection of expireable documents (e.g. NY State License, DEA, Infection Control Certificate, etc),
  • Oversee the Credentials Committee, the Executive Committee, the Performance Improvement Committee, and the Board of Trustees,
  • Sponsor a variety of education programs for the physicians
  • Assist with the orientation of new practitioners to the Medical Staff
  • Conduct periodic internal audits of files for Joint Commission readiness
  • Support all Department Directors and Chiefs

Applying For Medical Staff Membership