Clinical Staff Committees

Clinical Staff Executive Committee

Subject to the overall authority of the Medical Center Operating Board (MCOB), the Clinical Staff Executive Committee (CSEC) has the following duties:

  • Monitor, oversee and, where appropriate, manage the quality of clinical care delivered within the Medical Center;
  • Communicate to Members and Non-Members of the Clinical Staff regarding clinical practice issues and present the interests of the Clinical Staff to the MCOB;
  • Act for and on behalf of the Clinical Staff in the intervals between Clinical Staff meetings and independently with respect to those matters over which CSEC is given authority in these Bylaws;
  • Establish, review, and enforce the policies applicable to the Clinical Staff, including the Bylaws, the Code of Conduct, and all other Medical Center clinical policies regarding patient care;
  • Control and monitor the membership of the Clinical Staff through oversight of the appointment, credentialing, and privileging process;
  • Coordinate the activities and general clinical policies of the Medical Center to support an institutional and integrated approach to patient care within the Medical Center;
  • Oversee the functions of performance improvement of the professional services provided by the Clinical Staff within the Medical Center;
  • Advise the Medical Center management regarding the allocation and distribution of clinical resources, including assignments of beds, clinics, operating rooms, and other elements that are important to efficient and effective medical care within the Medical Center;
  • Provide Clinical Staff representation and participation in any Medical Center deliberation affecting the discharge of Clinical Staff responsibilities;
  • Report to the MCOB, as required, on the activities of the Clinical Staff Executive Committee and the Clinical Staff and makes specific recommendations to the MCOB relating to the clinical efforts of the Medical Center;
  • Approve the creation of and oversee committees of the Clinical Staff as necessary for compliance with accreditation standards, regulatory requirements and governance of the Clinical Staff;
  • Receive and act on reports and recommendations from the Clinical Staff committees and Departments;
  • Develop a procedure for managing such conflict as may arise between the Clinical Staff and the Clinical Staff Executive Committee on issues related to the adoption of or amendment to Clinical Policies of the Medical Center;
  • Notify Members of the Clinical Staff of its adoption of or amendment to Clinical Staff Policies of the Medical Center, and
  • Perform such other duties as may be assigned to it by the MCOB.


The membership of the Clinical Staff Executive Committee shall consist of the following individuals, all of whom shall be voting members:

  • President of the Clinical Staff
  • Vice President of the Clinical Staff
  • Chief Executive Officer of the Medical Center
  • Associate Vice President for Hospital and Clinics Operations
  • Chief Medical Officer of the Medical Center
  • Chief Nursing Officer of the Medical Center
  • Dean of the School of Medicine
  • Designated Institutional Officer for Graduate Medical Education
  • Chairs of the Departments of the Medical Center
  • Chair, Children’s Hospital Clinical Practice Committee
  • Five (5) Clinical Staff Representatives selected by the Clinical Staff and AHPs as provided in the Clinical Staff Bylaws
  • President of the Nursing Staff
  • President of the Clinical Staff of the University of Virginia Transitional Care Hospital
  • Vice President of the Clinical Staff of the  University of Virginia Transitional Care Hospital

In addition, the President(s) of the Housestaff Executive Council shall serve on the Clinical Staff Executive Committee as a non-voting, ex-officio member(s).  When the Department Chair is unable to attend a CSEC meeting, the Deputy may attend and vote in place of the Department Chair.  The Deputy will count in establishing a quorum.

The Clinical Staff Executive Committee shall meet at least (10) times per year at a time and place as designated by the Chair of the Clinical Staff Executive Committee, and the expectation is the each member of the Clinical Staff Executive Committee will attend these meetings.  Fifty-one percent (51%) of the membership of the Clinical Staff Executive Committee shall constitute a quorum.  Attendance at the Clinical Staff Executive Committee meetings is not assignable for voting purposes.

Chair: Robert S. Gibson, MD, MACP, FACC,
Administrative Contact: Carole Wagonhurst, MA, Clinical Staff Office, 924-2435,

Current Membership (as of August 2015)

Reid Adams, MD Surgical Specialties Representative to CSEC
A. Bobby Chhabra, MD Chair, Orthopedic Surgery
Anita Clayton, MD Chair, Psychiatry and Neurobehavioral Sciences
Jim Amato, MBA
Interim Chief Operating Officer
Randy Canterbury, MD
Dean, School of Medicine (interim)
Robert Powers, MD Clinical Staff President, Transitional Care Hospital
Lorna Facteau, DNSc, RN Chief Nursing Officer
James E. Ferguson, MD Chair, Obstetrics & Gynecology
Cree Gaskin, MD
Hospital Based Specialties Representative to CSEC
Chris Ghaemmaghami, MD Chief Medical Officer
Robert Gibson, MD, MACP President of the Clinical Staff
Tucker Gleason, PhD
AHP Representative to CSEC
G. Paul Matherne, MD
Chair, Children's Hosp Clinical Practice Committee
Pamela Sutton-Wallace, MPH
Chief Executive Officer, Medical Center
Karen Johnston, MD Chair, Neurology
Susan Kirk, MD Designated Institutional Officer; Associate Dean for Graduate Medical Education
Michelle Longley, MSN, RN
2015 President, PNSO Nursing Cabinet
Irving Kron, MD Chair, Surgery
James Larner, MD Chair, Radiation Oncology
Thomas Leinbach, MD Chair, Dentistry
Paul Levine, MD Chair, Otolaryngology
John Dent, MD Medical Specialties Representative to CSEC
Alan Matsumoto, MD Chair, Radiology
Dan McCarter, MD
Associate Chief Medical Officer for Ambulatory Services
Raymond Morgan, MD Chair, Plastic Surgery
Christopher Moskaluk, PhD, MD
Chair, Pathology
James Nataro, MD, PhD Chair, Pediatrics
Peter Netland, MD, PhD Chair, Ophthalmology
Robert O'Connor, MD Chair, Emergency Medicine
M. Norm Oliver, MD Chair, Family Medicine
Barbara Post, MD Primary Care Representative to CSEC
George Rich, MD Chair, Anesthesiology
Mitchell Rosner, MD Chair, Department of Medicine
Kevin Greer, MD Housestaff Co-President
Mark Shaffrey, MD Chair, Neurosurgery
Raymond Costabile, MD Chair, Urology
Scott Syverud, MD Vice President of the Clinical Staff
Robert P. Wilder, MD Chair, Physical Medicine
Barbara Wilson, MD
Interim Chair, Dermatology
Alex Michaels, MD Housestaff Co-President

Committees Reporting to CSEC

CSEC Organizational Chart

Nominating Committee

Bylaws Committee

Cancer Committee

Patient Safety Committee
· Safety & Security Subcommittee

Credentials Committee
· AHP Credentials Subcommittee
· AHP Peer Evaluation Subcommittee
· Clinician Wellness Subcommittee
· Professional Practice Evaluation Subcommittee
· Peer Support and Triage Subcommittee

GME Committee
· GME Education Subcommittee
· GME Policy Subcommittee
· GME Stipend and Benefits Subcommittee
· GME Clinical Learning Environment Review Subcommittee

Ethics Committee
· Patient Care Consulting Subcommittee

Children's Hospital Clinical Practice Committee
· Children's Patient & Family Centered Care Subcommittee

Patient Grievance Committee

Surgical and Invasive Procedure Review Committee

Pharmacy and Therapeutics Committee
· Medication Usage Safety & Informatics Subcommittee
Anticoagulation Subcommittee
· Anti-infective Utilization Subcommittee
· Drug Shortage Task Force Subcommittee
· Hematology/Oncology Subcommittee
· Pain Subcommittee



Operating Room Committee
· Executive OR Subcommittee
· Block Allocation Subcommittee
· Perioperative Patient Flow Subcommittee
· Patient Evaluation for Surgery Subcommittee
· Perioperative Regional Quality Subcommittee
· Robotics & Computer Navigated Surgery Subcommittee
· Tissue Review Subcommittee
· Children's Surgery Subcommittee
· New Product/Equipment Review Subcommittee
· Outpatient Surgery Subcommittee
· Capital Budget Subcommittee

Clinical Information Technology Oversight Committee
· Clinical Informatics Subcommittee
· Clinical Decision Support Subcommittee
· Clinical Reporting and Analytics Subcommittee
· Health Information Management Subcommittee
· Clinical Research Subcommittee
· Innovation Subcommittee
· Medical Technology Subcommittee

Patient Care Committee
. Ambulatory Care Subcommittee
· Critical Care Subcommittee
· Medical Emergency Response Subcommittee
· Patient & Family Education Subcommittee
· Radioactive Drug Research Subcommittee
· Acute Care Subcommittee
· Laboratory Utilization Subcommittee
· Transfusion Subcommittee

Quality Committee
· Nursing Quality Subcommittee
· Infection Prevention and Control Subcommittee

Clinical Radiation Safety Committee