15 MAC Pt. 3, R. 7.1.6
Medical Director
Cite as 15 Miss. Admin. Code Pt. 3, R. 7.1.6
Medical Director. There must be an identified NMD. The NMD must be
credentialed by the facility for treatment of neonatal patients and have their
responsibilities and authority defined in a job description. The NMD must
maintain a current status of successful completion of the Neonatal Resuscitation
Program (NRP) or a department-approved equivalent course. The NMD is
responsible for the provision of neonatal care services and must:
1. Examine qualifications of medical staff and advanced practice providers
requesting privileges to participate in neonatal/infant care and make
recommendations to the appropriate committee for such privileges.
2. Ensure neonatal medical staff and advanced practice provider competencies
in managing neonatal emergencies, complications, and resuscitation
techniques;
3. Monitor neonatal patient care from transport, to admission, stabilization, and
operative intervention(s), as applicable, through discharge, and review
variances in care through the neonatal Performance Improvement (PI) Plan;
4. Participate in ongoing neonatal staff and team-based education and training
in the care of the neonatal patient;
5. Oversee the inter-facility neonatal transport as appropriate;
6. Collaborate with the Neonatal Program Manager (NPM), maternal teams,
consulting physicians, and nursing leaders and units providing neonatal care
to include developing, implementing, or revising:
a. written policies, procedures, and guidelines for neonatal care that are
implemented and monitored for variances;
b. the Neonatal PI Plan, specific reviews, and data initiatives;
c. criteria for transfer, consultation, or higher-level of care; and
d. medical staff, advanced practice providers, and personnel competencies,
education, and training;
7. Participate as a clinically active and practicing physician in neonatal care at
the facility where medical director services are provided;
8. Ensure that the Neonatal PI Plan is specific to neonatal/infant care, is
ongoing, data driven, and outcome based;
9. Frequently lead the neonatal PI meetings with the NPM and participate in the
Perinatal Multidisciplinary Committee and other neonatal meetings, as
appropriate;
10. Maintain active staff privileges as defined in the facility's medical staff
bylaws; and
11. Develop and maintain collaborative relationships with other NMDs of
designated neonatal facilities within the applicable region.
12. Collaborate with the transport team to develop, revise, and implement written
policies, procedures, and guidelines, for neonatal care that are implemented
and monitored for variances;
13. Participate in ongoing transport staff competencies, education, and training;
14. Review and evaluate transports from initial activation of the transport team
through delivery of patient, resources, quality of patient care provided, and
patient outcomes; and
15. Integrate review findings into the overall Neonatal PI Plan and process.