Medical Staff Bylaws: Complying With CMS, NPDB, and Joint Commission

Medical staff bylaws and related rules and regulations are the key governance documents which establish processes measuring the competence of medical staff physicians and other providers.

Areas typically covered under the bylaws include peer review, encompassing credentialing, privileging, and corrective actions; governance, including membership, leadership selection, voting, and committee activities; and hearings, appeals, and reporting requirements.

Medical staff bylaws must comply with accreditation and CMS standards, NPDB requirements, and other federal and state mandates, creating technical challenges for medical staff and hospital attorneys.

Listen as our bylaws expert Elizabeth Snelson reviews recent developments and implications for healthcare providers and medical staff operations, and offers strategies for achieving compliant bylaws as well as implementing "best practices." Sample bylaws provisions will be featured throughout.

1. CMS/Joint Commission medical staff standards
2. National Practitioner Guidebook impact on bylaws
3. Best practices

Ms. Snelson will review these and other key issues:

• What potential pitfalls could be encountered in amending and approving revised bylaws--and what strategies can hospitals and medical staffs employ to overcome them?
• What are some ways to limit the need for hearings?
• How can bylaws improve Data Bank compliance?