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How often should we review our medical staff bylaws?

Medical Staff Legal Advisor, May 7, 2007

Medical staff bylaws' importance should compel every hospital and its medical staff leaders to ensure that they are adequate, accurate, and in compliance with applicable requirements. A thorough review of these documents should occur periodically to determine whether they accomplish the following:

  • Accurately reflect the structures and processes used by the medical staff
  • Incorporate recognized best practices for medical staff functioning and structure
  • Are organized into a user-friendly and flexible set of documents
  • Anticipate and adequately address potential future conflicts
  • Comply with regulatory standards


Keep in mind that your organization should assess the bylaws on an annual bases and whenever a regulatory body introduces a new standard or makes changes to an existing standard. However, a thorough assessment of your bylaws can occur less frequently.


For example, some medical staffs conduct a comprehensive bylaws document review every three to five years. Others undertake this task only when they decide it is necessary to take a rigorous look at the medical staff structure and processes to ensure that they perform efficiently and effectively. Because the bylaws are a blueprint for medical staff functioning, this is an opportune time to review these documents.


Although your medical staff may decide to reevaluate the governing documents on a more regular basis, do not allow more than three to five years to pass between such assessments.


Editor's note: The above is excerpted from Guide to Medical Staff Bylaws by Todd Sagin, MD, JD, and Joseph Cooper, MD and published by HCPro, Inc.