Medical Staff

Tip of the week: Delineate technical vs. substantive bylaws amendments

Medical Staff Leader Insider, April 19, 2012

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The Joint Commission requires medical staff bylaws and all associated documents to have a section that outlines the process for revision. Organizations should clearly distinguish between technical amendments (e.g., formatting, typographical errors, or spelling corrections) and substantive amendments and the process for making those revisions. Voting members of the medical staff do not have to vote on technical amendments. The medical executive committee and governing board can simply approve those. However, eligible voting members of the medical staff must vote on substantive amendments.

This week’s tip is from Legal Strategies for MSPs & Physician Leaders: Prevent Negligent Credentialing and Protect Peer Review by Anne Roberts, CPMSM, CPCS.



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