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Undertaking a bylaws review

Medical Staff Leader Connection, December 21, 2005

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Dear Medical Staff Leader:

The importance of medical staff bylaws 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 do the following:

• Accurately reflect the structures and processes utilized by the medical staff
• Incorporate recognized best practices for medical staff functioning and structure
• Anticipate and adequately address conflicts that may lie in the future
• Comply with regulatory standards

Keep in mind that your organization should assess the bylaws on an annual basis 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 necessary to take a rigorous look at the medical staff structure and processes to ensure it performs its work 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, don't allow more than three to five years to pass between such assessments.

That's all for this week!

All the best,

Todd Sagin, MD, JD
National Medical Director
The Greeley Company

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