Bylaws and other governing documents: The MEC’s role

Medical staffs have various documents that address how they self-govern themselves. All medical staffs are required to have medical staff bylaws. Frequently, the medical staff may also have rules and regulations, policies and procedures, or both. What is the difference between all these documents?

The bylaws serve as the “constitution” of the medical staff. They tend to be fairly high level (except for when mandated otherwise) with more detail in associated medical staff rules and regulations, policies and procedures, or hospital policies. The bylaws need to be approved by the voting members of the medical staff and by the governing body of the hospital. This approval by the medical staff cannot be delegated to the medical executive committee (MEC) or any other body. Each medical staff decides the quorum required for the vote and the manner of action to determine whether the motion passed.

Rules and regulations (and policies and procedures) tend to be more operational in nature. There are no requirements of what needs to exist in either document. Most medical staffs delegate approval of these documents to the MEC (since the MEC is the chosen leadership of the medical staff). It is important to note that CMS mandates rules and regulations also be approved by the governing body; there is no such requirement for policies and procedures.

In summary, most efficient medical staffs have the following: