Bylaws, regulations, policies: What's the difference?

Today's Quick Tip comes from Credentialing A to Z, a new book that offers spot training, answers frequently asked questions, includes sample forms, and provides quizzes for all levels of medical staff service. Knowing what differentiates medical staff bylaws, rules, regulations, and policies is the first step in understanding where information can be found.

Bylaws must describe the structure by which medical staff governance is accomplished. Bylaws are required by both CMS and The Joint Commission.

Rules and regulations outline the standards for quality patient care. They may include requirements such as timely completion of medical records, required content of a history and physical in the inpatient setting versus outpatient setting, and the process for transfer of care from one physician to another.

Medical staff policies contain the details by which the bylaws are carried out. For example, the medical staff credentialing process may be outlined in the bylaws, but the details of the process are contained in the policy.

Tip – Bylaws revisions require approval of the medical staff and the governing body. This process can take several months depending on the frequency of your meetings. Policies may be revised and approved by the medical executive committee, a much more expeditious process. It is beneficial to keep details of your processes in your policies so they can be amended in a more timely fashion as necessary.