Red flags that signal outdated bylaws
December 18, 2023
Many medical staffs’ current bylaws were originally written decades ago and are simply amended year
after year. Due to their piecemeal creation, such documents may have any number of faults, including the following:
- Contradictory passages that no one has noticed. A revised passage in the bylaws may indicate a new requirement for board certification, while an older passage in another part of the document omits this eligibility requirement.
- Confusing guidance. One passage in the bylaws may describe a formal process of investigation preceding a medical executive committee (MEC) recommendation for corrective action, while a second passage declares that the medical staff will investigate every complaint and adverse event.
- Important information related to credentialing scattered throughout hundreds of pages of bylaws, rules, regulations, and policies. Many medical staffs allow departments to create their own rules, but often fail to ensure that they are consistent with broader medical staff policies. It might be easy for a credentials committee vetting an applicant to miss a relevant privileging or performance requirement slipped into the rules and regulations of a particular department.
- Too much detail about the credentialing process present in the medical staff bylaws. A better practice is to provide only the broad description of the credentialing process in the bylaws (as required by some accreditation organizations) and to integrate all associated details in more flexible, adaptable medical staff policies. Many medical staffs gather credentialing policies in a manual where they are easily referenced and kept up to date.