Who should be involved in the medical staff bylaws revision process?

Revising the bylaws is not a chore that medical staff members look forward to participating in, but it is an important responsibility that cannot be ignored if the medical staff wants to have compliant, contemporary bylaws that address the issues that the medical staff faces.

When reviewing the bylaws, medical staffs should create a bylaws review committee, including individuals such as:

  • Vice president of medical affairs
  • Chief medical officer
  • Medical staff leaders
  • Medical staff members
  • MSPs

It is important to include seasoned medical staff leaders who, by their use of the bylaws, know the strengths and weaknesses of the current documents on that committee. However, medical staff leaders’ primary job is to oversee patient care activities – they perform their medical staff responsibilities in addition to their normal workload.

Most medical staff leaders do not keep new CMS regulations or accreditation standards top of mind; they also struggle to keep up with the legal cases that could affect the organized medical staff. Therefore, it is also important to include administrative personnel, such as the VPMA/CMO and MSPs. These individuals facilitate the medical staff operations and have a better day-to-day understanding of the bylaws than most individuals within the organization.

In addition, include one or two medical staff members who other medical staff members look up to and who are otherwise be considered contrarians. The medical staff knows that these individuals will question the process thoroughly. If this person agrees to the bylaws revisions, other members of the medical staff are likely to buy into the changes because they trust that this individual has vetted the new bylaws from top to bottom.  It is better to bring in these individuals into the process so that they can work within the process, have substantive input into the resulting product, and then be your best advocate for the proposed changes.