Bylaws amendments requirements

Bylaws should be carefully written to ensure that they can’t be changed casually, but also that amendments don’t face an unreasonable hurdle. This balancing act will be decided differently by various medical staffs.

However the medical staff authorizes amendments to its bylaws, changes must be ultimately approved by the hospital governing body. This is a requirement established under the Medicare Conditions of Participation (CoP), which state that the bylaws must “be approved by the governing body.”

In addition to bylaws, most medical staffs adopt rules, regulations, and policies. It is customary to allow modifications of policies to occur at the discretion of the MEC. However, the process for modifying “rules and regulations” varies greatly among medical staffs. Some treat rules and regulations in the same manner as bylaws and require changes to be ratified by a medical staff vote. In other organizations, the rules and regulations can be modified by the MEC in the same manner as policies.

Some medical staffs are eliminating “rules and regulations” and simply have two types of documents: bylaws and medical staff policies and procedures. Although “rules and regulations” is nomenclature used historically, it is not clear in most organizations what distinguishes a rule from a regulation, or how either is different than a policy. It is more efficient to simply replace rules and regulations with all-encompassing medical staff policies.