Ask the expert: Frequency of bylaw reviews and revisions
Q: How often should hospitals conduct a comprehensive review of medical staff bylaws? How often should they make targeted revisions?
Sara Cameron, CPMSM, CPCS, senior consultant with The Hardenbergh Group, a Sentact Company: Best practice is to conduct an annual review of the medical staff bylaws, consistent with the expectations of most accrediting bodies. This annual review is typically documented through medical executive committee acknowledgment that the bylaws have been reviewed.
In addition, organizations should plan for a more comprehensive, in-depth governance review every three to five years, which includes full committee engagement and substantive evaluation of structure, processes, and alignment with current operations.
If an annual review is not feasible, bylaws should be reviewed every three to five years at a minimum to ensure they continue to accurately reflect current medical staff governance practices and do not become outdated.
Targeted revisions should occur as needed, particularly when one of the following occurs:
- New service lines are introduced
- Telehealth expands
- Advanced practice provider oversight evolves
- Regulatory standards change
- Peer review structures are modified
Bylaws should evolve deliberately, not continuously. If you’re amending bylaws every few months, something is likely misplaced that belongs in policy instead.
Editor’s note: This Q&A was excerpted from our Credentialing Resource Center Journal newsletter.