Medical Staff Bylaws: Complying With CMS, NPDB and Joint Commission

Recording of a 90-minute CLE webinar with Q&A

Conducted on Wednesday, November 7, 2018

Recorded event now available

or call 1-800-926-7926
Program Materials

This CLE webinar will prepare healthcare counsel to advise and guide healthcare providers, medical staffs and hospitals working towards medical staff bylaws compliance with Joint Commission standards, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, the National Practitioner Data Bank (NPDB) requirements, and other applicable federal and state laws.


Medical staff bylaws and related rules and regulations are the key governance documents which establish processes measuring competence of medical staff physicians and other providers.

Areas typically covered under the bylaws include peer review, encompassing credentialing, privileging, and corrective actions; governance, including membership, leadership selection, voting, and committee activities; and hearings, appeals and reporting requirements.

Medical staff bylaws must comply with accreditation and CMS standards, NPDB requirements, and other federal and state mandates, creating technical challenges for medical staff and hospital attorneys.

Listen as our bylaws expert Elizabeth Snelson reviews recent developments and implications for healthcare providers and medical staff operations, and offers strategies for achieving compliant bylaws as well as implementing “best practices.” Sample bylaws provisions will be featured throughout.



  1. CMS/Joint Commission medical staff standards
  2. National Practitioner Guidebook impact on bylaw
  3. Best practices


Ms. Snelson will review these and other key issues:

  • What potential pitfalls could be encountered in amending and approving revised bylaws—and what strategies can hospitals and medical staffs employ to overcome them?
  • What are some ways to limit the need for hearings?
  • How can bylaws improve Data Bank compliance?


Snelson, Elizabeth
Elizabeth A. (Libby) Snelson, Esq.

Legal Counsel for the Medical Staff

Ms. Snelson represents medical staffs, medical societies and physician interests across the country. Her practice areas...  |  Read More

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Strafford will process CLE credit for one person on each recording. All formats include program handouts.

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