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

A live 90-minute CLE video webinar with interactive Q&A

This program is included with the Strafford CLE Pass. Click for more information.
This program is included with the Strafford All-Access Pass. Click for more information.

Tuesday, June 4, 2024

1:00pm-2:30pm EDT, 10:00am-11:30am PDT

or call 1-800-926-7926

This CLE course will prepare healthcare counsel to 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. Updates to address hospital employment and consolidation and other best practices will be presented.


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

Areas typically covered under the bylaws include peer review, 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 bylaws
  3. Best practices


The panelist 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?
  • How can bylaws improve Data Bank compliance?
  • What protections against peer review abuses should be included in bylaws?


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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You may pre-order a recording to listen at your convenience. Recordings are available 48 hours after the webinar. Strafford will process CLE credit for one person on each recording. All formats include course handouts.

To find out which recorded format will provide the best CLE option, select your state:

CLE On-Demand Video