Medical Staff Bylaws: Impact of Recent Regulatory Changes and Best Practices

Complying With CMS and Updating Hospital Governance Documents

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

Wednesday, September 13, 2017
1:00pm-2:30pm EDT, 10:00am-11:30am PDT

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

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 authoritative panel of healthcare attorneys reviews recent developments, the implications for healthcare providers and medical staff operations, and offers strategies for amending and approving compliant bylaws as well as example “best practices.”


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


The panel will review these and other key issues:

  • What are some example bylaw provisions to consider?
  • What potential pitfalls could be encountered in amending and approving revised bylaws—and what strategies can hospitals employ to overcome them?
  • What are some ways to limit the need for hearings?


Richard D. Barton, Partner
Procopio Cory Hargreaves & Savitch, San Diego

Mr. Barton has represented health care providers and health systems for over 30 years. As trial counsel, he has tried and arbitrated over 100 matters on behalf of health systems, hospitals, physician groups, and individual providers in business, class action, professional liability, fraud and abuse, and administrative matters in both Federal and State court. Mr. Barton has also been retained by numerous hospitals and health systems to serve in a consultative role to assist hospitals, medical staffs and physician groups in their oversight responsibilities.

Adrienne E. Marting, Partner
Nelson Mullins Riley & Scarborough, Atlanta

Ms. Marting’s practice focuses primarily on regulatory and litigation matters. She routinely represents hospitals, behavioral health providers, ambulatory surgery centers, home health agencies, rehabilitation centers, physician practice groups, and other healthcare facilities and providers before administrative agencies and state and federal courts. Ms. Marting lectures on a variety of healthcare topics, including confidentiality of medical records, EMTALA, and credentialing and peer review issues.

Alma L. Saravia, Shareholder
Flaster/Greenberg, Cherry Hill, N.J.

Ms. Saravia concentrates her practice in healthcare law. Her clients include physicians, nurses, chiropractors, hospitals, medical staff, nursing homes and other healthcare organizations. She counsels practitioners on licensure and disciplinary matters. She has extensive legislative and regulatory experience, and served as director of Legislative and Regulatory Affairs for the New Jersey Department of the Public Advocate. She is a frequent lecturer and author on healthcare law.

Elizabeth A. (Libby) Snelson, Esq., President
Legal Counsel for the Medical Staff, St. Paul, Minn.

Ms. Snelson represents medical staffs, medical societies and physician interests across the country. Her practice areas include medical staff bylaws, credentialing and clinical privileges, disruptive behavior issues, peer review, and other matters. Ms. Snelson has nearly 20 years of experience working with medical staffs, medical societies and medical staff professionals, and is a frequent author and lecturer on medical staff bylaws, among other issues.

Live Webinar

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This webinar is eligible for at least 1.5 general CLE credits.

CLE credits are not available for PR.

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Customer Reviews

It was interesting to understand what changes in medical staff bylaws are of most concern to hospitals.

Shelley Carder

DiCaro, Coppo & Popcke

The seminar was very informative and detailed, and I enjoyed the different perspectives of the speakers.

Melanie Martin

Cozen O'Connor

The speakers were well prepared and knowledgeable.

Kathleem Murphy

San Francisco General Hospital

The webinar was very clear & applicable to my practice.

Christine Lay

Bon Secours Health System

Strafford's seminar was excellent and I found the Q&A session especially helpful.

Ben Koplin

Fulbright & Jaworski

or call 1-800-926-7926

Health Law Advisory Board

Lowell C. Brown


Arent Fox

Jennifer L. Evans



Ryan S. Johnson


Fredrikson & Byron

Gina M. Kastel


Faegre Baker Daniels

Karen S. Lovitch


Mintz, Levin, Cohn, Ferris, Glovsky and Popeo

David A. Manko


Proskauer Rose

John J. Miles

Senior Counsel

Baker Donelson

C. Elizabeth O'Keeffe


Wyatt, Tarrant & Combs

J. Peter Rich


McDermott Will & Emery

Donald H. Romano

Of Counsel

Foley & Lardner

Judith A. Waltz


Foley & Lardner

John R. Washlick


Buchanan Ingersoll & Rooney

Jesse A. Witten


Drinker Biddle & Reath

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