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

Complying With CMS and Updating Hospital Governance Documents

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

Conducted on Wednesday, September 13, 2017

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 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?


Marting, Adrienne
Adrienne E. Marting

Nelson Mullins Riley & Scarborough

Ms. Marting’s practice focuses primarily on regulatory and litigation matters. She routinely represents...  |  Read More

Saravia. Alma
Alma L. Saravia


Ms. Saravia concentrates her practice in healthcare law. Her clients include physicians, nurses, chiropractors,...  |  Read More

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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