Medical Staff Bylaws: Meeting New Medicare Conditions of Participation and Joint Commission Requirements

Complying With CMS Changes and Updating Hospital Governance Documents

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

Conducted on Thursday, September 11, 2014

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 and hospitals on ensuring medical staff bylaws comply with Joint Commission standards, Centers for Medicare and Medicaid Services (CMS) conditions of participation, and federal and state law. The panel will also review the impact of healthcare reform on medical staff governance.


Medical staff bylaws map out how a healthcare organization will provide quality patient care. Counsel to healthcare providers must ensure that bylaws address areas emphasized by the Joint Commission, including emergency management oversight, privileging, credentialing, appointment, adverse actions, medical executive committee, and documentation.

Moreover, the CMS recently released two final rules modifying the Medicare Conditions of Participation. The CMS provided clarification for hospitals within a multi-hospital system and regarding who may be a member of a medical staff.

Counsel must thoroughly review their healthcare provider clients' bylaws, rules and regulations, and make necessary revisions to ensure compliance with Joint Commission requirements as well as the CMS' final rules.

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. The panel will also examine the impact of healthcare reform on medical staff governance.



  1. Introduction
    1. Recent regulatory and accreditation changes that affect medical staff bylaws, rules and regulations, and policies
  2. Overview of changes
    1. The Joint Commission
    2. CMS
  3. Recommended changes to bylaws, rules and regs, and policies
    1. MS.01.01.01 changes—advanced tips beyond just the basics people have heard before
    2. Telemedicine
    3. Effect on expiration of covering provider authenticating verbal order grace period
    4. Including NPs and PAs in bylaws and bylaw process
  4. Recent experiences with enforcement
    1. MS.01.01.01
    2. Anticipation on enforcement of authenticating verbal order if grace period expires
    3. Telemedicine


The panel will review these and other key questions:

  • What processes, roles and responsibilities must be included in medical staff bylaws?
  • What potential pitfalls could be encountered in amending and approving revised bylaws—and what strategies can hospitals employ to overcome them?
  • What impact have the revised Conditions of Participation had on medical staff bylaws?


Barton, Richard D.
Richard D. Barton

Procopio Cory Hargreaves & Savitch

Mr. Barton has represented health care providers and health systems for over 30 years. As trial counsel, he has tried...  |  Read More

Scott C. Gardner
Scott C. Gardner

Buerger Moseley & Carson

Mr. Gardner’s practice focuses on healthcare law and the representation of hospital corporations.  His...  |  Read More

Alma L. Saravia
Alma L. Saravia


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

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