Medical staff bylaws address self-governance and accountability to the governing body.

(1)

The organized medical staff adopts and enforces bylaws to carry out its responsibilities. The bylaws are approved by the governing body and include the following: - Statement of the duties and privileges of each category of medical staff (for example, active, courtesy) - Description of the organization of the medical staff, including those members who are eligible to vote - Description of the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body - Criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges, including the process for reprivileging physicians and other licensed practitioners - Process for credentialing and recredentialing physicians and other licensed practitioners - List of all the officer positions for the medical staff - Process by which the organized medical staff selects and/or elects and removes the medical staff officers - Process for adopting and amending the medical staff bylaws, medical staff rules and regulations, and policies - The qualifications and roles and responsibilities of the department chair, when applicable Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Distant-site physicians and practitioners requesting privileges to provide telemedicine services under an agreement with the hospital are also subject to the requirements in 42 CFR 482.12(a)(8) and (a)(9), and 42 CFR 482.22(a)(3) and (a)(4).

(2)

The medical staff bylaws include the qualifications for appointment and reappointment to the medical staff. Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff is composed of doctors of medicine or osteopathy. In accordance with state law, including scope of practice laws, the medical staff may also include other categories of physicians, as listed at 42 CFR 482.12(c)(1), and other licensed practitioners who the governing body determines are eligible for appointment. Note 2: Gender, race, creed, and national origin are not used in making decisions regarding the granting or denying of medical staff membership. (See also MS.20.01.01, EP 1)

(3)

The medical staff bylaws include requirements for the following: - Medical history and physical examination for each patient as described in PC.11.02.01, EP 2 - Updated patient examinations as described in PC.11.02.01, EP 3 - Assessments in lieu of medical history and physical examinations for patients as described in PC.11.02.01, EP 4 Note: The medical history and physical examination are completed and documented by a physician (as defined in section 1861(r) of the Social Security Act), an oral and maxillofacial surgeon, or other qualified licensed practitioner in accordance with state law and hospital policy.

(4)

The medical staff bylaws, rules and regulations, and policies; the governing body bylaws; and the hospital policies are compatible with each other and are compliant with law and regulation.

(5)

The organized medical staff has the ability to adopt medical staff bylaws, rules and regulations, and policies, and amendments thereto, and to propose them directly to the governing body.

(6)

The medical staff bylaws include the following requirements regarding the medical executive committee: - The function, size, and composition, as determined by the organized medical staff and approved by the governing body - The authority delegated to the medical executive committee by the organized medical staff to act on the medical staff’s behalf and how such authority is delegated or removed (for more information on the role of the medical executive committee, refer to Standard MS.14.02.01) - The process, as determined by the organized medical staff and approved by the governing body, for selecting and/or electing and removing the medical executive committee members Note: The medical executive committee includes physicians and may include other licensed practitioners.

(7)

The medical staff bylaws include the following requirements regarding the suspension or termination of a physician’s or other licensed practitioner’s medical staff membership or privileges: - Indications and process for automatic suspension of a physician's or other licensed practitioner’s medical staff membership or clinical privileges - Indications and process for summary suspension of a physician's or other licensed practitioner’s medical staff membership or clinical privileges - Indications and process for recommending termination or suspension of medical staff membership, and/or termination, suspension, or reduction of clinical privileges

(8)

The medical staff bylaws include requirements for the composition of the fair hearing committee.