In this presentation:

* Medical Staff Bylaws are the primary governance document for the Medical Staff

* Bylaws must contain key provisions in order to comply with:

- Medicare Conditions of Participation

- Accreditation Standards

- New York State Laws

* Health Care Quality Improvement Act

* Bylaws are viewed as a “standard of care” by the courts

- Must “substantially comply” with the Bylaws in credentialing and peer review actions and fair hearings.

- A breach of the Bylaws could be viewed as a breach of contract.

- Following the Bylaws is important in order to avoid or limit liability exposure under Doctrines of Corporate Negligence and Respondeat Superior (employer/employee).

* Bylaw amendments must follow a very deliberate process and cannot be unilaterally revised by either the Medical Staff or the Board of Directors.