Introduction

Pathways 2026 Session 1: The Medical Staff Bylways – Essentials & Updates

In the first Pathways installment of 2026, we will cover the document that lays the foundation for all Medical Staff activities and functions – the Medical Staff Bylaws! This document generally addresses the way membership on the Medical Staff is organized (Medical Staff categories), governance structure (officers, voting rights, etc.), and fundamental Medical Staff operations (holding meetings, dues, etc.). During the session, faculty members will review common missteps in drafting and provide specific language recommendations.

Topics Covered

Do Medical Staff membership and clinical privileges go hand-in-hand? When should/can you grant one without the other?
Medical Staff categories that value engagement and active participation, while remaining inclusive (for example, addressing voting and leadership roles for outpatient/ambulatory only providers, as well as those who will only refer but not practice in affiliation with any of the hospital’s facilities);

Drafting Medical Staff categories to help with EMTALA compliance (e.g., on-call participation);

The difference between Medical Staff membership and other “Status” categories (and when to use each);

The “Administrative Staff” category – what is it and do you need one?

Should you have a separate Staff category for long-term locum tenens providers who have been granted temporary clinical privileges?

What your Bylaws should say about application fees, dues, and Medical Staff accounts;

Nomination, election, confirmation, and removal of Medical Staff leaders

– Nomination procedures

– Eligibility criteria for officers, department chairs, and other leaders

– Acknowledging Board confirmation

– Removal criteria and procedures

– Elections and removals within multi-campus and unified Medical Staff structures

– The importance of a catch-call for filling vacancies

Medical Staff officers: It seems like the Chief of Staff is assigned responsibility for virtually every Medical Staff activity. What do Vice-Presidents of the Medical Staff, Secretary/Treasurers, and Immediate Past Chief of Staff actually do? Do you need them as part of your leadership structure?

Medical Staff meetings:

– Should you set attendance requirements for Medical Staff members? For Medical Staff leaders? For certain committees? If the Chief of Staff is a member of all Medical Staff committees, does the Chief have to attend all meetings?

– Requiring presence and/or participation, instead of live attendance

– Action without meeting (including phone, written ballot, and electronic methods)

– Reasonable quorum requirements (for meetings and other action);

Medical Staff leadership structures for unified and multi-campus Medical Staffs;

The amendment process – including tips for amending the Bylaws at the time of unification, making amendments to system Bylaws (must there be unanimous agreement?), and tailoring and adopting template Bylaws;

The increasing value of footnotes, headings, and appendices in an era of increasing responsibility and decreasing support for Medical Staff leaders (how to include them in your Bylaws documents, without living to regret it).

Who Will Benefit?

The 2026 Pathways program can benefit all of the following:

Medical Staff officers
Bylaws Committee members
Credentials Committee members
Medical Executive Committee members
Medical Staff Services Professionals (MSSPs) and other hospital or CVO personnel who support the Medical Staff
Chief Medical Officers
In-house counsel
Governing Board members
Medical Staff members looking to get more involved in Medical Staff leadership

About HortySpringer Pathways

What is Pathways? It’s a training program for hospital and physician leaders who are looking to develop and enhance the skills they need to manage and oversee the hospital’s Medical Staff. Key features:

FOCUSED
Each Pathways Series is focused on a topic – or “theme” – that health system, hospital, and physician leaders have told us is essential and timely. Avoiding the sound bites and consultant-talk that permeate so many leadership training courses that are on the market, Pathways favors a deeper discussion of the topics at hand and take-home tips that can be implemented right away.

INCLUSIVE
Medical Staff leadership does not occur in a vacuum. While the “self-governance” of the Medical Staff is largely the purview of the organization’s practicing physicians, a multitude of individuals and bodies support and oversee Medical Staff activities: Board members, advanced practice clinicians, health system and hospital administrators, quality professionals, medical staff services professionals, HR professionals, executive recruiters, and more! Pathways web-based format allows organizations to finally make Medical Staff leadership training available to all of these individuals, fostering shared understanding and the implementation of aligned and unified policies, procedures, and leadership strategies across the organization.

ACCESSIBLE
Each Pathways webinar has been designed to require a minimal-to-moderate time commitment and to allow training to be completed from the comfort of your own home or workplace. With four 2-hour web-based training sessions spread over the course of several months, participation in the Pathways leadership program means not having to forego leadership development when time for training is limited or travel is difficult or impossible.

Webinar Disclaimer

The information presented during a webinar and any supplementary materials provided to registrants are intended for educational and informational purposes only. Nothing contained therein is to be considered as the rendering of legal advice for specific cases or circumstances.

No one should act or refrain from acting on the basis of any information presented during a webinar without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer practicing as permitted by applicable laws, regulations or rules of professional conduct. No attorney-client relationship is formed by registration for a webinar or the use of the supplementary materials.