September 2021 Grand Rounds – Medical Staff Bylaws: Your Best Friend or Worst Enemy?

September 7, 2021 - 1:00 pm to 2:00 pm (ET)

We have a confession to make. We love medical staff bylaws! We love reading them, we love revising them, and we love totally rewriting medical staff bylaws.

This may seem a little odd but think about the world that we live in. Every day, we are advising our clients on how to deal with difficult applicants, addressing potentially impaired physicians, and tackling situations involving practitioners who engage in behavior that undermines a culture of safety. So, our fondness for bylaws makes perfect sense.

In the work that we do, we find that bylaws can be your best friend or your worst enemy. Your bylaws can be your best friend if they comply with the law, anticipate problem situations and provide guidance, and incorporate best practices. Your bylaws will be your worst enemy if they are convoluted and confusing, internally inconsistent, and do not reflect the practice that you follow.

Make friends, not foes. Join faculty Susan Lapenta and Mary Paterni as we provide you with tips and tools on how to make “best friend bylaws” that will work for you when you need them the most.

Learning Objectives

  • Discuss the benefits of breaking medical staff bylaws into component parts
  • Develop language pertaining to threshold eligibility criteria for appointment, reappointment, and clinical privileges
  • Discuss the importance of incorporating language into bylaws documents pertaining to initial collegial efforts and other progressive steps
  • Develop language to allow actions taken at one hospital in the system to be administratively implemented at other hospitals in the system.

Reading Resources

  • The Joint Commission Standard MS.01.01.01 pertaining to what must be included in Medical Staff Bylaws
  • State Operations Manual Interpretive Guidelines

Education Credit

Instructions on how to obtain your Continuing Education certificate for audio conferences will be e-mailed to the contact person for your organization at the conclusion of this audio conference.

Category 1 CME

Joint Provider Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Pittsburgh School of Medicine and HortySpringer Seminars.  The University of Pittsburgh is an affirmative action, equal opportunity institution.  The University of Pittsburgh School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

The University of Pittsburgh School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

CEUs Credit

Other health care professionals are awarded 0.1 continuing education units (CEUs), which is equal to 1 contact hour.

NAMSS Continuing Education Credit

This course has been approved for National Association of Medical Staff Services (NAMSS) continuing education credit and NAMSS hereby awards 1.0 NAMSS continuing education credits for participation in this activity.  Accreditation of this educational content in no way implies endorsement or sponsorship by NAMSS.

HortySpringer Audio Conference Disclaimer

The information presented during an audio conference 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 an audio conference 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 an audio conference or the use of the supplementary materials.

About Grand Rounds

The Grand Rounds 2021 Audio Conference Series consists of twelve audio conferences spread over the course of the year, with the goal of providing focused, manageable bites of education for Medical Staff leaders and those who support them.

  • Registration includes an MP3 containing the audio conference at no additional charge following each conference.
  • CME credit issued for live conference participation.
  • Register for the full series of 12 monthly audio conferences. More information on how to register will be provided shortly.

* Registration fee includes up to three phone lines; you may add two additional lines to your order for $50 each line (per audio conference).

Designed for even the busiest hospital and medical staff leaders, registration for the year-long series is a quick and inexpensive way for Medical Staff Officers, members of the Medical Executive Committee, Department Chairs, Chairs of the Credentials and Peer Review Committees, and the Chairs of other key Medical Staff committees to have access to the most up-to-date health care information at their fingertips while obtaining valuable CME credits as well.


PLEASE NOTE: To help your staff and medical professionals adhere to social distancing guidelines, we will waive the extra line fee for up to 3 additional lines so others in your organization are able to safely listen from their home or office.

Audio Conferences/Grand Rounds Registration: $250 and includes:

      • 1 AMA PRA Category 1 Credit*
      • 1.0 NAMSS continuing education credit*
      • One MP3 recording to share with your staff throughout the year
      • Three phones lines. You may purchase additional lines for $50/line, per audio conference.

Can’t make the live audio conference? No problem! We offer single MP3 recordings for $250/audio conference.

*Not all audio conferences will be approved for continuing medical education credits.

Register Online