We realize that there has been an incredible amount of discussion regarding where to put the Medical Staff’s Rules & Regulations. Historically, Medical Staffs have had the Rules & Regulations as a separate document from the Bylaws. The only issue has been whether the Rules & Regulations are approved by vote of the entire Medical Staff or whether they are approved by vote of only the Medical Executive Committee (as a delegation of authority by the Medical Staff) (both subject to governing body approval).

We have confirmed with The Joint Commission that the Rules & Regulations can continue to be a separate document i.e., they do NOT need to be incorporated into the Medical Staff Bylaws. Approval of the Rules & Regulations can occur in one of two ways:

  1. By the entire Medical Staff (with approval of the governing body).
  2. By the Medical Executive Committee (if the authority is delegated to it by the Medical Staff) with approval of the governing body. This delegation is consistent with MS.01.01.01 EP 9.

This approval process applies not only to Rules & Regulations, but also, to all other items listed as requirements for inclusion in the Medical Staff Bylaws.

Whether the second option will be revised in the future depends, of course, upon the final work of the current Joint Commission Bylaws Task Force. However, keep in mind that a change in the Joint Commission’s position may not necessarily require a rewriting of any documents; rather, it may only require a change as to who must vote to approve the document(s) i.e., the Medical Staff rather than the Medical Executive Committee.