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Medical Staff Bylaws Impact on Staff Structure and Credentialing Committees

Medical Staff Bylaws Impact on Staff Structure and Credentialing Committees

July 7th, 2021
July 7th, 2021

Every hospital is governed by medical staff bylaws specific to their organization. These bylaws dictate a variety of things, like how a medical staff structure is organized and categorized and how credentialing committees function. Read on for a deeper understanding of how it all works.


How do medical staff bylaws impact credentialing and privileging?

Medical staff bylaws exist to guide organizations in their journey of providing quality patient care. Bylaws are required by every regulatory agency—like the CMS—and they outline how a medical staff organization is run. Hospitals abide by these laws because it’s how they get access to government funding and receive reimbursement for treating Medicare/Medicaid patients. Bylaws also help hospitals keep up with individual state regulations which is important because these regulations can impact the issuing of medical licenses and malpractice coverage.


Membership and privileges

Providers need to meet certain requirements stated in the medical staff bylaws to be granted certain privileges. When a provider is on staff they can have membership, membership and privileges, or just privileges. Physicians have membership in a medical staff when they are appointed by a governing body, and to receive said membership they have to meet certain requirements listed in the bylaws, like having a current license or being board-certified.

Providers with membership can fall into various categories. Medical staff categories are dictated by medical staff bylaws and determine what voting rights each member has in medical staff meetings and credentialing committees. Categories vary by organization and are defined by the number and type of patients a provider sees within a certain amount of time. Some categories include:


  • Active
  • Consulting
  • Courtesy
  • Honorary
  • Associate
  • Refer and Follow

Medical staff structures: Small medical groups to large health systems

Hospital bylaws also determine medical staff and leadership structures, which impact credentialing committees and processes.

In a small, rural hospital setting with only a few beds, the structure is very simple. Usually they have one department, the Medical Staff Department, which is made up of all providers, with perhaps one chief of staff or chief medical officer.

A slightly larger hospital setting may have two departments, medicine and surgery. Providers will be divided into two departments and each department will have a leader. These leaders will be overseen by a Chief of Staff.

In an even larger setting, there may be a department for medicine and another for surgery, and within those large departments there may be separate sections with certain specialties. Each individual department will likely have a leader and these leaders will be overseen by a Chief of Staff.

The larger the hospital setting, the more complicated it’s structure can be. The organizational structure and how it impacts credentialing and privileging will be defined in the hospital bylaws.


Roles of Medical Staff

Within each structure, each member of the medical staff will have set roles and responsibilities. Medical staff bylaws outline those roles and responsibilities. They may look as follows:


  • Department Members
    • Physicians who have been granted membership to see patients at the hospital.
    • Every physician is assigned to one department according to their training and granted privileges.
  • Department/Section Chairs
    • Leaders who are typically elected by the physicians assigned to their respective departments.
    • Oversee what the members of the department/section do and typically recommend what procedures are performed at the hospital.
    • May also work with the quality department or medical staff office to decide what procedures are on track with ongoing professional evaluations and be tasked with reviewing provider applications before the credentials committee review.
  • Credentialing Committee Members
    • Physicians within the hospital who are tasked with reviewing and making recommendations about initial and reappointment applications. Combine department chair recommendations with their own and take it up the chain of command.
    • Members of this committee may be elected or be assigned by the Chief of Staff or hospital CEO.
      • Note: Smaller hospitals may not even have a credentials committee since TJC doesn’t specifically require a credentials committee.
  • Medical Executive Committee
    • Traditionally made up of all the department heads and credentialing committee chairs.
    • Reviews suggestions brought up by the credentials committee and make their own recommendations and decisions regarding patient care issues.
  • Chief Medical Officer/Chief of Staff
    • Acts as a liaison between the medical staff, the governing body, and the hospital staff and involved with a variety of initiatives throughout the hospital.
  • The Governing Body
    • Final decision-maker for the entire organization.
    • All committee recommendations and suggestions are reviewed by the governing body, and the final decision on whether a provider can see a patient or not is up to them.

Medical staff bylaws and credentialing

This is but a sampling of what medical staff bylaws dictate per hospital setting. As you can well imagine, all of these criteria have an impact on how an organization privileges and credentials their providers. Not only does granting privileges require each application to go through the committee structure, but any revisions or changes too. And as we know, timing is everything in the medical services field. Privileging a physician can take months, and if there isn’t a proper system in place to facilitate the process, it could take even longer.

CredentialStream® was created to ensure your organization can meet all medical staff bylaw requirements, from initial applications through final approval. If you're ready for improved workflows and reporting for critical tasks like initial credentialing and recredentialing and privileging, then it may be time to take a look at CredentialStream. Sign up for a demo today!

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