Medical Staff Bylaws Update

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Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional Information

Provided by MHA Health Institute
Health Institute

Date & Time

Thursday, Aug. 3, 2017
9 - 10:30 a.m.


Register on or before Friday, July 28, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Additional phone line connections each will be charged a registration fee. Multiple participants on the same connection is encouraged. Get more value by inviting colleagues to join you!

This webinar is being offered at a reduced registration fee to MHA-member hospitals because of a contribution from MHA Management Services Corporation.


CEOs, COOs, CMOs, medical staff leaders, medical staff office personnel, hospital leadership, governing body representatives, The Joint Commission coordinators, performance improvement directors, safety officers, risk managers and compliance personnel.

The following program content was provided by the speaker.


This webinar will discuss the latest medical staff bylaws update from the Centers for Medicare & Medicaid Services and The Joint Commission and whether separate medical staff for multiple hospitals is required. This webinar also will review the many CMS and TJC requirements for medical staff bylaws, rules and regulations, including policy differences and requirements. In addition, the challenging medical staff standards, requirements for physician extenders and the role of scribes, will be discussed.


  • discuss the responsibility of medical staff to be organized into a self-governing staff who oversees the quality of care provided by all practitioners
  • identify what is new in the standards
  • explain the differences between bylaws, rules and regulations, and policies
  • explain what is meant by accompanying detail associated with Elements of Performance 12-36 and where they can be placed
  • identify the standards that continue to be challenging for medical staff


Sandra M. McRae, BSN, MPH, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sandra McRae has experience in all levels of health care. She served as consultant and faculty for The Joint Commission from 1989 to 2004. In addition to being president of her own company, McRae brings outstanding experience as a nurse executive, administrator, risk manager, and patient safety and performance improvement expert to her role as a consultant. She is the clinical/TJC consultant for the Florida Hospital Association.

McRae assisted in the development of the Veterans' Administration National Center for Patient Education. In 2009-2010, she developed the Veterans' Administration National template for medical staff bylaws. She consults with multiple VA facilities and programs.

McRae taught a wide range of programs for TJC Department of Education and was consistently rated the highest of all faculty. She was one of only three people selected by TJC to do the nationwide education on the new 2004 standards and survey process. She spent a month in the Kingdom of Saudi Arabia teaching continuous quality improvement. McRae also has gone to Egypt and Ireland to help both countries begin the development of standards and an accreditation process. She has published Patient Care Trainee-Educational Employment, and her research has included a grant from Abbott Laboratories and work with the University of Florida in Perceptions of Education.