Medical Staff Governing Documents: Bylaws, Policies, & Procedures

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Medical Staff Governing Documents: Bylaws, Policies, & Procedures

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Available December 2017

Medical Staff Governing Documents: Bylaws, Policies, & Procedures

Available December 2017

Todd Sagin, MD, JD 

Policies and procedures and bylaws fall under the umbrella of governing documents, which the medical staff is not only responsible for creating but revising, following, and enforcing. It is imperative for bylaws and policies and procedures to align; conflicting documents open the organization up to lawsuits and can create a negative medical staff culture if physicians don’t know what guidelines to follow.

Medical Staff Governing Documents: Bylaws, Policies, & Procedures will help medical staff leaders and MSPs develop clear and thorough policies and procedures and bylaws for their organizations that comply with accreditors’ requirements and promote industry best practices. This comprehensive resource guides readers through creating both types of governing documents and understanding the connections between related bylaws and policies.

Author Todd Sagin, MD, JD, explains why each policy/bylaw is important to include, provides guidance on implementing it, and addresses potential issues that medical staffs need to think about when creating their governing documents. This book also provides sample documents that organizations can download and customize to suit their needs.

This book will help MSPs and physician leaders:

  • Understand the relationship between bylaws and their corresponding policies and procedures
  • Quickly develop various policies and procedures unique to the medical staff
  • Update existing policies and bylaws with new, compliant language
  • Replace time-consuming, arduous searches for information with a simple download of the forms they need
  • Sharpen their focus on both the legal issues of the organization and the needs of the medical staff


This updated edition includes five new policies and updated language reflecting the latest regulatory changes and best practices.


About the author:

Todd Sagin, MD, JD, is a physician executive recognized across the nation for his work with hospital boards, medical staffs, and physician organizations. He is the national medical director of Sagin Healthcare Consulting, LLC, and HG Healthcare Consultants, LLC, which provide guidance on a wide range of healthcare issues. He served for more than half a decade as the vice president and national medical director of The Greeley Company, Inc. Sagin is a practicing family physician and geriatrician who has held executive positions in academic and community hospitals and in organized medicine. He frequently lectures and facilitates retreats on medical staff affairs, physician leadership skills, relationships between hospitals and doctors, strategic healthcare planning, governance, and related topics.


Page count:400
Dimensions: 8.5” X 11”
ISBN:978-1-68308-665-9


Table of Contents

  • What Is the Difference Between Bylaws and Policies?
  • Bylaws:
    • Addressing the Preliminaries
    • Medical Staff Governance and Organization 
    • Member Rights, Corrective Action, and Fair Hearings
    • Credentialing and Privileging Procedures
    • Allied Health Professionals
    • Medical Staff Operational Issues
  • Policies and Procedures:
    • Administration
    • Credentialing and Privileging
    • Governance
    • Quality