Medical Staff vs. Governing Board Guidelines Q&A

Question:

Are there any requirements to have Governing Board Bylaws in addition to having Medical Staff Bylaws?  The question centers around the discussion of having provisions/criteria for a Governing Board Chairperson, Vice Chair, Secretary, appointment of the CEO, governing board responsibilities for approving medical staff privileges, etc.

I don’t think CMS specifically requires Governing Board Bylaws, although I am familiar with documents titled either hospital bylaws or governing board bylaws.

Answer:

There is no explicit requirement to have by-laws for the governing body, but TJC does have a requirement that the governing body “defines its responsibilities” as a governing body and puts that into writing.  There is also an expectation that you educate your board members.  

So, you would have to define their roles and responsibilities and you would have to put this in writing and train these new board members.  You will also want to check if there may be any unique state laws that define any additional requirements for incorporation, such as articles of incorporation and/or bylaws.