For approving medical staff privileges for a Governing Board Chairperson, Vice Chair, Secretary, appointment of the CEO, etc. are there defined medical governing board responsibilities?
How Do Medical Staff and Governing Board Responsibilities Differ?
I don’t think CMS specifically requires Governing Board Bylaws, although I am familiar with documents that are titled either hospital bylaws or governing board bylaws.
Medical Governing Board Responsibilities
There is no explicit governing board requirement for specific by-laws, 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.
Patton Healthcare Consulting
Patton Healthcare Consulting provides a complete range of Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.
We serve more than 200 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.
Leave a Reply