SAMPLE BYLAWS LANGUAGE
Amending the bylaws: Review, revision, adoption, and amendment
The medical staff shall be responsible for formulating, reviewing (at least biennially), and recommending any medical staff bylaws, rules, regulations, policies, procedures, and amendments to the board as needed. These bylaws, rules, regulations, policies, procedures, and amendments shall be effective when approved by the board. The medical staff can exercise this responsibility through its elected and appointed leaders or through direct vote of its membership.
Methods of adoption and amendment to bylaws
Proposed amendments to bylaws may be originated by the MEC or by a petition signed by [X%] of the members of the active category. Each active member of the medical staff will be eligible to vote on the proposed amendment via a printed or secure electronic ballot in a manner determined by the MEC. All active members of the medical staff shall receive at least [X] days advance notice of the proposed changes. The following is to be adopted:
- [Option 1: The medical staff receives a simple majority (50% plus one), 66% (twothirds), or 75% (threefourths) vote cast by those active members eligible to vote on adoption and amendment.]
- [Option 2: The medical staff receives an affirmative vote by a simple majority, 66%, or 75% of those members eligible to vote. An affirmative vote will be counted by returning the ballot marked “yes,” or by not returning the ballot.]
- [Option 3: The medical staff receives a return ballot marked “no” by 25%, 34%, or 50% of those members eligible to vote.]
Amendments so adopted shall be effective when approved by the board.
Methods of adoption and amendment to any medical staff rules, regulations, and policies
The medical staff may adopt additional rules, regulations, and policies as necessary to carry out its functions and meet its responsibilities under these bylaws. A rules and regulations manual and a policies manual may be used to organize these additional documents. The organized medical staff may delegate this responsibility to the MEC.
Proposed amendments to the rules and regulations manual, and policies manual may be originated by the MEC. The MEC will communicate the proposed amendment to the organized medical staff prior to a vote.
The MEC shall vote on the proposed language changes at a regular meeting, or at a special meeting called for such purpose. Following an affirmative vote by the MEC, any of these documents may be adopted, amended, or repealed, in whole or in part, and such changes shall be effective when approved by the board.
In addition to the process described in [section on amendment process], the organized medical staff may recommend amendments to any rules, regulations, or policies directly to the board by submitting a petition signed by [X%] of the members of the active category. On presentation of such petition, the adoption process outlined in [section on amendment process] will be followed.
The MEC may adopt such amendments to these bylaws, rules, regulations, and policies that are, in the committee’s judgment, technical or legal modifications or clarifications. Such modifications may include reorganization or renumbering, punctuation, spelling, or other errors of grammar or expression. Such amendments need not be approved by the entire board but must be approved by the hospital CEO. Neither the organized medical staff nor the board may unilaterally amend the medical staff bylaws or rules and regulations.
If the organized medical staff does not delegate the responsibility of adopting and amending medical staff rules or regulations, The Joint Commission allows that the MEC can enact rules and regulations that are necessary for legal or regulatory compliance after receiving approval by the board (MS.01.01.01 EP 11).
The MEC and the board may adopt such provisional amendments to these rules and regulations that they deem necessary for legal or regulatory compliance. After adoption, the MEC will communicate these provisional amendments to the rules and regulations to the organized medical staff for its review.
If the medical staff approves of the provisional amendment, the amendment will stand.
If the medical staff does not approve of the provisional amendment, this will be resolved using the conflict resolution mechanism noted in Section [X]. If a substitute amendment is then proposed, it will follow the usual approval process.