We assist in the preparation of medical staff documents. Typical documents include medical staff bylaws, rules and regulations, manuals and policies.

Services typically begin with discussions with leaders to determine consensus. Since these are medical staff documents, we spend considerable time with medical staff leadership to determine the structures and processes they prefer. We also consult with hospital administration officials during our work, since the board must ultimately approve many final documents.

Education precedes drafting where it appears necessary to familiarize leadership with available options.

Drafting, consensus development and redrafting results in a final product.

Our document work proceeds from several core ideas:

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• Medical staff documents must comply with all requirements of the Joint Commission on Accreditation of Healthcare Organizations (or other accrediting body), including frequent, complex changes on a monthly basis.

• Documents should maximize peer review immunity protection under state and federal law.

• Documents should be simple, easy to read and easy to understand.

• Physicians must play key roles in document development, in cooperation with administration.




To see examples of how we have handled these core ideas occur in practice, click here.