Medical Staff Services Information
Guidelines for Organized Medical Staffs

Welcome to Medical Staff Services Information Center!

Your Medical Staff's source of guidelines for organization and governance.

Medical Staff Rights, Responsibilities & Relationships:

  • The overiding basis of the relationship between the governing body and the medical staff is cooperation with accountability to each other in maintaining and improving patient quality medical care.
  • The medical staff is a legally distinct and separate, but not wholly independent, unincorporated association of medical professionals with inherent rights, authority and responsibilities.
  • It has the right to organize and act in its own name.
  • It has the right to write bylaws, elect officers, elect or appoint department chairs, committees, etc., credential members, specify sanction/appeal processes, establish standards of care, etc..
  • It has the right to its own legal counsel and the right to institute legal proceedings including suits.
  • The medical staff has a primary responsibility to the patient - not to the hospital - and must act to protect the patient if governing body/administration actions endanger patient care or safety.
  • The medical staff is made up of physicians who are required to have integrity and professionalism with the responsibility and authority to take care of fellow humans.
  • The hospital enabling statutes under Commonwealth (Pa.) law are the basis of the creation of the medical staff and a governing body, but neither is required to be derived from the other.
  • The governing body does not delegate to the hospital medical staff its functions under medical staff bylaws, but the governing body reviews medical staff bylaws to assure that they are legally proper and reasonable, and the medical staff is conducting itself in a fair and unbiased manner.  The governing body may not unreasonably withold or delay approval of the medical staff bylaws if the foregoing conditions are met.
  • The medical staff bylaws should assure that the medical staff is able to perform in a smooth expedient manner the discharge of its responsibilities and fulfill its mission of service to patients and the community.
  • Medical staff bylaws are considered an integral part of a contract with bidirectional accountability between the governing body and the medical staff - neither party can unilaterally usurp rights and obligations of the other party, such as unilateral amendment of each other's bylaws.
  • Neither the governing body nor the medical staff are constrained to take actions in behalf of the other's interest.

GUEST EDITORIAL by John Malcolm, Jr. MD*

In our travels around Pennsylvania helping medical staffs with updating their bylaws, we've regularly pointed out that the Commonwealth's regulations governing hospitals, hospital governing bodies and medical staffs are predicated on an expected cooperative relationship between all parties. As an example the medical staff is assigned primary responsibility by regulation for evaluation and assurance of quality patient care (107.1, 107.26(b)(4), 107.51, 107.52).  In addition, the governing body is required to delegate to the medical staff the authority to carry out certain responsibilities assigned by these regulations to the medical staff (103.4(9)).  Further, the governing body is required to provide administrative support to the medical staff to aid its carrying out the assigned responsibilities (103.4(13)).  The role of the governing body to the medical staff is one of oversight to assure that the medical staff is meeting its responsibilities in an efficient, effective, appropriate and fair manner.  Should the medical staff fail to meet their assigned responsibilities, the governing body is required to step in.  For example, in practice, if the governing body has a concern over a quality of care issue, it would alert the medical staff of their concerns with the expectation that the medical staff would promptly address the issue.  Should the medical staff fail to act, fail to act appropriately or the governing body does not agree with the medical staff's action(s) - then the governing body can take further action to remediate their concerns.  The process for further action by the governing board is spelled out in the regulations and is again based on cooperative actions by both the medical staff and the governing body such as an initial review by a joint conference committee composed of equal numbers of members from the medical staff and governing body.

Again, as noted in the adjacent column the first and overiding priority is a cooperative relationship between the hospital's medical staff and governing body.  It is also with some concern that we have noted that most medical staffs we have met with are only vaguely aware of, or unaware of the content of the Commwealth's regulations governing hospitals, their governing body/administration and their medical staffs.  We would urge medical staff's leadership to familiarize themselves with these regulations as they review and update their bylaws.

* Dr. Malcolm is a past chair of the Pennsylvania Medical Society's Organized Medical Staff Section.

Additional informational references on this topic:

Commonwealth of Pennsyvania Codes - Title 28, Part IV, Subpart B, Chapters 101, 103, 107.

"Guidelines for an Effective Medical Staff", 4th Edition, Pennsylvania Medical Society

"Physician's Guide to Medical Staff Organization Bylaws", 5th Edition, American Medical Association 

"The Medical Staff Handbook", 3rd Edition, The Joint Commission