Are Your Medical Staff Bylaws in Compliance?

The Joint Commission, which accredits all but one of the privately accredited hospitals in North Carolina, has developed new requirements for hospital medical staffs. These changes, known as MS .01.01.01, take effect March 31, 2011 and will require bylaws amendments in nearly all accredited hospitals.

The NCMS has developed the Revised Model Medical Staff Bylaws for NCMS members, which is available at

The revised version includes changes made by the NCMS Physician Hospital Issues Committee to address MS.01.01.01, as well as new or revised NCMS House of Delegates policy and AMA policy. In addition, the revised version covers DNV (Det Norske Veritas Healthcare) standards, for those hospitals that are accredited by that organization.

“This document is a valuable resource for our members as we strive to ensure that physicians have a viable  voice in medical staff governance in hospitals,” said William M. Johnstone, Jr., MD, JD, Chair of the NCMS Physician Hospital Issues Committee. “I urge members to review the Revised Model Medical Staff Bylaws to ensure that their local bylaws are in compliance with the Joint Commission standard.”

If you have questions or need more information, please contact Melanie Phelps at [email protected] or call 800-722-1350.


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