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Hospital Medical Staff Issues
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Applicable Laws, Rules and Policies

Indiana Code

Hospitals: Hospital Licensure
The Indiana Code includes provisions on the licensure of hospitals.

  • IC 16-21-2-5 defines the responsibilities of the hospital governing board.
  • IC 16-21-2-7 defines the responsibilities of the hospital medical staff.

County Hospitals: Powers of Hospital Governing Boards
The Indiana Code includes provisions on the powers of county hospital governing boards.

  • IC 16-22-3-1 defines the board's authority and responsibilities and the responsibilities of the hospital medical staff.
  • IC 16-22-3-9 discusses the hospital medical staff eligibility, appointment and termination and medical staff bylaws creation and approval.

Governing Board
IC § 16-18-2-149 defines "Governing Board" as the board of trustees, governing board, board of directors, or other body responsible for governing a hospital.

Indiana Administrative Code

The Indiana Administrative Code includes rules on hospital medical staff bylaws and hospital governing boards.

  • 410 IAC 15-1.4-1 defines the responsibilities of the hospital governing board.
  • 410 IAC 15-1.5-5 defines the responsibilities of the hospital medical staff, the procedures for adopting hospital medical staff bylaws, and the provisions they must include.

American Medical Association

The American Medical Association released the fourth edition of its Physician’s Guide to Medical Staff Organization Bylaws in 2009.  The guide requires AMA members (requires user name and password).  In the alternative, call the AMA Press at (800) 621-8335. 

The AMA also has other resources available on its Web site>>

The Joint Commission

Many hospitals are accredited by the Joint Commission. The Joint Commission addresses medical staff bylaws in several ways.

Medical Staff Standard MS.2.1 defines the process for adoption and amendment of medical staff bylaws. The Joint Commission does not publish their standards on the Web site; however, they are available for purchase online or by phone at (877) 223-6866.

The Joint Commission publishes a book entitled, The Medical Staff Handbook: A Guide to Joint Commission Standards (ISBN 0-86688-536-6). The guide is available for purchase online or by phone at (877) 223-6866.

Process for Filing a Complaint

The Joint Commission

Physicians may report hospital medical staff by-laws disputes to the Joint Commission Complaint Hotline by telephone, mailed letter, e-mail or facsimile. The Joint Commission requests that written complaints be two pages in length and include the name, street address, city and state of the accredited healthcare organization. Complaints may be reported anonymously.

Contact the Complaint Hotline at (800) 994-6610. The Joint Commission representative will provide you with a case number that you can use to track the status of the complaint (i.e., open or closed).

Postal Mail
Mail your complaint to the following address:

Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181



Fax your complaint to the Office of Quality Monitoring at (630) 792-5636.

Complaint Investigation and Resolution
After you file the complaint, you can call in and use your case number to find out the status of the complaint.

Once the Joint Commission receives a complaint, it will require the facility to respond. If the Joint Commission finds violations, it will work to resolve them and help the facility get back into compliance with the Joint Commission standards.

The Joint Commission will record the noncompliance on the facility's record. Persons can request the number and category of complaints an organization has had by contacting the Joint Commission at (800) 994-6610.

Further, if an on-site review results in a change of accreditation status or additional recommendations for improvement, the changes will be reflected in the organization's performance report, which is available online or by calling Customer Service at (630) 792-5800.

AMA-Organized Medical Staff Section (OMSS)

A physician who wishes to report a medical staff by-laws violation should submit a letter to the AMA-OMSS at the following address:

Attn: James DeNuccio
515 N. State St.
Chicago, IL 60610

The letter should ask for input or an investigation. It should describe the issue, include any relevant documents, and address what level of involvement the state medical association has had. The letter should also copy the state medical association.

Complaint Investigation and Resolution
Once it receives a complaint letter, the AMA-OMSS will contact the state association immediately to see what its involvement has been and what input it has. If the medical staff has not contacted the state medical association, the AMA representative will advise them that they must request assistance from the state medical association initially. The manner in which the AMA-OMSS handles a situation will vary widely based on the priority (e.g., low, high, or urgent) of the complaint. For instance, it might send a representative to the location, send the issue to the AMA Litigation Center, or send the facility a letter from the AMA.

Get more information on this procedure>>

Questions may be directed to Mr. DeNuccio at (312) 464-4757.


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