adopted , amended , or repealed , in whole or in part and such changes shall be effective when approved by the Board . Policies and procedures will become effective upon approval of by the Board .
9.3.3 In addition to the process described above , the organized Medical Staff itself may recommend directly to the Board an amendment ( s ) to any Rule and Regulation , or policy by submitting a petition signed by ten percent ( 10 %) of the members of the Active category . Upon presentation of such petition , the adoption process outlined in 9.2.1 above will be followed .
9.3.4 Urgent Amendments . Notwithstanding the foregoing , if there is an urgent need to amend the Medical Staff Bylaws , Rules 2 and Regulations or polices to comply with law or regulation , the MEC may adopt the necessary amendment provisionally and submit to the Board for provisional approval , without prior notification of the Medical Staff . Immediately following the MEC ’ s adoption and the Board ’ s provisional approval of such urgent provisional amendment , the MEC will notify the Medial Staff and offer the opportunity for any Medical Staff member to submit written comments to the MEC within 30 days of the notice . The amendment will become effective at the end of the comment period if there is no substantial conflict regarding the provisional amendment ( there is no substantial conflict unless at least 10 % of the voting members of the Medical Staff express opposition to the amendment in writing ). If the comments indicate a substantial conflict over the provisional amendment , the MEC shall implement the Conflict Management process as set forth in Section 8.1 of these Bylaws and , if necessary , may submit a revised amendment to the Board for approval .
9.3.5 The MEC may adopt such amendments to these Bylaws , Rules and 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 .
9.4 Unified Medical Staff Provisions 9.4.1 Bylaws , Policies , and Rules and Regulations of the Unified Medical Staff :
Upon approval of a unified Medical Staff structure , the unified Medical Staff will adopt Medical Staff Bylaws , policies , and rules and regulations that :
9.4.1.1 take into account the unique circumstances of each participating hospital , including any significant differences in the patient populations that are served and the clinical services that are offered ;
2
The Joint Commission Standard , MS . 01.01.01 . Element of Performance 11 , allows for the urgent amendment of “ rules and regulations .” This standard does not expressly allow for the urgent amendment of Medical Staff Bylaws . Some Medical Staffs still include a reference to the urgent amendment of Bylaws , but that is technically outside of the standard .
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