DMC Bylaws Review - Hala Al Masoud

Dammam Medical Complex
Medical Staff Bylaws Revision Report
This report was done upon the request of Dr. Hamed Al Omarn, Assistant to CEO of DMC for Medical Services, to
review the current Medical Staff Bylaws and provide a sample of much suitable bylaws.
Due to the importance of medical staff bylaws every hospital and its medical staff are
required to assure they are suitable, accurate, and in compliance with applicable requirements.
Medical staff bylaws must be:
1. Reflecting the structures and processes used by the medical staff of that
2. Including best practices for medical staff functioning and structure
3. Well-organized into a user-friendly and flexible set of documents
4. Anticipating and adequately addressing potential future conflicts
5. Complying with regulatory standards
Medical Staff Bylaws: Outside Facilities
Prior to reading and/or reviewing the medical staff bylaws published by Dammam
Medical Complex, I managed to review several bylaws from different outside facilities; both
international and national. A total of 10 health facilities’ bylaws were reviewed. Three of those
were chosen based on the complexity of specialties and similarities to our facility.
The chosen hospitals are:
1. El Camino Hospital, California, US
2. The Johns Hopkins Hospital, Baltimore, US
3. King Khalid University Hospital, Riyadh, KSA
Their medical bylaws are well organized, written in a very clear way, subjects and issues
stated are vital processes and procedures, and up-to-date.
Medical Staff Bylaws: Current Situation
Afterward, I read the current medical staff bylaws published by DMC. I noticed several
issues that require modification and correction. These issues include but not limited to the
One of the major issues that causes problems whenever someone is looking for a certain
subject, that it doesn’t contain a table of contents. Also, it was noticed that it was
randomly written. It is totally unorganized. For example, some issues are not listed in
proper numerical order; or proper grouping to chapter or articles.
A second major issue is that it contains spelling mistakes which can lead to
misinterpretation of the bylaws.
Third, it is undated. Latest update was not even documented, which places a gap
between the hospital and the national and international standards.
Fourth, it neglects so many major subjects and processes that DMC needs such as
committees illustration, medical boards and so on.
Finally, there are other minor faults that need to be revised such as the placing of so many
job descriptions, and non-dated signatures.
Based on the above review of DMC bylaws and outside facilities’, I recommend the
Form a committee to select bylaws subjects and topics, set bylaws document
organization, review the first draft of the new bylaws, and produce the final copy.
Compare between El Camino and the Johns Hopkins bylaws to choose the optimum
bylaws from each that suites DMC functions to be used for DMC bylaws update.
1. El Camino Hospital, Medical Staff Bylaws, 2015.
2. The Johns Hopkins Hospital, Medical Staff Bylaws, 2015.
3. King Khalid University Hospital, Medical Staff Bylaws, 2010.
Prepared by:
Hala Al Masoud
Health Informatics Specialist