Joint Commission revises medical staff standard

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The Joint Commission has approved the revisions to Medical Staff Standard MS.01.01.01, formerly known as MS.1.20, to contribute to patient safety and quality of care through the support of a well-functioning, positive relationship between a hospital’s medical staff and governing body.

Standard MS.01.01.01 addresses the medical staff’s self-governance and its accountability to the governing body for the quality and safety of patient care. The standard recognizes that although a hospital’s governing body is responsible for the quality and safety of care, the governing body, medical staff and administration must collaborate to achieve this goal, according to the Oakbrook Terrace, Ill.-based accreditation organization.

To achieve this collaboration, the Joint Commission has a written set of documents, known as medical staff bylaws, which describes the medical staff’s organizational responsibilities and how the medical staff and governing body will work together. Standard MS.01.01.01, which was field-reviewed by accredited organizations, physicians and other interested parties, provides the framework for constructing, writing and implementing these bylaws, the organization stated.

In a hospital accreditation program, revisions include the requirements for a description of those members of the medical staff who are eligible to vote, a list of all officer positions for the medical staff, the process for adopting and amending the medical staff bylaws and the process for adopting and amending the medical staff rules and regulations and policies.

In addition, "[i]f the voting members of the organized medical staff propose to adopt a rule, regulation or policy or an amendment thereto, they first [must] communicate the proposal to the medical executive committee," the revisions stated.

The revised standard goes into effect March 31, 2011, which gives hospitals and their medical staff a year to come into compliance with the revised requirements, and provides the Joint Commission with an opportunity to answer any questions that may arise about the revised standard.

According to the Joint Commission, following the March 31, 2011 implementation date, all hospitals and critical access hospitals must be in full compliance.