JCAHO MS.1.20 (i.e. the proposed medical staff by-laws standards to be adopted by the Joint Commission for the Accreditation of Healthcare Organizations) has been generating significant controversy since amendments were first proposed in January of 2004, which amendments would have required approval of both the medical staff and the hospital governing board to adopt and amend the medical staff by-laws. Enforcement of these accreditation standards would prohibit unilateral amendment of medical staff by-laws by a hospital or its governing board, which created significant controversy among hospitals and their governing board because of the perceived “veto” power and granted to the medical staff. Although medical staff leadership welcomed this approach, said leadership has never felt nearly as threatened about this standard as the hospitals have because medical staff leadership have never expected unilateral amendment opportunities.
The latest iteration of MS.1.20 was recently posted on the JCAHO website (http://www.jointcommission.org/Standards/FieldReviews/fr_ms120.htm). The proposed standards are available for review and comment through October 27, 2006. Significant among the performance standards are the following:
“A.2. Medical staff by-laws are adopted and amended by the medical staff and approved by the governing body.”
“A.4. The governing body acts in accordance with the medical staff by-laws, rules and regulations, and policies that are adopted by the medical staff and approved by the governing body.”
A.7. to A.11. The medical staff by-laws or rules and regulations and policies adopted by the organized medical staff and approved by the governing body delineate the structure of the medical staff, both practitioners who are eligible for membership in the organized medical staff, most practitioners who are eligible to vote on the medical staff by-laws and their amendments, and the organized medical staff officers and the methods for their selection and removal.
These accreditation guidelines will also be interesting when viewed in relation to the issue of whether medical staff by-laws create enforceable contracts, because of the standards which are applied. Even in those states which have decided that medical staff by-laws in and of themselves do not create contracts with medical staff members, the general opinion has been the adoption of medical staff by-laws nevertheless creates an obligation or requiring the hospital to act in accordance with the by-laws, regulations and policies which it has adopted.