Revisions to Standard MS.1.20 Approved

At its June meeting, the Joint Commission Board of Commissioners approved revisions to Standard MS.1.20, which addresses medical staff bylaws, rules and regulations, and policies. These revisions were written with the intent of supporting and reinforcing a productive working relationship between the organized medical staff and the governing body – consistent with the requirements of the new Leadership Chapter – while minimizing disruptions to the hospital, including its medical staff. All of the requirements in Standard MS.1.20 must be jointly approved by the organized medical staff (or the medical staff executive committee, if so delegated by the organized medical staff) and the governing body.

The main revisions to Standard MS.1.20 are as follows:

The Introduction was revised to include a discussion of the relationship between the organized medical staff and the medical staff executive committee, and the definitions of “process” and “procedural detail.”
A note was added referring the organization to Standard LD.2.40 for guidance on managing conflict that might arise concerning the medical staff bylaws, rules and regulations, and policies.
A note was added to explain the revised structure of the standard.
Lead-in sentences to groups of EPs were added to clearly delineate what must be in the medical staff bylaws, and what must be either in the bylaws, or in rules and regulations or policies.
Two new EPs were added to align the standard with the Centers for Medicare and Medicaid Services’ requirements regarding medical staff bylaws.
An EP was added to underscore the organized medical staff’s ability to propose medical staff bylaws, rules and regulations, and policies directly to the governing body.
A requirement was added that the medical staff bylaws must indicate the authority delegated to the medical staff executive committee by the organized medical staff to act on its behalf, and how that authority is delegated and removed.

The revised standard seeks to resolve several important issues. First, it addresses situations in which a medical staff believes that its medical staff executive committee is not representing its views on issues of patient safety and quality of care. The revised standard now states that the medical staff bylaws must indicate what authority the medical staff has delegated to the medical staff executive committee, and how that authority is delegated and removed. Also, the revised standard now states that the medical staff has the ability to adopt medical staff bylaws, rules and regulations, and policies and propose them directly to the governing body, even if the subject matter had been delegated to the medical staff executive committee. While the revised standard does not state what a medical staff should do if it does not agree with an action taken by its medical staff executive committee, the Introduction to the standard urges the medical staff to consider in advance what action it would take if such a situation occurred.

The revised standard also seeks to allow for an efficient process, for the hospital and its medical staff, for creating and maintaining medical staff bylaws, rules and regulations, and policies. To do this, the standard indicates what must appear in the medical staff bylaws, and what must appear either in the bylaws, or in rules and regulations or policies. The requirements in Elements of Performance (EPs) 9 through 33 must appear in the medical staff bylaws. However, the procedural details associated with the processes listed in EPs 26 through 33 must appear either in the medical staff bylaws, or in rules and regulations or policies (see text of standard below). The organized medical staff may, if it desires, delegate to its medical staff executive committee approval of the procedural details associated with the processes listed in EPs 26 through 33, when these procedural details are placed in rules and regulations or policies.

To understand these requirements, the difference between “process” and “procedural detail” needs to be explained. A process is a series of steps taken to accomplish a goal. A procedural detail describes in detail how each step in the process is to be carried out. For example, the process for credentialing licensed independent practitioners (see EP 26) can be stated in several steps such as collecting information on a physician, evaluating the information, and making a decision about the information. That process will be contained in the medical staff bylaws. The procedural details associated with this process might include who collects the information, how files are kept, what organizations need to be contacted to collect all the necessary information, etc. For EPs 26 through 33, the medical staff decides whether such procedural details will be retained in the medical staff bylaws (which must be approved by the entire organized medical staff), or in rules and regulations or policies (whose approval may be delegated to the medical staff executive committee).

Revised Standard MS.1.20 becomes effective July 1, 2009. The Joint Commission is allowing two years for the field to make any changes to medical staff bylaws that may be necessary to bring organizations into compliance with the revised standard. In the meantime, the current version of Standard MS.1.20 will be in effect.

STANDARD MS.1.20

Effective July 1, 2009

Introduction for Standard MS.1.20 (CAH, HAP)

The (HAP: organized) medical staff and the governing body work together, reflecting clearly recognized roles, responsibilities, and accountabilities, to enhance the quality and safety of care, treatment, and services provided to patients. To support this work, the (HAP: organized) medical staff creates a written set of documents that describes the organizational structure of the medical staff and the rules for its self-governance. These documents are called medical staff bylaws. The medical staff bylaws create a system of rights, responsibilities, and accountabilities between the (HAP: organized) medical staff and the governing body, and between the (HAP: organized) medical staff and the medical staff members.

In addition to the medical staff bylaws, the (HAP: organized) medical staff may create other medical staff governance documents such as rules and regulations and policies. In doing so, the (HAP: organized) medical staff may recommend that the procedural details of those requirements listed in Elements of Performance 26-33 of this standard be retained in the medical staff bylaws, or in rules and regulations or policies, in accordance with applicable law and regulation.

In developing its bylaws, the (HAP: organized) medical staff may include within the scope of responsibilities of the medical staff executive committee the authority to adopt, on the behalf of the entire (HAP: organized) medical staff, any procedural details associated with Elements of Performance 26-33 appearing in rules and regulations or policies. The (HAP: organized) medical staff can also propose medical staff bylaws, rules and regulations, and policies, and amendments thereto, directly to the governing body.

When approval of procedural details associated with Elements of Performance 26-33 appearing in rules and regulations or policies is delegated to the medical staff executive committee, it is to represent to the governing body the organized medical staff’s views on issues of patient safety and quality of care. The organized medical staff can take action to revise the authority it has delegated to the medical staff executive committee to act on its behalf. The organized medical staff is urged to determine what steps it will take if it does not agree with an action taken by the medical staff executive committee. Such steps might include a process that would allow the organized medical staff, at its discretion, to extract and consider an action by the medical staff executive committee prior to the action becoming effective.

The significance of the medical staff bylaws cannot be overstated. For this reason, the medical staff leaders should assure that all medical staff members understand the content and purpose of the bylaws, and the bylaws adoption and amendment processes.

Note: If conflicts regarding the medical staff bylaws, rules and regulations, or policies arise between the governing body and the (HAP: organized) medical staff, the organization’s conflict management process is implemented, as set forth in Standard LD.2.40.

Standard MS.1.20 (CAH, HAP)

Medical staff bylaws address self-governance and accountability to the governing body.

Note regarding Elements of Performance 9-33: All requirements appearing in Elements of Performance 9-33 must be in the medical staff bylaws. These requirements may have associated procedural details. Any procedural details associated with the requirements in Elements of Performance 9-25 must also be in the medical staff bylaws. Any procedural details associated with Elements of Performance 26-33 must be either in the medical staff bylaws, or in rules and regulations or policies. All requirements and procedural details addressed in the medical staff bylaws must be adopted and amended by the whole of the (HAP: organized) medical staff and approved by the governing body. All procedural details addressed in rules and regulations or policies must be adopted and amended by either the whole of the medical staff or the medical staff executive committee, if so delegated by the (HAP: organized) medical staff, and approved by the governing body.

Elements of Performance for Standard MS.1.20

(CAH, HAP) The (HAP: organized) medical staff develops medical staff bylaws, rules and regulations, and policies.
(CAH, HAP) The (HAP: organized) medical staff adopts and amends, and the governing body approves, medical staff bylaws.
(CAH, HAP) The (HAP: organized) medical staff, or the medical staff executive committee as delegated by the (HAP: organized) medical staff, adopts and amends, and the governing body approves, any rules and regulations and policies that address procedural details of the requirements in Elements of Performance 26-33.
(HAP) Regardless of whether the medical staff executive committee is empowered to act on behalf of the organized medical staff, the organized medical staff as a whole has the ability to adopt medical staff bylaws, rules and regulations, and policies, and amendments thereto, and propose them directly to the governing body.
Note: Please see the Introduction to this standard for further discussion of the organized medical staff’s relationship to the medical staff executive committee.
(CAH, HAP) The governing body acts in accordance with those medical staff bylaws, rules and regulations, and policies that are adopted by the (HAP: organized) medical staff or, as delegated by the (HAP: organized) medical staff, the medical staff executive committee, and approved by the governing body.
(HAP) The organized medical staff enforces the medical staff bylaws, rules and regulations, and policies.
(HAP) The medical staff bylaws, rules and regulations, and policies and the governing body bylaws do not conflict.
(CAH, HAP) The organized medical staff and its members comply with the medical staff bylaws, rules and regulations, and policies.

The medical staff bylaws must include the requirements and any associated procedural details in Elements of Performance 9-25.
(CAH, HAP) The structure of the (HAP: organized) medical staff.
(CAH, HAP) The process for privileging licensed independent practitioners.
(CAH, HAP) Qualifications for appointment to the (HAP: organized) medical staff.
(HAP) Indications for automatic suspension of a practitioner’s medical staff membership or clinical privileges.
(HAP) Indications for summary suspension of a practitioner’s medical staff membership or clinical privileges.
(HAP) Indications for recommending termination or suspension of medical staff membership, and/or termination, suspension, or reduction of clinical privileges.
(HAP) The composition of the fair hearing committee. (See also EP 32.)
(CAH, HAP) The roles and responsibilities of each category of practitioner on the medical staff (active, courtesy, etc.).
(CAH, HAP) Requirements for performing medical histories and physical examinations.
(HAP) Those practitioners who are eligible to vote on the medical staff bylaws and their amendments.
(HAP) A list of all the officer positions for the organized medical staff.
(HAP) The medical staff executive committee’s function, size, and composition; the authority delegated to the medical staff executive committee by the organized medical staff to act on its behalf; and how such authority is delegated or removed. (See also Standard MS.1.40.)
(HAP) The process for selecting and removing the medical staff executive committee members.
(HAP) That the medical staff executive committee includes physicians and may include other practitioners as determined by the organized medical staff.
(HAP) That the medical staff executive committee acts on the behalf of the organized medical staff between meetings of the organized medical staff, within the scope of its responsibilities as defined by the organized medical staff. (See also Standard MS.1.40.)
(HAP) The process for adopting and amending the medical staff bylaws.
(HAP) The process for adopting and amending medical staff rules and regulations, and policies.
The medical staff bylaws must include the requirements in Elements of Performance 26-33. The procedural details, if any, associated with Elements of Performance 26-33 must appear either in the medical staff bylaws, or in rules and regulations or policies (see Elements of Performance 1-4).
(CAH, HAP) The process for credentialing licensed independent practitioners.
(HAP) The process for appointment to membership on the organized medical staff.
(HAP) The process for selecting and removing the organized medical staff officers.
Corrective Actions
(HAP) The process for automatic suspension of a practitioner’s medical staff membership or clinical privileges.
(HAP) The process for summary suspension of a practitioner’s medical staff membership or clinical privileges.
(HAP) The process for recommending termination or suspension of medical staff membership and/or termination, suspension, or reduction of clinical privileges.
Fair Hearing and Appeal
(HAP) The fair hearing and appeal process (see also EP 15), which at a minimum shall include:
– The process for scheduling hearings
– The process for conducting hearings
– The appeal process

Qualifications and Roles and Responsibilities of the Department Chair
(HAP) If departments of the organized medical staff exist, the qualifications and roles and responsibilities of the department chair, which shall include the following:
Qualifications:

Certification by an appropriate specialty board or comparable competence affirmatively established through the credentialing process.

Roles and responsibilities:

Clinically related activities of the department.

Administratively related activities of the department, unless otherwise provided by the hospital.

Continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges.

Recommending to the organized medical staff the criteria for clinical privileges that are relevant to the care provided in the department.

Recommending clinical privileges for each member of the department.

Assessing and recommending to the relevant hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the organization.

Integration of the department or service into the primary functions of the organization.

Coordination and integration of interdepartmental and intradepartmental services.

Development and implementation of policies and procedures that guide and support the provision of care, treatment, and services.

Recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services.

Determination of the qualifications and competence of department or service personnel who are not licensed independent practitioners and who provide patient care, treatment, and services.

Continuous assessment and improvement of the quality of care, treatment, and services.

Maintenance of quality control programs, as appropriate.

Orientation and continuing education of all persons in the department or service.

Recommending space and other resources needed by the department or service.