Medical staffs across the country have been waiting for more than three years for The Joint Commission to commit to standard MS.01.01.01 (formerly MS.1.20), and the day has finally come. Medical staffs in Joint Commission-accredited hospitals will need to comply with MS.01.01.01 as of March 31, 2011.
MS.01.01.01 has been through several revisions, the first of which, when issued in 2007, sent medical staffs into an uproar. One of the issues that came up for debate was which documents could be included in the medical staff bylaws and which could be kept in supporting documents, such as medical staff policies and procedures.
Medical staffs protested that if every medical staff process was included in the bylaws, the entire medical staff would need to vote on relatively simple decisions, taking up too much time and too many resources.
Many medical staffs also expressed discontent that the 2007 standard allowed the medical staff to bypass the medical executive committee and go straight to the governing board if they felt that the medical executive committee was not adequately representing the medical staff's needs. Some argued that this change undermined the authority of the medical executive committee, whose job is to represent the medical staff to the hospital's governing board.
The draft of the standard that passed this week strikes a balance between what The Joint Commission wants to include in its standard and what the field thinks is reasonable. Many medical staffs were afraid that they would need to extract processes and procedures from their supporting documents and include them in the bylaws to comply with MS.01.01.01. Although it sounds pretty simple, the medical staff would then need to vote each addition into the bylaws, and all it takes is one person to hold up that process.
The way the current standard is written, medical staffs may choose to include the key provisions in a brief summary of, say, their fair hearing processes in the bylaws, but include all of the details in supporting documents, says Ann O'Connell, Esq., with the Sacramento, CA office of Nossaman, LLP. O'Connell has served for the past few years on the MS.01.01.01 task force.
"I think there are a variety of ways to implement the changes. It could range from totally revamping the bylaws and incorporating your extraneous documents into your bylaws, or it could mean that you leave them in separate documents, but summarize the key requirements within your bylaws," says O'Connell.
Also, according to O'Connell, as long as the key requirements are addressed in the bylaws, The Joint Commission staff has assured the task force that it does not intend to micromanage what comprises a "detail" for purposes of implementing the standard.
O'Connell explains that when it comes to the medical staff bypassing the medical executive committee and going straight to the board, The Joint Commission compromised there too. Whereas the 2007 standard allowed the medical staff to directly address the board regarding just about anything, the new standard limits the medical staff to approaching the board regarding amendments to the bylaws, policies and procedures, and rules and regulations only—and it does require the medical staff to present its proposed changes to the MEC first (but MEC approval is not a prerequisite to getting the proposal to the board).
However, this isn't a big change for many hospitals, O'Connell says. "I know many hospitals that have a provision that would allow the medical staff to propose an amendment to the governing board—requiring perhaps a 10% or a 25% petition of the medical staff."
Although some continue to worry that this provision undermines the medical executive committee's authority, "If you don't interpret it too severely, all it says is that we have to have some mechanism to let medical staff members talk to the MEC," says Joseph Cooper, MD, CMSL, a consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.
Hospital leaders may not be concerned whether certain provisions are included in the medical staff bylaws, but they might care about provisions that allow the medical staff to propose amendments to the medical staff bylaws, rules and regulations, and policies and procedures directly to the governing board because the governing board sets the direction for the hospital.
If the medical staff brings an amendment in front of the governing board that would affect credentialing or privileging, for example, the governing board needs to decide whether that amendment would improve or diminish the quality of physicians on the medical staff, and the quality of physicians directly affects the hospital's quality outcomes.
When The Joint Commission sent the most recent version of the standard out for field review in December 2009, it received relatively positive feedback, says O'Connell. Sixty-six percent of respondents indicated that this current standard is an improvement over the past versions and only 4% said it is worse.
The remaining 30% are unsure whether the standard is better or worse and need further clarification. To that end, O'Connell says The Joint Commission will be issuing educational materials in the coming weeks and months.
Liz Jones is an associate editor at HCPro, Inc. She writes Medical Staff Briefing, Hospitalist Leadership Advisor, and Credentialing and Peer Review Legal Insider. She can be reached at ejones@hcpro.com.