The standard formerly known as MS.1.20 is on the move again. The Joint Commission opened up the standard (MS.01.01.01 under the 2009 numbering rules) to field review this summer following the recommendations by the MS.1.20 Implementation Task Force.
In January 2008, 18 staff members of the MS.1.20 Implementation Task Force convened and determined that further revisions to the standard were needed, and reached a consensus in March 2009. MS.1.20/MS.01.01.01 has undergone several iterations over the past five years. In 2004, when the standard was created, many concerns about the intent of the requirements were raised.
These concerns included:
- The number of details required in the bylaws
- The associated cost and burden with changing bylaws
- The potential for disrupting relationships between the medical staff and governing body
- The role of the medical executive committee (MEC)
The results of the field feedback will be brought to the Joint Commission by October 15, and if the field supports the proposed standard, the Joint Commission's Board of Commissioners will then decide whether to authorize the conduct of a formal field review. Currently, hospitals are expected to be in compliance with Medical Staff standard MS.01.01.01 in the 2009 Comprehensive Accreditation Manual for Hospitals. (Until further notice, the current standard will remain in effect.)
"It is clear that the task force worked through their own collaborative process to create the proposed revision," says Sally J Pelletier, CPCS, CPMSM, a healthcare consultant based in Intervale, NH.
This revision addresses many of the previous concerns expressed by the field, says Pelletier, while also:
- Recognizing the vital role of the MEC as the conduit for communicating on behalf of the medical staff to the board
- Reinforcing that MS bylaws cannot be unilaterally amended
- Clarifying those requirements that must remain in the MS Bylaws while leaving the rest up to the medical staff. This covers details that may reside elsewhere, including how those details that reside outside of the MS bylaws are amended and adopted
What's changed
The procedures specified in the EPs 3 through 11 assume an organized medical staff that is informed, has valid processes for determining its collective opinions, and sufficient participation to ensure that the collective voice is truly representative, says Dan Lang, MD, a recently retired medical director of the Hospital Association of Southern California.
This is often not the case if physicians are independent and community-based.
There is some concern that the MEC is weakened by the current round of changes.
"The role of the medical executive committee is diminished by the emphasis on the requirement that its authority be delegated by the organized medical staff as a whole," says Lang.
A stronger statement in favor of delegation of authority to its representative leaders on the MEC would tilt the balance toward a more pragmatic and realistic approach.
"For example, EP 6 speaks of enforcement by the organized medical staff," says Lang. "In practice, it is the medical executive committee that is charged with and has the tools to carry out enforcement."