New Hospital Accreditation Standards Designed to Empower Medical Staffs

Recent developments at the Joint Commission (JC), the national organization that accredits hospitals, should greatly enhance the standing of individual physicians in the hospital setting. The JC’s revision of its accreditation standard for medical staff bylaws, MS.1.20, means that hospitals will need to comply with a number of new sub-requirements (the so-called “Elements of Performance” or EPs), which should strengthen the role of active members in medical staff governance and in relations with a hospital’s governing board.

The JC’s stated intent for the new standard is to support a productive working relationship between the organized medical staff and the hospital’s governing body. The new standard also promotes the expectation that a medical executive committee (MEC) will reflect the wishes of the organized medical staff.

The revised standard specifies details for carrying out various EPs that must be contained in the medical staff bylaws or may be relegated to other medical staff documents, such as rules, regulations, or policies. This is important because amendments to bylaws must be approved by the medical staff as a whole, while changes to other documents may be made by the MEC without medical staff approval. Among the medical staff functions that will need to be detailed in the medical staff bylaws are the privileging process, criteria for suspension and termination of medical staff appointment and privileges, and the composition of fair hearing committees. Under the revised MS.1.20, the procedural details of these functions cannot be changed without the okay of the whole medical staff.

The revised standard also empowers the organized medical staff to adopt and propose medical staff bylaws amendments directly to the governing board (potentially bypassing the MEC). In addition, the medical staff may revise the authority of the MEC to act on its behalf.

Recently, the revised MS.1.20 — slated to take effect on July 1, 2009 — has generated much discussion among physicians, hospitals, and health care attorneys. The JC recently appointed a task force to address implementation issues, and implementation guidance may be forthcoming this spring.

In a companion development, at its November 2007 interim meeting, the AMA adopted a set of 12 “Principles for Strengthening the Physician-Hospital Relationship,” which offer authoritative guidance for medical staff self-governance and organization. Of particular note is the concept that medical staff bylaws are a binding contract among the medical staff, the governing board, and individual medical staff members. The principles also call for fixing the fair hearing and appeals process in the medical staff bylaws, so that voting members of the medical staff decide on any proposed changes.

These recent developments reflect a generally increased tension in medical staff–hospital relationships over the past several years. Physicians should be inspired to take an active role in their implementation.

– Dean P. Nicastro, Esq., Pierce & Mandell, P.C.