Joint Commission

The intent of the Joint Commission requirement (MS.11.01.01) is consistent in many aspects with the mission of PHS, which is to assist physicians with health concerns and therefore provide protections to patients. In this regard, Joint Commission requires medical staff and organization leaders to design a process that provides education about physician health; addresses prevention of physical, psychiatric, or emotional illness; and facilitates confidential diagnosis, treatment, and rehabilitation of physicians from a potentially impairing condition.

PHS can assist hospitals in implementing this requirement through consultation and through written guidelines entitled “Guidelines for Establishing Hospital and HMO Physician Health Committees.” These guidelines and accompanying statutes and regulations provide guidance to a facility in the establishment of a medical peer review committee that exclusively addresses physician health issues.

By following these guidelines and through the functions of this committee, a hospital will be able to meet the criteria of the Joint Commission requirement and provide a confidential, educational, preventive, and responsible manner for dealing with matters of physician health. This committee can also fulfill a hospital’s or HMO’s mandate under the Board of Registration in Medicine’s regulation 243 CMR 3.09 to address issues of impairment.

As an alternative to developing a committee, PHS has advised hospital organizations to directly refer matters to Physician Health Services by ensuring the hospital has clear guidelines on the referral process. “Joint Commission accepts delegation to existing external programs as a means to meeting the standard,” Roger Wise, M.D., Joint Commission vice president of standards, Division of Research. PHS can provide an annual education program to hospitals to ensure awareness, and up-to-date information is available to your medical organization.

PHS guidelines provide an organized means by which a medical peer review committee can be established with the mechanisms above serving as the functions of the committee. For further information, please contact Physician Health Services at 781-434-7404.

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