Joint Commission Approves Revised Medical Staff Bylaws Standard MS.01.01.01

(OAKBROOK TERRACE, Ill. - March 18, 2010) The Joint Commission today announced the approval of revisions to Medical Staff Standard MS.01.01.01, formerly known as MS.1.20, that is designed to contribute to patient safety and quality of care through the support of a well-functioning, positive relationship between a hospital's Medical Staff and Governing Body.  The revisions are based on the unanimous recommendations of an 18-member expert task force representing the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, Federation of American Hospitals, National Association Medical Staff Services, as well as hospital trustees and health care attorneys.

Standard MS.01.01.01 addresses the Medical Staff's self-governance and its accountability to the governing body for the quality and safety of patient care, and recognizes that while a hospital's governing body is ultimately responsible for the quality and safety of care, the Governing Body, Medical Staff and Administration must collaborate to achieve this goal.  An important element for achieving this collaboration is a written set of documents, known as Medical Staff Bylaws, that describes the Medical Staff's organizational responsibilities and how the Medical Staff and Governing Body will work together.  Standard MS.01.01.01, which underwent an extensive field review with accredited organizations, physicians and other interested parties, provides the framework for constructing, writing and implementing these bylaws.

The revised standard goes into effect March 31, 2011, which provides hospitals and their Medical Staff a year to come into compliance with the revised requirements, and The Joint Commission an opportunity to answer any questions that may arise about the revised standard.  Following the March 31, 2011 implementation date, all hospitals and critical access hospitals must be in full compliance.  The Joint Commission will provide additional education to support hospitals and prepare them for implementation of the standard.

"The intent of these revisions is that the Medical Staff Bylaws can both maintain the Medical Staff's self-governance and enhance its collaboration with the hospital's Governing Body, while optimizing the efficiency of maintaining the bylaws," says Robert Wise, M.D., vice president, Division of Standards and Survey Methods, The Joint Commission.  "We are grateful to our expert task force members and accredited organizations for their contributions in making this standard one that enhances the quality and safety of care provided to patients."

Detailed information about revised standard MS.01.01.01 can be found on The Joint Commission Web site,, and in the 2011 version of the accreditation manuals for hospitals and critical access hospitals that will be published and distributed in the fall of 2010.