Joint Commission revises hospitals' medical staff bylaws standard

The Joint Commission has adopted revisions to its medical staff bylaws standard that is designed to promote patient safety and quality of care by establishing a high-functioning relationship between a hospital's medical staff and governing body. Revised Medical Staff Standard MS.01.01.01, which replaces the June 2007 version known as Standard MS.1.20, will take effect on March 31, 2011--giving hospitals and critical-access facilities a year to achieve full compliance. However, the Joint Commission believes that the revised standard's flexibility will limit excessive, time-consuming or costly revisions to medical staff bylaws.

Standard MS.01.01.01 provides the framework for constructing, writing and implementing the medical staff bylaws that delineate the medical staff's organizational responsibilities and explain how the medical staff and governing body will interact.

"The revised version provides more flexibility for governing bodies and medical staffs to determine what will be placed in the medical staff bylaws and what will be placed in other documents," says the Oakbrook Terrace, Ill.-based accreditation organization. "The revised version also provides for notification by the medical staff to the medical executive committee [MEC] when it wishes to propose a change to a rule, regulation, or policy directly to the governing body. At the same time, the MEC must provide notice to the medical staff concerning proposed changes to rules or regulations [policy changes by the MEC do not require notification]. While disagreements in well-functioning organizations would be rare, the revised standard calls for a process to manage conflict that might occur."

The Joint Commission approved the revisions based on the unanimous recommendations of an 18-member task force that included representatives from the American College of Physicians, the American College of Surgeons, the American Dental Association, the American Hospital Association, the American Medical Association, the Federation of American Hospitals and the National Association Medical Staff Services. The revised standard will be included in 2011 accreditation manuals, which will be published this fall.

To learn more about the revised bylaws standard:
- read the Joint Commission's press release
- check out the prepublication standard and frequently asked questions