Expect more changes for medical staff standards

Significant revisions made after pilot review

After a February 2006 field review identified major concerns, the Joint Commission has revised its medical staff standards, with significant changes made from the previous proposed standards. Hospitals argued that the proposed standards would disrupt their operations by requiring them to open and review their medical staff bylaws and undertake other resource-consuming activities in order to comply, and would interfere with an organization's right to design the structure of its medical staff executive committee (MEC).

Significant changes were made based on these responses from the field, with the new standards expected to go to the board for approval in spring 2007.

"To me, the changes reemphasize the value the Joint Commission places on the role of the medical staff," says Alice Gosfield, a Philadelphia, PA-based health care attorney who works with organizations on issues including medical staff credentialing. "The bylaws are reaffirmed as the constitution of the medical staff in fulfilling its delegated authority from the hospital board."

Under the revised standards, the MEC has the ability to adopt rules and regulations for the medical staff. "To assure that the MEC does not act as a roadblock to what the medical staff as a whole may want, the medical staff itself can propose bylaws to the governing body without going through the MEC, which otherwise speaks to the governing body for the medical staff," says Gosfield.

There is a general emphasis on greater clarity regarding important issues such as who votes on bylaws changes, the composition of the MEC as the primary intersection between the medical staff and the board, and the selection and termination of medical staff officers.

"All of these issues have been contentious between the medical staff and the board, and occasionally between the MEC and the medical staff as a whole, throughout the country," notes Gosfield.

The revised standards also address the differences in determining competence of physicians currently on staff and those who are not yet on staff, as well as terminating and suspending them. The standards permit the medical staff to treat those on staff differently from those applying to become members, says Gosfield.

"Overall, I think the changes speak to the ongoing importance of the medical staff to the hospital's quality mission," says Gosfield. "The issues addressed reemphasize the need for the medical staff and the hospital to be jointly engaged and passionate about the quality mission. But to do that, they need to have clear vehicles and processes to work together."

[For more information, contact: Alice G Gosfield, 2309 Delancey Place, Philadelphia PA 19103. Telephone: (215) 735-2384. Fax: (215) 735-4778. E-mail: AGGosfield www.gosfield.com.]