ED Accreditation Update

Standard is revised for medical staff bylaws

Joint Commission: It provides more flexibility

The Joint Commission has approved revisions to Medical Staff (MS) 01.01.01, formerly known as MS.1.20. This standard, it says, "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."

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. It 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.

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.

The revised standard goes into effect March 31, 2011, which provides a year for ED managers and other hospital leaders to come into compliance with the revised requirements. The deadline also gives officials with The Joint Commission an opportunity to answer any questions that might arise about the revised standard. They also say it will provide additional education to support hospitals and prepare them for implementation of the standard.

The medical staff bylaws issue has been a subject of interest from physicians and hospitals for several years, notes Charles A. Mowll, FACHE, executive vice president of business development, government, and external relations for The Joint Commission. Changes had been proposed in 2007, but hospital officials had thought they were overly proscriptive and they didn't really see a quality and safety impact, he says.

"The standard defines those elements that need to be cited in the bylaws, but when we put the standard out we also said all the attendant detail and descriptions of those items had to be in the bylaws as well, and that was just not reality in many hospitals; many have them in policies and procedures and rules and regulations," Mowll explains. "If we had let it stand in its old form, hospitals would have had to go in and move a lot of material around from rules and regulations to bylaws, and bylaws require joint endorsement of both medical staff and the governing body."

Under the revised standard, if the medical staff wants to have the associated details in the bylaws they can, but they can also reference them in rules and regulations or policies and procedures, he says.

For ED managers, says Mowll, the revised standard might not require many changes at all. "It is our hope that this change will not have any dramatic impact on well-functioning staff in terms its relationship with the governing body," he says. "We don't want to fix what isn't broken."

Michael R. Humphrey, MD, the chief clinical officer at St Rita's Medical Center in Lima, OH, agrees. "Everything they're saying should be changed, we have had in the form of written bylaws," Humphrey says. "Maybe we're unique or fortunate, but there's not one line-item we would have to change."

Collaboration means safety

Another key aspect of the standard is its emphasis that the medical staff's self-governance be maintained and its collaboration with the hospital's governing body enhanced, says Mowll.

"We want to emphasize the goal here is safe, high quality care," says Mowll. "When these three [medical staff, the medical executive committee, and the governing body] work together collaboratively, the patient benefits."

This change led to a change in the standard concerning communication. "What we all assume is that when the medical executive committee acts on behalf of the medical staff, it lets them know what changes it is making in advance," Mowll says. "That was never written down before, so we added it into the changes — that there needs to be pro-active communication between the med-exec committee and med staff and vice versa — so if the medical staff makes changes and takes it to the governing body, that is communicated beforehand with the medical executive committee."

That active communication builds trust and a more positive working relationship, he says. In addition, Mowll says, the features that are required in the bylaws, such as the credentialing process, ensuring a fair hearing and appeals process for doctors under scrutiny, and formal processes such as history and physicals "have a direct impact on patient safety." That's why the various leadership groups must see eye to eye in these key areas, he emphasizes.

The ED at St. Rita's has a clinical director and an administrative director, notes Humphrey. "They are the ones who build all the policies and procedures applying to the department itself," he says. It is usually the clinical director who makes bylaws recommendations, Humphrey says.

In terms of quality improvement, there is strong communication with the medical executive committee, he says. "We operate on a 6-point quality assurance level," Humphrey says. "Any case rated 3 or above gets referred to the med-exec committee, and they will determine what needs to be done."

Another thing the revised standard accomplishes is a sense of shared responsibility for patient safety and quality, Mowll says. "The new emphasis in the way we rewrote the standard is that you can't point fingers," he explains. "It's not just the hospital's responsibility. It is the hospital and medical staff working collaboratively and supporting each other." (Editor's note: Detailed information about revised standard MS.01.01.01 can be found on The Joint Commission Web site, ww.jointcommission.orgw. On the right-hand side of the page, under "Joint Commission News," click on "Joint Commission approves revised medical staff bylaws standard MS.0.01.011.)