If you work with medical staff bylaws, you know that the Joint Commission standard for medical staff bylaws (MS 1.20) has been in a state of flux for years. Because hospitals campaigned against changes that would strengthen medical staffs, the published standard has been “corrected,” “clarified,” revised, published, and now-“suspended.” The time, resources and efforts that hospital executives and hospital lawyers have dedicated to undermining medical staff self-governance demonstrate the importance of self-governance in putting clinicians, rather than executives, in charge of patient care decisions.

The Joint Commission will not consider action on MS 1.20 until April, 2009, at the earliest. Any changes will not be effective until 2011, at the earliest. The action of the Joint Commission to suspend the version of MS 1.20 it published in July, 2008, leaves in effect the MS 1.20 it published in the 2007 Joint Commission Accreditation Manual—except for Element of Performance 19, which “is not effective at this time.” And just in case this is not sufficiently confusing, the Joint Commission is changing its numbering system again, so that the MS 1.20 in effect now will be MS 01.01.01. Access that bylaws standard at http://www.jointcommission.org/NR/rdonlyres/80A13661-D905-4B34-B4FC-7B8309EC9E40/0/HAP_MS.pdf.

So what should medical staffs do? Don’t wait for the Joint Commission to improve your bylaws. Changes made since 2007–in the good faith belief that the Joint Commission would implement its published standards-may well comply with MS 01.01.01. Those who had not taken steps to comply with the last two versions of MS 1.20 need to get to work. Get rid of those cumbersome, gimmicky and one-sided “manuals” and “plans” and keep credentialing, privileging, hearing and appeals, and medical staff organization and operations in the bylaws, where they belong. That approach complies with MS 1.20, past, present and everything on the table for the future--- and with Medicare CoPs, most if not every state’s statutes, AMA policy, and any other meaningful measure of a quality medical staff. In addition to MS 1.20/01.01.01, the Joint Commission will begin surveying to see that the medical staff addresses disruptive behavior and conflicts of interest. These issues should also be in your medical staff bylaws. Do not spend time and money taking things out of the medical staff bylaws.

©2008 Elizabeth A. Snelson Legal Counsel for the Medical Staff PLLC