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Medical Staff Standard revisions recently adopted by the Joint Commission on Accreditation of Hospitals (the Joint Commission) will likely affect every hospital's Medical Staff Bylaws, Rules and Regulations and related policies. These new and controversial pronouncements could also impact the traditional interrelationship of Governing Body, Administration, Medical Staff Leadership and the medical staff body.

Almost four years after it first proposed revisions to MS.1.20, the Joint Commission recently approved revisions to the Accreditation Manual. MS.1.20 is the section of the Joint Commission's Accreditation Manual for Hospitals that describes the expectations by and between the organized medical staff and the hospital, and which details what provisions must be included in medical staff bylaws as opposed to in the rules and regulations, policies and certain separate manual documents. A key issue in the debate engendered by the Joint Commission's proposed revisions back in 2004 was whether hospital administration should be able to move "key" medical staff bylaws provisions outside of the medical staff bylaws and into the rules and regulations where the provisions could be controlled by administration, or a smaller, more controlled leadership group (e.g., Medical Executive Committee) rather than through the larger medical staff democracy.

The revisions introduced in 2004 were not well received, and the Joint Commission backed off of its position and issued revised standards in 2006, which would have deferred to the hospital and the medical staff as to which provisions must be within the medical staff bylaws. However, the Joint Commission reversed itself in its final decision. Under the final MS.1.20, every substantive medical staff bylaws category dealing with privileging, credentialing, hearings, election of officers and the process¹ for each must be contained within the medical staff bylaws document, which must be approved by the organized medical staff. The only permitted sections that can be or remain included in the rules and regulations, policies or separate manuals are procedural details,² approval of which may be delegated to the medical executive committee. The Joint Commission provided little by way of example as to what is a "procedural detail" versus a "procedural process." One might well posit that the more ministerial and clerical provisions (e.g., who is the election official to open and count votes) would be the only kinds of rules allowed outside of the medical staff bylaw document per se.

The Revision to Standard MS.1.20 also states that the medical staff bylaws must indicate what authority the medical staff has delegated to the medical staff executive committee, and how that authority is removed. Further, the new Joint Commission pronouncement states that the medical staff has the ability to adopt medical staff bylaws, rules and regulations and policies and propose them directly to the governing body, even if the subject matter had been delegated to the medical staff executive committee. While the revised standard does not specifically mandate what kind of action hospital leadership governance should take if it does not agree with an action taken by its medical staff executive committee or the medical staff as a whole, the introduction to the Standard urges the medical staff to consider in advance what action it would take if such a situation occurred.³

The revised MS.1.20 becomes effective July 1, 2009. Hospitals have two years to revise medical staff bylaws necessary to bring them into compliance. These changes, and more particularly the process for effecting change, should be taken into account with regard to any work in which you are currently engaged with respect to your institution's medical staff bylaws, related documents and customs. Your institution may have provisions in its Rules and Regulations, policies or manuals that may be arguably perceived to be more substantive and process-descriptive in nature and will need to be included in the medical staff bylaw revisions in order to comply with the new Joint Commission Standard. Those purely procedural details can remain in the documents that are revised more easily.


  1. Joint Commission defines a "process" as a series of steps taken to accomplish a goal.
  2. A "procedural detail" describes in detail how each step in the process is to be carried out. For example, the process for credentialing licensed independent practitioners can be stated in several steps such as collecting information on a physician, evaluating the information and making a decision about the information. That process will be contained in the medical staff bylaws. The procedural details associated with this process might include who collects the information, how files are kept, what organizations need to be contacted to collect all the necessary information, etc.
  3. In conversations Donna Fraiche has had with representatives of the Joint Commission, she took away an impression that there could be concerns about the impact on patient care if the level of dissent and discourse among a medical staff, its leadership and board reach such an impasse that may be reflective of deeper systemic operational issues in the delivery of health care. Additionally, the Joint Commission study efforts on this subject reflected on the need for leadership training, better medical staff communication and a method to resolve potential conflict.

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