The Joint Commission (formerly "JCAHO") recently approved several key revisions to its standards:

Medical Staff Standard 1.20 - Bylaws, Rules, and Regulations

These revisions, which take effect July 1, 2009, relate to medical staff bylaws, rules, regulations and policies. The most significant revisions include:

  • A requirement that medical staff bylaws indicate what authority the medical staff has delegated to the medical staff executive committee and the processes through which that authority is to be delegated or removed.
  • Underscoring of the medical staff's ability to bypass the medical staff executive committee and propose medical staff bylaws, rules, regulations and policies directly to the governing board.
  • Clarification of which "processes" and "procedural details" must be included in the medical staff bylaws and which may be included in the rules and regulations. A "process" is defined as a series of steps taken to accomplish a goal. A "procedural detail" describes in detail how each step in the process is to be carried out.

Medical Staff - Credentialing/Appointment Process

In an attempt to improve the credentialing process and move toward more objective evidence-based evaluations, the Joint Commission implemented several new standards for credentialing medical staff. Posted in April 2006, most of these new standards became effective as of January 2007, and the remainder become effective in January 2008. While Standards MS 4.00 through MS 4.45 and MS 4.70 are revisions, the revisions are based upon three new concepts.

  • A focus on six areas of general competencies: patient care; medical/clinical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism; and systems-based practice.
  • A Focused Professional Practice Evaluation is a new process whereby the medical staff must evaluate a specific aspect of a practitioners practice. This process is used whenever there is an undemonstrated competence or whenever there is a question regarding a practitioners competence. This Standard does not become effective until January 2008.
  • Changing to Ongoing Professional Practice Evaluations is intended to eliminate the old practice of "privileging by exception" and instead implement continuous monitoring of quality and performance in order to identify current trends.

Leadership Standards

As part of the Joint Commission's regular standards renewal process, the Joint Commission also recently published revisions to the leadership standards for all accreditation programs, which revisions will take effect January 1, 2009. The published revisions include several additional standards and a reordering of the chapter into four sections: (i) Leadership Structure, (ii) Leadership Relationships, (iii) Organization Culture and System Performance and (iv) Operations. Some of the key changes and terms include:

  • New standards related to leadership accountabilities, with the governing body, senior managers, and the organized medical staff identified as potential leadership groups.
  • New standards requiring leadership groups to work together to identify the skills required of individual leaders.
  • New standards addressing management of conflicts between leadership groups, and addressing traditional conflicts of interest (e.g., relationships with other care providers) and requiring the development of policies for the oversight and control of such situations.
  • Development of a culture of safety and quality concept addressing disruptive behavior (with the elements of performance requiring hospitals to have a code of conduct that defines acceptable and disruptive and inappropriate behaviors).
  • Additional guidance regarding oversight of care, treatment and services provided through contractual arrangement.

If you should have any questions regarding any of the above topics or other issues, please feel free to contact any of the members of the Buchanan Ingersoll & Rooney Health Care Section or the Buchanan Ingersoll & Rooney attorney with whom you work.