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Joint Commission Standard MS.01.01.01

MS.1.20 Task Force Reaces Consensus

Key messages concerning Standard MS.1.20 (now MS.01.01.01) and the Task Force

At its June 2007 meeting, The Joint Commission’s Board of Commissioners approved revisions to the hospital Medical Staff standard MS.1.20 related to medical staff bylaws and associated rules and regulations and policies.

Following concerns received from professional organizations and hospitals related to the cost and burden of the newly adopted MS.1.20, The Joint Commission Board established an 18-member Task Force to analyze the potential impact of implementing the revised standard. AMA representatives on the Task Force: Jay A. Gregory, MD, James A. Goodyear, MD, and Brian D. Johnston, MD. Drs. Gregory, Goodyear, and Johnston are members of the AMA Organized Medical Staff Section (OMSS) Governing Council.

The Task Force, which was convened in January 2008, consists of representatives from medical and hospital associations and hospital leaders representing administration, medical staff and hospital trustees.

At its May 2008 meeting, The Joint Commission Board of Commissioners suspended the July 2009 implementation of the June 2007 revised standard.

The Task Force, which met 12 times, focused its discussions on several key issues, including:

  • What needs to appear in the medical staff bylaws and how such decisions are made.
  • The relationship between the organized medical staff and the medical executive committee.
  • How to foster a collaborative and positive relationship among the management, medical staff and governing body.
  • How to manage conflict that may arise between the organized medical staff and the governing body, or between the organized medical staff and the medical executive committee, regarding medical staff bylaws, rules and regulations, and policies.
  • The definitions of terms that appear in the standard.

The Task Force was guided by two principles in the development of its recommendation. These principles attempted to balance hospital executives' and medical staff representatives’ concerns. The two principles are as follows:

  1. The requirements set forth in Elements of Performance 12-36 must be in the medical staff bylaws. For those EPs involving a process, the medical staff bylaws must include the basic steps required for implementation of the requirement. Associated details may reside in the medical staff bylaws, rules and regulations or policies as determined by each hospital’s organized medical staff and governing body.
  2. If the organized medical staff delegates authority to the medical executive committee concerning the details related to EPs 9-33 (contained in rules or regulations), they must be informed of proposed amendments and have the opportunity to respond prior to submission of proposals to the governing body. For minor details contained in policies, they simply need to be informed about the amendment. A reciprocal process is proposed so that when the organized medical staff proposes an amendment, they consult with the medical executive committee before a proposed change is brought to the governing body.

In March 2009, The Task Force reached consensus and unanimous agreement on a totally new "draft" standard that would replace the current MS.01.01.01 (previously named MS.1.20). Consensus means that each member of the Task Force has agreed to actively support the adoption of the recommended new standard.

Task Force members believe that the proposed standard contributes to patient safety and quality of care through the support of a well-functioning, positive relationship between the medical staff and governing body.

If there is sufficient support of the proposed standard among the organizations represented on the Task Force, The Joint Commission would ask these organizations to share the proposed standard with their constituents over a five-month period (May 15 – Oct. 15, 2009) to gather additional feedback. If the feedback supports the proposed standard, The Joint Commission will then consider authorizing the conduct of a field review to provide all interested parties an opportunity to comment on the proposal.

Anything in the draft standard that is found to be in conflict with the Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation, and consequently could threaten The Joint Commission’s hospital deeming status, will be changed to align with the CMS requirements.

Hospitals are currently expected to be in compliance with Medical Staff standard MS.01.01.01 (the standard number changed due to the Standards Improvement Initiative) in the 2009 Hospital Accreditation Manual. The current standard will remain in effect until further notice. There is an indefinite moratorium on the implementation of Element of Performance 19 of the current MS.01.01.01.

Working Draft for Standard MS.01.01.01

Standard MS.01.01.01 presentation slides

Proclamation of support for working draft