• E-mail
• Print
• RSS

JCAHO delays MS requirement until 2007

Accreditation Connection, May 9, 2005

Medical services professionals (MSPs) can breathe a huge sigh of relief. The JCAHO announced it will delay until January 2007 a new requirement that would have forced many hospitals to rework their medical staff bylaws.

In response to "serious concerns" from hospitals that the proposed changes to standard MS.1.20 are "prescriptive and burdensome," the JCAHO said in its just released April issue of This Month at the Joint Commission, that it would not implement any new requirements under controversial Element of Performance (EP) 19 until 2007.

The April announcement followed three prior clarifications of the standard that left MSPs wondering whether compliance required that they
 
 reference specific medical staff functions and procedures in the bylaws if those procedures are detailed in separate documents

 shift credentialing, privileging, appointment, and fair hearing and appeal processes from separate documents back into the medical staff bylaws

 include criteria in the bylaws that identifies administrative procedures that are addressed in supplemental documents
 
For now, it appears that the JCAHO is sparing MSPs the time and headache of transferring information related to credentialing, privileging, appointment, and fair hearing and appeal processes from separate documents back into the medical staff bylaws-a task that some MSPs began to tackle when the JCAHO first announced its 2004 standards.

"Delaying implementation allows further exploration and possible modifications" to address hospitals concerns that the previously proposed modifications to the standard would require extensive changes to medical staff bylaws and supplemental documents, the JCAHO said.

"This is excellent news," says Carol Cairns, CPMSM, CPCS, president of PRO-CON, and a consultant for The Greeley Company in Marblehead, MA. "The previous [change to MS.1.20] was burdensome and would have required many hospitals to undertake a costly revision, spending time and money without benefit to medical staffs who use supplemental documents."

The new EP 19, just released by the JCAHO in the latest announcement, requires that the medical staff and governing body agree on the following:

 The issues hospitals must address in the bylaws.
 The criteria hospitals will use to identify the issues they must address in the bylaws.
 The process used for joint adoption/approval of other issues that hospitals address in their rules, regulations, and policies.

The announcement is good news for hospitals and medical staffs, says Todd Sagin, MD, JD, national medical director of The Greeley Company, who has worked with hospitals across the country to modernize bylaws. "The JCAHO deserves credit for stepping back from this onerous regulation and giving further consideration to the issues involved. In the wake of the decision, most hospitals will be well served by moving ahead with any plans to update and modernize their medical staff bylaws."

• E-mail to a Colleague
• Print
• RSS
• Archive