Accreditation

Revised MS.1.20 'huge improvement', out for comment again

Briefings on The Joint Commission, October 1, 2006

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1. describe two changes in the latest revision of MS.1.20

JCAHO has again revised the proposed language for medical staff standard MS.1.20, which contains bylaws requirements and has been the subject of heated debate since it was first introduced in 2003.

The latest field review includes 19 questions that may be answered and submitted electronically on the JCAHO Web site through October 27.

This is the third time that MS.1.20 has been revised and put into field review. The required implementation date of the standard remains January 1, 2007.

There are some interesting points in the latest revision, according to consultants with The Greeley Company in Marblehead, MA, a division of HCPro, Inc., which publishes this newsletter. The revision states that the governing body must

  • approve policies
  • comply with the medical staff rules

    Consult the JCAHO's Web site for the proposed language of the MS.1.20 standard, a five-page PDF found under the "Standards" tab on the home page.

    The Greeley consultants also observed the following nuances in the elements of performance (EP):

  • EP 1 seems to require that a hospital have both rules and regulations and policies. Although most tend to have these, there is no reason for JCAHO to require both, the consultants say.
  • EP 6 and EP 7 are implementation expectations, yet they are assigned level "A" scoring designations, leaving no room for variation (Level A EPs are scored yes or no). A hospital could receive a requirement for improvement if a single physician does not comply with an MS policy.

    Despite these issues, Todd Sagin, MD, JD, Greeley vice president and national medical director, said "this is a huge improvement over what has been threatened in the past."

    "The only issue is whether they intend to insist on the existence of rules and regulations," Sagin says. "In the introduction, [the JCAHO says organizations] 'may' have them, but in EP 1 and elsewhere, they talk as if they are mandatory."

    The Greeley consultants say the preferred approach is to call everything aside from the bylaws "policies," as there are no definitions for "rules" or "regulations."

    The only other area of concern, Sagin says, is in EP 18, which contains the term "summary suspension." This term is not defined and has been the subject of confusion in legal cases.

    "This EP means that the term would have to be utilized in some way in the bylaws," he says. "We prefer the language 'precautionary' suspension, but this is an easy thing to address through the semantics of the bylaws."

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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