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MS.1.20, Part II: Clarification or Confusion?

Credentialing Resource Center Connection, November 15, 2007

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center in Dallas, where she oversees the medical administration, graduate medical education, and medical staff services department.

Dear credentialing colleague:

On November 1, 2007, The Joint Commission (formerly JCAHO), held a conference call for accredited hospitals to discuss the revisions to the MS.1.20 standard. Although the call was meant to provide clarification, the discussions between the MSPs and healthcare attorneys seem to indicate that the call actually may have caused more confusion than clarification.

For example, the new standards-slated to go into effect in July 2009-refer to the "organized medical staff" in several areas. During the conference call Joint Commission representatives indicated that what they meant by "organized medical staff" was those physicians who have been identified as having voting rights. Even MSPs who have been in the field for just a short period of time will recognize that most organizations refer to the medical staff in its entirety as the "organized medical staff". If The Joint Commission does not mean the "organized medical staff" as most organizations define it, why not clearly state what it means? That is, physicians who have been identified by the organization as having voting rights.

Another point of confusion is current language in the standard that says "The requirements of EP's 9-33 must be in the medical staff bylaws. However, the procedural details associated with EP's 26 through 33 must appear either in the medical staff bylaws or in the rules and regulations or policies." So, when The Joint Commission indicates that all of the requirements for EP's 9-26 must be in the bylaws this includes the process for privileging Licensed Independent Practitioner's. But, how much of this process must be included? Does The Joint Commission mean the entire privileging process, from developing privileges, establishing criteria for privileges, and granting, revising, or renewing privileges? This would be a manual in and of itself.

The issue regarding vetoing the authority of the medical executive committee, by allowing the organized medical staff to submit a petition directly to the board, was briefly discussed but again the statement "it was not our intention" was used. If it was not their intention, why not clearly state what the intention is?

The one issue that was clear is that The Joint Commission will be issuing documentation that provides further clarification, but I remain concerned about the effectiveness of such a course of action. If a standard needs a clarifying document, then why not re-write the standard and clearly indicate its intent from the start? For now, however, to the best of our knowledge the standard is not changing, so we can only hope for further clarification.

Editor's note: You can download a MP3 file of the November 1 Joint Commission teleconference at www.jointcommission.org/AccreditationPrograms/07_calls.htm.

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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