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Ask the Expert: What are The Joint Commission requirements for meeting attendance?

Credentialing Resource Center Connection, February 21, 2008

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Q: Is there a Joint Commission requirement that physicians attend a certain number of meetings per reappointment cycle in order to remain on staff or to remain in a particular category, i.e., "Active"? In particular, the general staff meeting, or any meeting that a physician may have been appointed to? If we remove the committee attendance requirement from our bylaws will we be in jeopardy? 

A: The 2008 Hospital Accreditation Standards published by The Joint Commission do not mandate that physicians attend a certain number of medical staff meetings (general or committee) in order to retain medical staff membership or to maintain status in a particular category of staff membership.

However, a healthcare facility invites a whole host of problems (both legal and non-legal) if it eliminates the attendance requirements from its medical staff bylaws. Practically speaking, if attendance requirements are eliminated, there may not be enough medical staff members in attendance at meetings to meet quorum requirements, thereby disabling the medical staff to carry out its important work of overseeing the quality of care, treatment, and services provided by practitioners with privileges on the medical staff, as required by standard MS.1.10.

Overall, there is a trend toward greater governance accountability in the healthcare industry. If attendance requirements were eliminated, then the medical staff would lag behind in the current good governance environment. 

This week's reader-submitted question was sent in by Monique Flynn, CPMSM, credentials coordinator at Casa Colina Centers for Rehabilitation in Pomona, CA.  Fatema Zanzi, Esq., a lawyer in the healthcare practice group at Drinker Biddle & Reath, LLP, in Chicago, IL answered it.

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