• E-mail
• Print
• RSS

Joint Commission updates and compliance with CMS regulations

Credentialing Resource Center Connection, March 5, 2009

Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

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

Dear credentialing colleague:

The Joint Commission updated its 2009 standards to reflect regulations required by the Centers for Medicare & Medicaid Services. Although these standards are already in effect, surveyors will not begin scoring hospitals against these new standards until July.

One of the updates that will likely impact most MSPs who oversee the revisions to the Medical Staff Bylaws and Rules and Regulations at their facility is the new element of performance (EP 20) for MS.01.01.01. EP 20 indicates that for hospitals that use Joint Commission accreditation for deemed status purposes, the requirements for completing and documenting medical histories and physical examinations must be in the medical staff bylaws. As many organizations include this language in their rules and regulations, moving this data to the bylaws may require revisions and a vote from the active staff, depending on how your organization processes amendments to the bylaws. MSPs should work closely with the medical records department or medical records committee, as well as medical staff leadership, to update their bylaws as needed.

Additionally for those hospitals, MS.01.01.01, EP 21 indicates that medical staff bylaws must include a statement of the duties and privileges related to each category of the medical staff (i.e, Active, Associate). While most organizations already have this language in their medical staff bylaws, these new standards give us all a good reason to conduct a detailed assessment of the content of our bylaws.

Despite the pending review of the standard formerly known as MS.1.20 (which outlines what must be in the bylaws versus other documents) your medical staff may want to include more information about credentialing and privileging in your bylaws. Some organizations currently only include brief statements in their bylaws, such as “the credentialing and privileging process is outlined in the medical staff policies and procedures.” Organizations may want to include a summary in the bylaws and elaborate upon the process for credentialing and privileging. This addition may reference the location and details of  associated documents. Elaborating upon the process does not mean including five pages of credentialing process and procedure; the organization can summarize those five pages into a general statement and reference the policy for additional information. This summary should not include items that may change routinely.

Some of the other medical staff standards that changed may also have an impact on the medical staff rules and regulations. These clarifications focus on autopsies and supervision of ionizing radiology services. MSPs should review these new standards and work with all parties to ensure that these updates are reflected in your medical staff governing documents as applicable.

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

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

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