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JCAHO releases second clarification of bylaws standard

Credentialing Resource Center Connection, September 30, 2004

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As rumored at the National Association Medical Staff Services' annual conference in Miami last week, the JCAHO issued yet another clarification of its bylaws requirement standard, MS.1.20, on September 29, 2004.

The good news is that the clarification does not appear to require medical staff leaders to shift credentialing, privileging, appointment, and fair hearing and appeal processes from separate documents back into the medical staff bylaws as some feared it would.

The latest clarification does state that if your hospital opts to include "administrative procedures," which are associated with processes described in the medical staff bylaws for corrective actions, fair hearing and appeals, credentialing, privileging, and appointment, in supplemental documents, it must
1. Describe in the bylaws the mechanism for the approval of the administrative procedures
2. Include in the bylaws the criteria to identify those administrative procedures that can be in the supplementary documents
3. Ensure the administrative procedures detailed in supplementary documents are approved by the medical staff and governing body through the mechanism described

Stay tuned to Medical Staff Briefing and Briefings on Credentialing for more information.

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