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JCAHO releases yet another bylaws clarification

Credentialing Resource Center Connection, October 27, 2004

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If you weren't already confused, the JCAHO on October 21 released its third clarification within the last 10 months on its bylaws requirement standard MS.1.20.

The JCAHO warned that all hospital medical staffs and governing bodies must evaluate

their existing medical staff bylaws and supplemental governance documents for compliance with the criteria in the clarification and make any necessary changes before January 1, 2006.

In the latest clarification, the JCAHO spells out more specifically what must be contained in the bylaws and what administrative procedures can be in supplemental documents. While the JCAHO says administrative procedures that have a minor impact on the outcome of a process may be described in supplemental documents (such as rules and regulations and policies), the accreditor says hospitals must include in their bylaws a description of the steps that have a major impact on outcomes associated with the processes for corrective actions, fair hearing and appeal, and credentialing, privileging, and appointment.

Some hospitals may need to rewrite their bylaws to comply with the new clarification, says Richard Sheff, MD, chair and executive director of The Greeley Company in Marblehead, MA. But he cautioned that hospital leaders should not over react.

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