Medical Staff

Joint Commission task force inches toward an MS.01.01.01 resolution: What the working draft means for medical staff bylaws

Medical Staff Briefing, October 1, 2009

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All in all, the working draft allows medical staffs enough wiggle room to put certain processes and procedures into credentialing manuals or rules and regulations rather than the medical staff bylaws, as long as those processes and procedures are mentioned in the bylaws, says Joseph Cooper, MD, a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.
Element of performance (EP) 3 in the working draft states that the items specified in EPs 12-36 must be included in the bylaws, but the details—some of which are extensive—associated with those items may reside in the medical staff bylaws, rules and regulations, or policies. It also allows the medical staff to adopt what constitutes the associated details, where they reside, and whether their adoption can be delegated.

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