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JCAHO's proposed medical staff standards

Medical Staff Leader Connection, June 20, 2003

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Dear Medical Staff Leader,

The Joint Commission recently released a "prepublication edition" of their revised Medical Staff Standards on its Web site. Medical staff leaders may want to instruct their management team to take a good look at these standards and present the medical executive committee with a brief analysis--allowing medical staff leaders to make "mid-course" changes in structure and process when (and if) these standards become effective.

This week I would like to present you with a brief profile of these standards. The overview included with the prepublication standards makes it clear that the medical staff's primary role is overseeing the quality of patient care and making recommendations concerning medical staff membership, clinical privileges, and practitioner competence.

The overview may cause some initial confusion regarding the privileging of physician assistants and advanced practice registered nurses. These standards do not mandate that these practitioners go through the medical staff privileging process unless they are practicing entirely independently.

The JCAHO's overview again suggests that the medical staff is self-governing, but that the governing body has the ultimate authority for hospital and medical staff operations.

This pre-publication edition is organized into five standard categories: medical staff structure; management of patient care treatment and services; performance improvement; credentialing, privileging, and appointment; and continuing education.

Of significance to your organization are provisions indicating that the governing body approves and complies with medical staff bylaws and that the medical staff enforces and complies with medical staff bylaws.

In addition, the JCAHO states that "the medical staff bylaws create a system of rights and responsibilities between the organized medical staff and the governing body, and between the organized medical staff and its members." This language may add fuel to the discussion in some states as to whether or not the medical staff bylaws constitute a legal contract.

Hospitals and their medical staffs will find that these prepublication standards permit greater flexibility when expediting the processing of applications for appointment or reappointment. They also clearly indicate that the JCAHO will only be concerned with the credentialing of physicians engaged in telemedicine when such physicians are permitted to write orders and direct care. Standards indicate less concern when such physicians simply interpret images, tracings, specimens, or provide non-directive consultation to fully credentialed attending physicians.

Although it is important to review the proposed standards, a well-organized, well-run medical staff that works effectively with its governing board and management will find little new substance in these standards.

That's all for this week.

All the best,

Hugh Greeley

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