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JCAHO may take another look at bylaws

Medical Staff Leader Connection, September 23, 2004

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The JCAHO may soon issue yet another clarification of its bylaws requirement standard, MS.1.20, according to speakers at the National Association Medical Staff Services' annual conference in Miami this week.

The JCAHO's publication of its 2004 medical staff standard MS.1.20 initially prompted some medical staff leaders to begin shifting credentialing, privileging, appointment, and fair hearing and appeal processes from separate documents back into the medical staff bylaws. However, the accreditor's December 23, 2003, clarification of the standard put an end to this tedious work.

The clarification stated that the accreditor would allow hospitals the option of continuing to only reference specific medical staff functions and procedures in the bylaws as long as those procedures are detailed in separate documents. However, the accreditor may soon change its stance on this issue and require that these documents be included in the bylaws.

John Harringer, associate director of JCAHO's standards interpretation, would not confirm this news. However, Harringer did say that he is waiting to hear from the standards and survey procedures committee, which is currently taking another look at the standard, before commenting on the standard's requirements. Stay tuned to Medical Staff Briefing and Briefings on Credentialing for more information.

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