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JCAHO takes yet another look at its medical staff bylaws standard

Medical Staff Leader Connection, March 1, 2006

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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) made available for field review revised medical staff standards addressing what information must be included in hospital bylaws versus that which may be included in supplemental documents, such as manuals and policies. The revisions, meant to clarify a set of similar revisions proposed roughly a year ago, have left many in the field more confused than before. Opportunity for comment closes March 10, 2006.

The JCAHO has issued three clarifications on standard MS.1.20 in as many years, each resulting in significant public debate. In 2005, the Joint Commission assigned a special task force to deliberate on the proposed revisions and clarify its stance on the issue.

Separately, an ad hoc advisory group whose results were reviewed by the JCAHO's Board of Commissioners Standards and Survey Procedures Committee identified two primary areas of concern:

• Ambiguity regarding the meaning of the term "administrative processes."
• The potential impacts for organizations that might need to open and revise their medical staff bylaws in order to comply with the revised standard.

The JCAHO seeks comments on whether the revisions were sufficiently clear, whether the revisions would necessitate significant change to organizations' existing medical staff bylaws, and, if so, whether organizations would have sufficient time to implement the changes before the revisions go into effect January 1, 2007.

"The revisions certainly suggest that a great many medical staffs that have chosen to write flexible, user-friendly governance documents will have to undertake a major rewrite effort," said Todd Sagin, MD, JD, vice president and national medical director of The Greeley Company, a division of HCPro, Inc.

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