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JCAHO delays new medical staff requirement until 2007

Medical Staff Leader Connection, May 23, 2006

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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced that the implementation of the new requirement for Medical Staff standard MS.1.20 has been delayed until January 2007. The JCAHO closed a field review of MS.1.20 in early March 2006 addressing what information must be included in hospital bylaws versus that which may be included in supplemental documents, such as manuals and policies.

The standard is expected to undergo a second field review in late summer to address hospital concerns about requiring extensive review of existing medical staff bylaws and other documents.

The JCAHO's Standards and Survey Procedures Committee will provide additional input for the field review at its July 17 meeting, and a possible implementation date will be determined at that time, the National Association of Medical Staff Services (NAMSS) reports on its Web site.

Under the standard, the new Element of Performance (EP.19) would require that the medical staff and the governing body agree on the following:

• the issues that must be addressed in the medical staff bylaws
• the criteria used to identify the issues that must be addressed in the medical staff bylaws
• the process used for joint adoption/approval of other issues that are addressed in the rules, regulations and policies

The proposed EP evoked serious concerns from the field, which sees the new requirement as prescriptive and burdensome for the fact that it requires an extensive review of existing medical staff bylaws and other documents.

The JCAHO stated on its Web site that delaying implementation allows further exploration and possible modifications that would address these concerns. MS.1.20 originated from the 2004 reformatting of the standards. Following confusion in the field regarding the intent of MS.1.20, EP.19 was developed. 

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