Element of Performance 19 Controversy

Accreditation Monthly, February 15, 2005

Dear Colleague,

This month, I would like to discuss MS.1.20-"medical staff bylaws address self governance and accountability to the governing body." In particular, I would like to focus on the evolving controversy surrounding element of performance 19, which addresses corrective actions, fair hearing and appeal, credentialing, privileging, and appointment documents that supplement the bylaws.

According to Dr. Todd Sagin, National Medical Director of The Greeley Company, one issue that all hospitals struggle with is assuring that they possess medical staff bylaws that are clear, effective, and compliant with regulatory standards. Some medical staffs have modified their bylaws in a perfunctory manner over many years-resulting in a document that is often extremely lengthy, rife with inconsistencies, contains disorganized content, and offers little clarity and guidance regarding medical staff duties and operations. The consequences can range from relatively minor organizational confusion to more serious claims of breach of contract-leading to lawsuits.

On the other hand, many medical staffs have put considerable effort into careful review of their governing documents, making sure they drive best practices in medical staff structure and processes. Often they organize these bylaws into a series of organizational manuals, which are user-friendly and flexible.

Over the last few months, the JCAHO has promulgated two clarifications detailing additional steps accredited organizations must meet when related medical staff documents supplement the bylaws. The most recent clarification in December 2004 provided additional information on element of performance 19 that in effect requires hospitals to flow chart the steps in the process of related documents in order to identify major or substantive components from minor components.

According to this most recent clarification, major or substantive components must be incorporated into the bylaws proper. Based on feedback, the JCAHO has realized that they have not created clarity with their pronouncements on bylaws, and they have expressed an interest in hearing from accredited organizations regarding this issue.

So, if you have not yet provided feedback to the JCAHO on MS.1.20, please send your comments or concerns to John Herringer, Associate Director, Standards Interpretation Group, at Comments will be accepted through February 15, and a response to these comments is expected to be released in March 2005. It is recommended that organizations make no bylaw changes specifically related to this requirement until after the release of comments in March.

I hope you continue to find this information of value in your ongoing preparation efforts. If The Greeley Company can be of any further assistance, please do not hesitate to give us a call at 888-749-3054.


Steven Bryant
Practice Director
Accreditation & Regulatory Compliance
The Greeley Company

For more information on our accreditation and regulatory compliance consulting services, click here or contact Denise Paquette, Practice Manager, at or call 888/749-3054, ext. 3436.

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