Medical Staff Questions, Feedback
If none of these outstanding (if I do say so myself!) sources of help, information, direction and connection quite address the medical staff problem you are facing, the CMA wants to know and to help. Contact Deborah Winegard, CMA vice president and general counsel, at dwinegard@cmanet.org. The CMA strives to empower medical staffs, and all the efforts are lavished on you Californians. Go ahead. Gloat.
Elizabeth "Libby" Snelson, Esq., legal counsel to the medical staff, represents staffs in California and elsewhere. In addition to conducting medical staff bylaws analysis and drafting, she is a frequent speaker at medical staff leadership retreats and in programs sponsored by the California Medical Association, the American Medical Association and other organizations. Her articles on physician advocacy and medical staff legal issues have appeared in several medical society publications. She is the author of The Physicians' Guide to Medical Staff Organization Bylaws, published by the AMA. She can be reached at 651/293-0321 or easesq@snelsonlaw.com.
FEATURE ARTICLE SIDEBAR
Joint Commission Changes Medical Staff Bylaws Standard
After years of revisions and controversy, the Joint Commission standard on medical staff bylaws has been finalized. The revised standard clearly supports medical staff self-governance, a long-standing requirement for Joint Commission accreditation for hospitals. Joint Commission standard MS 1.20 calls for important elements of self-governance such as selection of medical staff leaders and delegation of authority to the medical staff executive committee to be clearly established in the medical staff bylaws.
The standard does not go into effect until July 1, 2009, to allow ample time to develop amendments for the approval of the medical staff and the hospital governing body. Even the strongest medical staff bylaws will need revision to meet the new MS 1.20, which includes requirements not called for in previous Joint Commission standards. Medical staffs should not hesitate to begin considering amendments. Of course, it is critical that medical staffs proceed with caution to make amendments that protect and preserve the interests of the medical staff while achieving compliance with the revised MS 1.20.
The revised standard boosts medical staff self-governance by requiring that most elements be addressed in bylaws voted on by the medical staff, rather than by the medical executive committee acting on behalf of the medical staff. Under the revised MS 1.20, the medical staff must retain the ability to propose directly to the hospital board not only bylaws, but also rules, regulations and policies, and any amendments thereto. However, certain procedural details are allowed to be addressed in rules and regulations or policies subject to approval only by the medical executive committee. Further, in addition to describing what authority the medical staff confers on the medical executive committee, under the revised MS 1.20, medical staff bylaws must describe how the authority is delegated and removed. These new requirements should protect medical staffs from being controlled by medical executive committees comprised chiefly of hospital-appointed department heads and administrative representatives.
The revised standard MS 1.20 preserves the intent of the original MS 1.20, to provide medical staffs and hospitals with a list of what has to be in medical staff bylaws. Medical staff bylaws that had been divided into separate plans and manuals will require revision to comply with the new MS 1.20. Generally, any medical staff that has a "Fair Hearing Plan," a "Credentials Manual" or an "Operations and Functions Manual" will need to revise its bylaws. The revised MS 1.20 should help to make medical staff bylaws more transparent and responsive to medical staff members.
The standard is at www.jointcommission.org/AccreditationPrograms/Hospitals/revisions_std_ms120_approved.htm.
