The Joint Commission, formerly the Joint Commission for the Accreditation of Hospital Organizations, produced its annual standards for hospital accreditation for 2008. The Hospital Accreditation Procedure manual gives a full description of the expected standards for hospital compliance. The standards related to medical staff governance created havoc for some hospital organizations. After learning of the issues, we at the California Medical Association's Organized Medical Staff Section chose to reread Shakespeare's Much Ado About Nothing in preparation for our discussion!

In order to participate in the Medicare program, hospitals must receive oversight from the Centers for Medicare and Medicaid Services. The CMS developed a series of standards for participation in the Medicare program. The Joint Commission, which was established prior to CMS, had a system of hospital inspections. The CMS contracts with the Joint Commission to certify that hospitals comply with the standards of participation. This contract elevates the importance of being certified by the Joint Commission. The Joint Commission also establishes its own standards to push for improvement in the delivery of patient care in hospitals.

On a regular basis, the Joint Commission's Standards Committee reviews and changes the standards based upon input from many sources. Major changes to the HAP occur every five to 10 years, so you should expect some major changes in 2009. The change that excited the American Hospital Association, however, occurred subtly in 2008: the infamous MS. 1.2!

Hidden in the Medical Staff Section, MS. 1.2 sought to destroy the relationship between hospitals and medical staffs. Yes, a plot by the American Medical Association--caught just in time by the AHA--surfaced, threatening the viability of the Joint Commission's survey program. Stop the presses!

From the Comprehensive Accreditation Manual for Hospitals: the Official Handbook:

Standard MS.1.20
Medical staff bylaws address self governance and accountability to the governing board.

Element of Performance
A description of the medical executive's function, size and composition, and of the methods for selecting and removing its members and the organized medical staff officers.

Aye, there's the plot: to remove members of the Medical Executive Committee. Imagine after all the effort to stack the MEC with administration-friendly physicians, the medical staff might actually remove them. You mean, once all the paid medical directors take their assigned places on the MEC, the medical staff could actually vote to remove them? What was the Joint Commission thinking? You mean the medical staff bylaws need adjustment to allow this element of performance? Most AMA-recognized attorneys estimated less than $2,000.

Thank California for this mess. Those darn doctors in Ventura did this! The administration in that small community's hospital decided to stack the MEC with their chosen few. The doctors of the medical staff objected and voted to remove the MEC members, replacing them with their own elected medical staff members. Then the Board of Trustees unilaterally changed the bylaws, forcing a legal battle heard around the country. In California, this battle set the stage for the passage of California Senate Bill 1325, which defined in statute the rights of medical staff members to self governance.

So now the battle over the right of the medical staff to remove the MEC surfaces on a national level. The CMA OMSS and AMA OMSS conference calls abound with this issue. Will the Joint Commission capitulate and remove this innocuous standard? Will the AHA win a concession? Will removal of "and removing" satisfy the AHA? If removed, will the medical staff be truly self-governing?

Please stay tuned and, if you have time, reread Shakespeare's Much Ado About Nothing!