Health Law

JOINT COMMISSION MANDATES CHANGES IN HOSPITAL/MEDICAL STAFF COMMUNICATION EFFECTIVE MARCH 31, 2010.

By Greg Piche'

In less than 6 months, March 31, 2011 to be exact, the new Joint Commission Standard for hospital medical staff bylaws, MS 01.01.01, will be implemented. The focus of the new standard is to improve communication and coordination among a hospital?s governing body, its medical executive committee and the hospital medical staff. The Joint Commission is actively sponsoring a more collaborative relationship and more definitive accountability among the groups by requiring certain processes to be included in the medical staff bylaws, in particularly those contained in Elements of Performance 12 -36 which are mandated.

The standards require greater transparency in process including, among others,  the method of selection, election and removing a member of the MEC by the medical staff ( EP 21), how the medical staff can remove MEC authority (EP 20) and the process for amending medical staff rules, regulations and policies (EP 25), the inclusion of peer review processes in the bylaws (EP 30, 31), and the delineation of qualifications and specific powers and responsibilities of any medical staff department.

EP 11 requires a process for the resolution of conflict between the medical staff, the MEC and or the Governing Body of a hospital. The Joint Commission in adopting MS 01.01.01 recognizes that efficient and effective patient care and safety require the effective interplay between these constituent entities within the hospital and that there must be some reasonable process to stimulate communication, allocate responsibility and overcome dysfunctional behavior in the management of hospitals. SEE www.jointcommission.org.

Full post as published by Healthcare Law Blog on October 16, 2010 (boomark / email).