2004 JCAHO standards: Don't react just yet

Dear Medical Staff Leader:

The Joint Commission on Accreditation of Healthcare Organizations recently released a prepublication version of its revised 2004 medical staff. In this draft version, standard MS.1.20 states that the medical staff bylaws address self governance and accountability to the governing body. The standards include "elements of performance". In this most recent draft, the elements of performance for MS.1.20 identify a number of items you must include in your medical staff bylaws.

The 2004 standards include several requirements that specifically relate to the credentialing and privileging process. This change has generated interest because many medical staffs have developed medical staff bylaws over the last several years that are more concise and easier to use than in the past. In so doing, many medical staffs pulled information related to credentialing and privileging, committees and departments, and quality and peer review out of the bylaws and put in manuals. This approach aims to make the bylaws serve as a "medical staff constitution," that delineates the rights and responsibilities of all medical staff members and how they will be governed. The bylaws should be hard to change, and medical staffs should think long and hard before changing these elements.

In contrast to these rights and responsibilities, the steps for processing a credentialing application, required application information, and credentials committee membership and responsibilities may need to be changed with some frequency as regulations, case law, and best practices evolve. Many medical staffs have entrusted these changes to the medical staff leaders [e.g., medical executive committee (MEC)] with excellent results. This approach works well because the bylaws include a provision that allows medical staff members a hearing before the MEC if the MEC adopts unpopular policies or procedures. In addition, medical staff members are permitted to call a special meeting of the medical staff to discuss controversial issues. These provisions protect the rights of physicians in a democratically organized medical staff.

Some medical staffs that have adopted this approach are now wondering, in light of the current draft of the 2004 JCAHO medical staff standards, if they must move credentialing and privileging information back into their bylaws. It is quite premature for medical staffs to make any changes. Keep in mind, the standards will not be finalized and disseminated until late August of this year. The release of the standards will be followed by discussion in the field regarding the potential affect of the final standards. We will then have to wait to see how surveyors interpret and apply the new standards. In short, there is no need for any medical staff to take action on this issue at this time. We will all know more as the next year unfolds.

That's all for this week.

All the best,

Rick Sheff, MD