Deadline approaches for MS.01.01.01 compliance for Joint Commission-accredited hospitals

The deadline for complying with Joint Commission standard MS.01.01.01 is March 31. If you have updated your bylaws in compliance with MS.01.01.01, congratulations. If not, don’t panic!

The first thing to remember is don’t over-interpret the standard.  Many medical staffs make more of standards than is necessary. Just stick to the letter of the law, so to speak, meaning if your bylaws were compliant with 2010 standards, then there are only a few areas that need to be addressed: 

• The bylaws must be approved by the voting members of the general medical staff. No longer can other groups, such as the MEC, approve parts of the bylaws prior to going to the board for approval.
• The fair hearing, appeal, and credentialing processes must be in the bylaws proper, but the procedures aligned with these processes can still reside in associated documents. Therefore, if you choose, you can put only the big picture items of the process in the bylaws and still keep the details of the procedure in those associated documents. Alternatively, you can choose to put the big picture items and the details in the bylaws and be compliant.
• You must have a way that the general medical staff can propose amendments to the bylaws without being stifled by other medical staff committees. This is to prevent one individual from bogging down the entire process with endless requests for bylaws amendments. Therefore, if there is significant support (defined by the organization – usually somewhere between 10-25% of the voting medical staff as noted on a signed petition) by the general medical staff, it should at least be brought up in a forum for a proper vote.
• There must be a conflict resolution process when issues arise between the organized medical staff and the MEC. This ensures that when a significant number of medical staff members express concern regarding an issue, the MEC cannot avoid meeting with the organized medical staff to discuss the issue. This provides a checks-and-balances mechanism that allows the elected leadership to govern and ensures that they listen to their electorate.
• In the past, the organized medical staff has delegated certain authority to the MEC. This authority can also be removed, usually through a bylaws amendment process.
   

The above limited changes should be addressed in the short term. Although the above changes are due at the end of March, this is a good time to ask how well your current bylaws work for your medical staff. Take the opportunity review the bylaws and determine how they can be improved. If you need assistance with this process, please feel free to contact our organization. 

Mary Hoppa, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Danvers, MA.