JCAHO postpones new requirement for medical staff bylaws

Medical services professionals (MSPs) can breathe a huge sigh of relief, as the JCAHO announced it will delay until January 2007 a new requirement that would have forced many hospitals to rework their medical staff bylaws.

 

In response to "serious concerns" from hospitals that the changes to standard MS.1.20 are "prescriptive and burdensome," the JCAHO said in its just released April issue of This Month at the Joint Commission, that it would not implement any new requirements under controversial Element of Performance (EP 19) until 2007. The JCAHO also left the door wide open for further modifications before that date.

 

Under a change to EP 19 proposed in October 2005, the JCAHO came out with a confusing requirement on what administrative procedures hospitals needed to describe in the bylaws and what processes for corrective actions, fair hearing and appeals, credentialing, privileging, and appointment could be placed in supplemental documents.

 

The new EP 19, just released by the JCAHO, requires the medical staff and governing body agree on the following:

·        The issues hospitals must address in the bylaws.

·        The criteria hospitals will use to identify the issues they must address in the bylaws.

·        The process used to joint adoption/approval of other issues that are addressed in the rules, regulations, and policies.

 

Standard change addresses LIP responsibility

In other news from the JCAHO, the accreditor has revised Leadership standard LD.3.70 to address hospitals' responsibilities for individuals not employed by the organization who provide services under the direct responsibility of a licensed independent practitioner (LIP). The revised standard takes effect January 1, 2006.

 

It will require hospitals to implement a process to determine the competence of  providers-such as nurses, therapists, technicians, and surgical assistants who are employed by an LIP-and ensure the level of competence is equal to that of individuals employed by the healthcare organization to perform the same or similar services. Go to http://www.jcaho.org/about+us/news+letters/this+month+/index.htm#Revised to read the JCAHO's April newsletter.