Joint Commission revises standards to align with CMS

The Joint Commission last week announced revisions to its medical staff standards for hospitals and critical-access hospitals. The changes align with CMS’ revised Conditions of Participation (CoPs) announced in May, and address medical staff structure for multihospital systems; requirements for practitioners who are not appointed to the medical staff and who are ordering outpatient services; and governing body consultation with the medical staff.

According to the commission’s Prepublication Requirements document, if a multihospital system with separately accredited hospitals chooses to establish a unified, integrated medical staff, the following must occur:

• Each separately accredited hospital in the system demonstrates that a majority of its medical staff members have voted to accept the unified medical staff structure or to opt out and maintain a separate medical staff for their hospital.
• The unified, integrated medical staff considers each hospital’s unique circumstances and any significant differences in patient populations and services offered in each hospital.
• The unified, integrated medical staff establishes and implements policies and procedures that consider the needs and concerns expressed by medical staff members at each hospital, regardless of practice or location.

The revisions will be effective September 29.

Source: The Joint Commission