MS.01.01.01 crunch time
As most of you know, the deadline for meeting Joint Commission standard MS.01.01.01 is March 31. The reason that this standard represents a seismic shift for medical staffs is because for decades, the only way that the organized medical staff could communicate to the governing board was through the medical executive committee (MEC). Effective with the new standards, the organized medical staff will be able to communicate directly to the governing board regarding issues related to the medical staff bylaws, rules/regulations, and policies/procedures. The Joint Commission came to this decision because of the growing concern among medical staffs that as fewer physicians practice in the hospital, opting for ambulatory settings, the MEC may not adequately represent the interests and perspectives of a significant number of rank and file medical staff members. These individuals represent a strategically important group.
The following is a list of some of the key new standards and what you should do to make sure you are prepared to meet the intent of the accreditation standards:
MS.01.01.01, EP 3: Every requirement set forth in Elements of Performance 1 through 36 is in the medical staff bylaws. These requirements may have associated details, some of which may be extensive; such details may reside in the medical staff bylaws, rules and regulations, or policies. The organized medical staff adopts what constitutes the associated details and determines where they reside and whether their adoption can be delegated. The medical staff cannot delegate the adoption of associated details that reside in medical staff bylaws. For Elements of Performance 12 through 36 that require a process, the medical staff bylaws must include at a minimum the basic steps (as determined by the organized medical staff and approved by the governing body) needed to implement the requirement. The organized medical staff submits its proposals to the governing body for action. Proposals become effective only after the governing body has approved them.
Solution: Due to deeming status requirements (the need for all Joint Commission standards to
be consistent with CMS’ Conditions of Participation), all CMS medical staff conditions of participation must be referenced in the medical staff bylaws. The “associated details” may either be in the bylaws or in the rules and regulations or policies. Many organizations wonder what constitutes “associated details” as opposed to the basic steps. Each medical staff should clarify this definition with The Joint Commission directly. Suffice it to say, when there is any doubt, it is easier to merely cut and paste all of the relevant information from your policies, procedures, rules, and regulations directly into the bylaws, and there won’t be any question.
MS.01.01.01, EP 8: The organized medical staff has the ability to adopt medical staff bylaws, rules, and regulations, policies, and amendments and to propose them directly to the governing board.
Solution: The governing board must amend its corporate bylaws to enable the organized medical staff to go through a defined process (e.g., creating a petition with 10% of the medical staff members’ signatures) and present issues regarding medical staff documents directly to the board. This board-approved process should be reflected in the medical staff bylaws.
MS.01.01.01, EP 9: If the voting members of the organized medical staff propose to adopt a rule, regulation, policy, or an amendment, they must first communicate the proposal to the medical executive committee. If the medical executive committee (MEC) proposed to adopt a rule, regulation, or amendment, it first communicates the proposal to the medical staff; when it adopts a policy or an amendment, it communicates this to the medical staff. This element of performance applies only when the organized medical staff, with the approval of the governing body, has delegated authority over such rules, regulations, or policies to the MEC.
Solution: Many medical staff bylaws still enable the MEC to go directly to the board for any amendment to a rule, regulation, or policy. In the interest of optimal conflict management (LD.02.04.01) and in compliance with this element of performance, the MEC should always be required to go through the organized medical staff. This process does not need to be cumbersome or require a regular or special medical staff meeting; it can be handled electronically or through voting by proxy as long as quorums are adjusted to reflect “those participating and eligible to vote” and require only a simple majority.
The final sentence of this element of performance refers to medical staffs that do not have an MEC; rather, the medical staff acts as a “committee of the whole” as described in the rationale for MS.02.01.01.
MS.01.01.01, EP 10: The organized medical staff has a process to manage conflict between the medical staff and the MEC on issues including, but not limited to, proposals to adopt a rule, regulation, or policy or an amendment. Nothing about this process should prevent medical staff members from communicating with the governing body on a rule, regulation, or policy adopted by the organized medical staff or the MEC. The governing body determines the method of communication.
Solution: The medical staff must amend its bylaws to create a conflict resolution process between the medical staff and the MEC when there are legitimate differences around bylaws, rules/regulations, or policies/procedures. This may be as informal as an ad hoc medical staff committee made up of 50% of the medical staff and 50% of MEC members that can meet on an “as-needed” basis to resolve differences.
Again, the governing body must determine how the organized medical staff will communicate directly to the board, and this method of communication should be clearly articulated in the corporate bylaws.
MS.01.01.01, EP 11: In cases of a documented need for an urgent amendment to rules and regulations necessary to comply with law or regulation, there is a process by which the MEC (if delegated to do so by the voting members of the organized medical staff) may provisionally adopt and the governing body may provisionally approve an urgent amendment without notifying the medical staff beforehand. In such cases, the MEC will immediately notify the medical staff. The medical staff has the opportunity to retrospectively review and comment on the provisional amendment. If there is no conflict between the organized medical staff and the MEC, the provisional amendment stands. If there is conflict over the provisional amendment, the process for resolving conflict between the organized medical staff and the MEC is implemented. If necessary, the MEC submits a revised amendment to the governing body for action.
Solution: Due to corporate compliance concerns, the medical staff bylaws, rules/regulations, and policies/procedures may never be inconsistent with federal, state, regulatory, and local legal and statutory obligations. These urgent compliance changes must go into both the corporate and the medical staff bylaws so that they are consistent. Again, it will require a conflict resolution process between the organized medical staff and the MEC and the MEC and governing body (often a joint conference committee made up of 50% of the medical staff and 50% of board and senior management).
As you can see, these changes are significant and will require timely changes to both your hospital’s corporate bylaws and medical staff bylaws so that you will be compliant in time for any unannounced Joint Commission survey after March 31, 2011. If you would like a “solutions packet” with recommended bylaws language, please click here. Otherwise, please work with your hospital and medical staff counsel to come up with language that is acceptable to both the governing board and the medical staff so that you can address the new standards that reflect the delicate balance between leadership groups of the medical staff, the management team, and the governing board.
As ever, please let anyone at The Greeley Company know if you’d like further assistance.
Wishing you continued success,
Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc., in Danvers, MA.