MS.01.01.01: Medical staffs must prove compliance in the bylaws

The effective date for Joint Commission standard MS.01.01.01 compliance is now past. Many medical staffs have fully complied with this standard, while others are still in the process. There are yet others who believe they are compliant but aren’t. Here are some hints to ensure your organization is meeting the goals of this standard.

First, MS.01.01.01 is a bylaws standard. This means that compliance must be shown in the bylaws. Medical staffs most commonly have difficulty complying with these areas: 
 

• Rules and regulations amendment
• Conflict resolution between the MEC and the organized medical staff
• Process and procedure for credentialing and fair hearings
   

Medical staffs have long separated their governing documents into bylaws, rules and regulations, and policies and procedures. For most medical staffs, the amendment process for all of these documents is delineated in the bylaws. But some have defined their approval and amendment process in the document itself. For examples, the rules and regulations amendment procedure are spelled out in the rules and regulations. Keep in mind that MS.01.01.01, element of performance (EP) 8 states that the organized medical staff has the ability to propose bylaws, rules and regulations, or policies amendments directly to the hospital’s governing board. This means that the entire approval and amendment process for these various documents must all reside within the medical staff bylaws.

The same scenario goes for the development of a conflict resolution mechanism between the organized medical staff and the medical executive committee (MEC) (see MS.01.01.01, EP 10). We have seen elegant conflict resolution mechanisms written in policy format, but this mechanism must be brought into the bylaws for compliance with MS.01.01.01.

The final area, although less common, is the consideration of the procedures for credentialing and fair hearings. In both of these areas, the process must be defined in the bylaws, while the procedure may be detailed in associated documents, such as the rules and regulations, manuals, or policies. Regarding the fair hearing process, most medical staffs are including this, in total, into their bylaws because it seems so fundamental, and change is rare (the Health Care Quality Improvement Act of 1986, which is the foundation for this standard, was last amended in 1998).

Medical staffs across the country are divided on how much of their credentialing process and procedure should be in the bylaws. Some have taken the time to separate process from procedure and only include the process in their bylaws because they know this document is much harder to amend when changes are needed. Some have placed the entirety of their credentialing process and procedure into their bylaws and have simplified the overall amendment process such that they will still be able to make changes when necessitated by legal or regulatory change or by a change in their own internal process. Either method is acceptable because it places the process in the bylaws; you can choose to place more in the bylaws than is required by regulatory authority but you cannot place less.

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