What do medical staff leaders need to know about MS.01.01.01?
After seven years of study, debate, and field testing, The Joint Commission has finally adopted standard MS.01.01.01, which will go into effect March 31, 2011. The standard will significantly affect the relationship between the medical executive committee (MEC) and the organized medical staff. It will also have implications regarding the content of your medical staff bylaws and the means by which the medical staff can amend its bylaws, rules and regulations and policies.
What is changing?
1. The MEC’s accountability to both the governing body and the organized medical staff
The Joint Commission has added language to MS.01.01.01 that addresses the relationship between the MEC, the organized medical staff, and the hospital governing board. Since the 1980s, the MEC has been the representative voice of the organized medical staff. With the rapidly shifting economic incentives, an ever increasing number of physicians and practitioners are moving out of the hospital into ambulatory settings in an effort to stabilize their declining revenues and increasing overhead costs and gain greater control over their professional lives. As a result, the MEC sometimes inadvertently represents the voices of hospital-based physicians, but that leaves many non-hospital-based physicians feeling increasingly disenfranchised from hospital affairs. Thus, medical staffs feel a greater need to ensure that the MEC is accountable not only to the governing body, but to the organized medical staff as well. Members of the organized medical staff want their views represented, regardless of their practice commitments. They want to be able to vote, recall an election, recall an MEC decision (including modifications to the bylaws and related documents), have a seat on MEC if desired, and secure an audience with the MEC if desired to communicate issues of importance. Many MECs are reconsidering their composition—rather than the traditional model of department chairs and medical officers, they are inviting hospital and non-hospital based physicians to join to better reflect the new and evolving physician demographic.
2. Ability of the organized medical staff recommend amendments to the governing body with or without the MEC
MS.01.01.01, EP9 permits the organized medical staff to introduce amendments to the medical staff bylaws, rules and regulations, and relevant policies directly to the MEC and the governing body. If the MEC declines to consider the proposed amendment or disagrees with it, the organized medical staff may propose the amendment directly to the governing body, as long as the medical staff attempts to resolve its differences with the MEC.
3. Conflict resolution requirements for the organized medical staff and the MEC
MS.01.01.01, EP10 requires that the medical staff develops a conflict resolution process in case the MEC and the organized medical staff disagree regarding the medical staff bylaws, rules and regulations, and relevant policies. This is similar to the 2009 leadership standard that requires the MEC and governing board to develop a conflict resolution process to resolve their differences. The new standard now requires both the MEC and governing board and the MEC and medical staff to have conflict resolution policies because it is concerned that conflicts have the potential to undermine the safe provision of quality clinical services. The organized medical staff does not have the right to question an MEC action with regards to a confidential peer review decision; however, The Joint Commission would like the MEC to be responsive to the perspective and opinions of all medical staff members to ensure that it communicates the medical staff’s concerns directly to the governing body.
4. Medical staff-related Conditions of Participation (CoPs) must be included in the medical staff bylaws
MS.01.01.01, EPs 12-36 cover all of the elements that medical staffs must now include in the bylaws. The Centers for Medicare & Medicaid Services (CMS) has been concerned that not all of its medical staff Conditions of Participation (the minimum requirements necessary to receive payment from the federal government) are prominently articulated in the medical staff bylaws. Some of these elements of performance include areas traditionally covered in the medical staff rules and regulations, such as the requirements for completing and documenting medical histories and physical examinations (EP 16) and the process for adopting and amending the medical staff rules and regulations and policies (EP 25). Although it is not necessary to include all of the operational details of these elements within the bylaws, many medical staffs will find it easier to move these sections into the bylaws so as not to debate over what constitutes a basic versus a detailed process.
5. The MEC and governing body may pass provisional amendments to be in compliance with federal, state, and regulatory requirements
MS.01.01.01, EP 11 permits the MEC to recommend urgent amendments of the rules and regulations directly to the governing body without consulting the organized medical staff when there is a significant concern regarding compliance with federal, state, or regulatory requirements. The MEC may later consult the organized medical staff, and if the medical staff agrees, the provisional amendment shall stand. If there is a difference of opinion between the organized medical staff and the MEC, then a conflict resolution process (EP 10) shall be implemented. The two parties may develop a revised amendment and submit it to the governing body.
In conclusion, MS.01.01.01 represents a significant shift in the accreditation requirements pursuant to the relationship between the organized medical staff, the medical executive committee, and the governing body. These changes reflect political concerns that the MEC may not always accurately communicate the views and perspective of the organized medical staff to the governing body. In addition, CMS would like its medical staff Conditions of Participation (CoPs) to be clearly communicated in the medical staff bylaws to ensure that the organized medical staff and the governing body are aware of their mutual obligations and responsibilities.
If your organization is Joint Commission-accredited, your medical staff will need to modify its bylaws over the next year to conform to these accreditation requirements. Medical staff leaders will need to communicate these changes to members of the medical staff and governing body so there is a clear understanding of the upcoming changes. If your organization is not Joint Commission-accredited, medical staff leaders may wish to discuss implementing many of these changes, as they are considered a best practice and reflect the evolving and complex relationship between the medical staff, the MEC, and the governing body.
Jon Burroughs, MD, MBA, FACPE, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.