Bylaws and governance monthly: Resolving conflicts between the MEC and medical staff

As we reported in the December 24 issue of Medical Staff Leader Connection, The Joint Commission has released its latest version of medical staff standard MS.01.01.01 for field review. This new standard addresses how medical staffs and medical executive committees (MEC) should manage conflicts.

According to the standards, these conflicts may include, but are not limited to, those pertaining to the adoption or amendment of a rule, regulation, or policy. The standard also states that The Joint Commission’s intention is not to prevent medical staff members from communicating with the governing body regarding a rule, regulation, or policy that has been adopted by the medical staff or the medical executive committee, and that the governing body determines the method of communication.

Some may think that this regulation will force the medical staff to develop an entirely new process, but medical staffs and MECs have had their fair share of conflicts in the past, and most medical staff bylaws already have a means for resolving those conflicts. Complying with this standard may be as simple as adjusting some clauses that are already in your bylaws.

Below is some model bylaws language that you can use to resolve medical staff/MEC conflicts. This will allow you to be ready to comply with the latest version of MS.01.01.01, which will likely go into effect as is in 2011.

• Each staff member in the active category may initiate a call for a general staff meeting to discuss a matter relevant to the medical staff. On presentation of a petition signed by 10% of the members of the active category, the MEC shall schedule a general staff meeting for the specific purposes addressed by the petitioners. No business other than that detailed in the petition may be transacted.
• Each staff member in the active category may challenge any rule or policy established by the MEC. In the event that a rule, regulation, or policy is thought to be inappropriate, any medical staff member may submit a petition signed by 10% of the members of the active category. On presentation of such a petition, the adoption procedure outlined in [the appropriate section of these bylaws] will be followed.
• The above sections do not pertain to issues involving individual peer review, formal investigations of professional performance or conduct, denial of requests for appointment or clinical privileges, or any other matter relating to individual membership or privileges.

For further assistance in complying with MS.01.01.01, please contact me at mhoppa@greeley.com. 

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