On March 15, The Joint Commission ("JC") announced its approval of the revised Medical Staff Standard MS.01.01.01 (formerly known as MS.1.20).  This revised standard requires medical staff bylaws to address the working relationship among hospital governance, medical staff leadership, and the medical staff.  All Joint Commission-accredited hospitals and critical access hospitals will be required to meet the new requirements effective March 31, 2011. 

Discussion

Standard MS.01.01.01 addresses the medical staff's self-governance and its accountability to the governing body for the quality and safety of patient care.  The JC has explained this standard is intended to recognize that while a hospital's governing body is ultimately responsible for the quality and safety of care, the governing body, medical staff and administration must collaborate to achieve this goal.  Medical staff bylaws are a key document governing this collaboration. MS.01.01.01 also provides the framework for constructing, writing and implementing medical staff bylaws.

The revisions to MS.01.01.01 are based on the unanimous recommendations of an 18-member expert task force representing the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, Federation of American Hospitals and the National Association of Medical Staff Services, as well as hospital trustees and medical staff attorneys.  Standard MS.01.01.01 underwent an extensive field review with accredited organizations, physicians and other interested parties.  The most recent field review ended on January 28, 2010. 

Now that MS.01.01.01 has been approved, JC accredited hospitals and medical staffs will need to begin the process to review and likely revise their medical staff bylaws to ensure compliance with the revised standard.  The 2011 version of the accreditation manuals for hospitals and critical access hospitals that will be published and distributed in the fall of 2010 will contain the revised standard. 

Should you have any questions regarding standard MS.01.01.01 or anything contained in this article, please contact your regular Hall Render attorney or Kendra L. Conover (kconover@hallrender.com) at (317) 633-4878.