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New Joint Commission Standards for Medical Staff Bylaws

In June 2007, the Joint Commission adopted revisions to its standard addressing medical staff bylaws, rules and regulations and policies (Standard MS.1.20). The new Standard, which becomes effective January 1, 2009, significantly changes the requirements for which provisions must be set out in the medical staff bylaws versus the rules and regulations and policies. While earlier standards deferred considerably to the medical staff and the hospital’s governing body, the new Standards sets out specific provisions which must be set out in the bylaws. For example, the requirements and procedural details related to the fair hearing process must be set out in the bylaws; they may no longer reside in separate documents, such as a fair hearing manual. This change in approach will mean many hospitals and their medical staffs must review and revise their bylaws to incorporate provisions now set out in separate rules, policies and manuals.

The new Standard also requires the bylaws to include a provision indicating what authority the medical staff has delegated to its executive committee and how that authority is delegated and removed. The medical staff is also permitted to adopt bylaws, rules and regulations and policies and propose them directly to the governing body even if that action has been delegated to the executive committee.

While hospitals will have eighteen months to work with their medical staffs and governing bodies to revise their medical staff bylaws, rules and regulations, and policies to comport with the new Standard, it is not too early to begin the processes of educating the medical staff and the governing body about the new requirements, developing the necessary amended documents, and obtaining the approvals from the medical staff and the governing body. Our Health Law experts can help you throughout this process.



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