New Joint Commission's Medical Staff Bylaws Standard Strikes Balance

Liz Jones , March 19, 2010

However, this isn't a big change for many hospitals, O'Connell says. "I know many hospitals that have a provision that would allow the medical staff to propose an amendment to the governing board—requiring perhaps a 10% or a 25% petition of the medical staff."

Although some continue to worry that this provision undermines the medical executive committee's authority, "If you don't interpret it too severely, all it says is that we have to have some mechanism to let medical staff members talk to the MEC," says Joseph Cooper, MD, CMSL, a consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.

Hospital leaders may not be concerned whether certain provisions are included in the medical staff bylaws, but they might care about provisions that allow the medical staff to propose amendments to the medical staff bylaws, rules and regulations, and policies and procedures directly to the governing board because the governing board sets the direction for the hospital.

If the medical staff brings an amendment in front of the governing board that would affect credentialing or privileging, for example, the governing board needs to decide whether that amendment would improve or diminish the quality of physicians on the medical staff, and the quality of physicians directly affects the hospital's quality outcomes.

When The Joint Commission sent the most recent version of the standard out for field review in December 2009, it received relatively positive feedback, says O'Connell. Sixty-six percent of respondents indicated that this current standard is an improvement over the past versions and only 4% said it is worse.

The remaining 30% are unsure whether the standard is better or worse and need further clarification. To that end, O'Connell says The Joint Commission will be issuing educational materials in the coming weeks and months.

Liz Jones is an associate editor at HCPro, Inc. She writes Medical Staff Briefing, Hospitalist Leadership Advisor, and Credentialing and Peer Review Legal Insider. She can be reached at

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