Hospitals Can Weigh in on Revised Joint Commission Standard

Liz Jones , December 28, 2009

The Joint Commission recently asked hospitals to weigh in on the long disputed standard MS.01.01.01 (formerly MS.1.20). Hospitals only have until January 28, 2010 to read the revised standard and relay their responses to The Joint Commission.

Carol S. Cairns, CPMSM, CPCS, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, suggests that hospital and medical staff leaders who disagree with the latest draft standard of MS.01.01.01 communicate not only with The Joint Commission, but also with their associated professional organizations, such as the American Medical Association or the National Association Medical Staff Services. She also suggests that hospitals respond as an organized group, rather than as a handful of individuals.

For those who are unfamiliar with the standard, found in the Joint Commission's Comprehensive Accreditation Manual for Hospitals, and its resulting debate, here's a rundown: In 2007, The Joint Commission sent proposed revisions of the standard out for field review and met with heavy resistance. The Joint Commission felt the revised standard would improve the relationships between the hospital governing board, the medical staff, and the medical executive committee.

However, critics questioned the appropriateness of allowing the medical staff to circumvent the medical executive committee and bring matters straight to the governing board. Opponents also claimed that the requirement to incorporate the details usually found in rules, regulations, policies, and procedures into the bylaws were too costly and time consuming. The standard has gone through several revisions since then.

The latest draft was developed by a task force charged with finding a reasonable solution to this years-long debate. It has the backing of the American Hospital Association, American Medical Association, American College of Surgeons, American College of Physicians, American Dental Association, Federation of American Hospitals, and National Association Medical Staff Services.

The highlights of the latest version of the standard are:

  • Certain processes and procedures need to be mentioned in the bylaws, but their associated details, which are often lengthy, can be incorporated into rules, regulations, policies, and procedures. The previous draft of MS.01.01.01 would have required the associated details to be included in the bylaws. "The adoption of the associated details that reside outside of the bylaws has a process of approval that doesn't take the whole medical staff. In previous versions, that was not always clear or allowable," says Cairns.
  • The medical staff and the medical executive committee must design a process for resolving disputes. According to Michael Callahan, Esq., partner at Katten Muchin Rosenman in Chicago, leadership standard LD.02.04.01 requires the medical executive committee and the hospital governing board to develop a conflict resolution process. However, the requirement to develop a conflict-resolution process between the medical staff and the medical executive committee is new. "Everyone is going to have to change their bylaws to accommodate this change."
  • The medical staff can go directly to the governing board to amend or adopt a rule, regulation, or policy, but it needs to communicate its intention with the medical executive committee first. On the same note, if the medical executive committee wishes to adopt or amend a rule, regulation, or policy, it must also communicate that to the medical staff. "My guess is that this is going to be an infrequently used element of performance because most of the time, most medical staffs aren't that far of track with their medical executive committees," says Cairns. "However, there are medical staffs out there that have serious conflicts internally, and this allows the medical staff a route to make a bylaws change and send it to the board."

In its "Frequently Asked Questions Regarding Standard MS.01.01.01 (formerly MS.1.20)," The Joint Commission states that many medical staffs will only need to revise small portions of their bylaws, if they need to make any revisions at all, but it might not be that easy, says Cairns. "They say it isn't going to be a big deal for most organizations. I'm not sure it will be as simple as a little tweak here and a little tweak there, and that is why the field needs to speak up." To send your comments to The Joint Commission, visit

Callahan expects that The Joint Commission will fast track the adoption of this standard and that the current working draft will be passed as is. "It is not a perfect document, but people are tired of dealing with it and want to move on," he says. "If they don't like it, they can vote with their feet and go to a different accrediting body, such as DNV or HFAP, but they need to carefully evaluate those options before they jump."

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

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