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May 2010

 

Joint Commission Standard MS.01.01.01

Revised EP Provisions to be Included in Medical Staff Bylaws

 

On March 18, 2010, the Joint Commission issued the revised Medical Staff standard MS.01.01.01, which was originally known as MS.1.20. This standard addresses the governance structure of the Medical Staff and its accountability to the hospital’s Governing Body. The standard was originally created in 2004 and was subsequently revised in 2007. Since the 2007 revision, there have been many questions regarding the requirements for terms in the Medical Staff bylaws, the role of the Medical Executive Committee, and the cost and burden imposed on hospitals associated with changing the Medical Staff bylaws.

The final changes made to MS. 01.01.01 are important as they likely will require significant changes to many hospitals’ Medical Staff Bylaws. It is important to note that anything contained in Standard MS.01.01.01 that conflicts with the Centers for Medicare & Medicaid Services Hospital Conditions of Participation, either now or in the future, will be changed to align with the CMS requirements. Standard MS.01.01.01 goes into effect March 31, 2011, providing hospitals and their Medical Staffs with one year to comply with the revised requirements.

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