Hospitals have just under a year to comply with the Joint Commission's recently revised medical staff bylaw standards, but top commission officials are urging administrators not to make a beeline for their lawyers.

Revisions to the Medical Staff Standard MS.01.01.01, which is designed to bolster patient safety and quality of care by fostering collaboration between a hospital's governing body, senior management and the organized medical staff, were released in mid-March with an effective date of March 31, 2011.

The standard addresses several key issues:

  • What needs to appear in the bylaws and how such decisions are made;
  • The relationship between the organized medical staff and the medical executive committee;
  • How to foster a collaborative and positive relationship among the management, medical staff and governing body; and
  • How to manage conflict between the organized medical staff and the governing body, or between the organized medical staff and the medical executive committee, regarding medical staff bylaws, rules and regulations, and policies.

Joint Commission Senior Vice President Paul Schyve, M.D., says hospital executives will be tempted to have general counsel begin bylaw revisions immediately to ensure timely board approval and compliance with the standard, but "that's setting the hospital up for creating conflicts that aren't there."

"I would actually suggest that people start by reading the leadership chapter—especially the first part—because that really stresses the importance of this collaborative relationship and will set the tone for what is it that they're trying to accomplish," Schyve says. What follows should be a three-way tête-à-tête. "If the theme of the bylaws is to foster collaboration between the hospital's leadership, board and medical staff, then it seems the most logical first step is for representatives of all three groups to sit down together and discuss necessary revisions. This can uncover some disagreements that are creating barriers to collaboration that actually have been underneath and unknown to people."

Charles A. Mowll, the Joint Commission's executive vice president for business development, government and external relations, notes that the new standard is much less "proscriptive" than the 2007 iteration and that hospitals should "understand that [inherent] flexibility," particularly insofar as it allows governing bodies and medical staffs more latitude to determine what will be placed in the medical staff bylaws and what will be placed in other documents such as rules and regulations, and policies. This, in turn, will influence if and when the medical executive committee must notify the entire medical staff about future changes.

The American Hospital Association, which was represented on a task force that developed the standards, endorses the final version. Nancy Foster, the association's vice president for quality and patient safety policy, doesn't anticipate that many hospitals will have to change bylaws, although they may have to tweak other documents. But no matter what's required, hospitals should document their decision-making.

"Even if a change in the bylaws is not needed," she says, "it would be in the best interest of the hospital if leadership could say, 'We looked at this, here's why we believe we don't need to change, and here's how we're complying with rules that establish a firm foundation for work between those key parties.'"

Finally, hospital boards should understand any revisions they endorse, says Ann O'Connell, a partner with the law firm Nossaman, San Francisco, and a member of the task force. "In my experience, boards have typically been pretty hands-off in reviewing and approving bylaws; normally they'll approve what's in front of them," says O'Connell, who has written bylaws for the California Hospital Association. "That's a mistake, because by approving something they don't understand, they can box themselves into something that abrogates their responsibility as a board. I always say, I don't care what way the board goes if they pay attention to which way they're going."

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