The Joint Commission recently approved revisions to Standard MS 1.20, which addresses Medical Staff Bylaws, rules and regulations and policies. These revisions are intended to be consistent with new Leadership Chapter requirements. They go into affect July 1, 2009, presumably to allow Medical Staffs and Governing Boards time to revise their facility’s Medical Staff Bylaws and Rules and Regulations.

Following are the main revisions to Standard MS 1.20:

1. A note was added referring the organization to Standard LD (Leadership) 2.40 for guidance on managing conflict that might arise concerning the Medical Staff Bylaws, rules and regulations, and policies.
2. The procedural details for certain Elements of Performance (EPs) were referenced as being delegable to the Rules and Regulations (versus having to appear in the Bylaws). The Medical Executive Committee (MEC), as opposed to the Medical Staff, may revise these procedural details. However, the Medical Staff may “overrule” the MEC and/or pull back delegated authority if it believes that the MEC is not acting in the best interests of quality of care.
3. The Medical Staff Bylaws must indicate the authority delegated to the MEC by the organized medical staff to act on its behalf, and how that authority is delegated and removed. In addition, the Standard requires that the Bylaws include a mechanism which will allow the Medical Staff direct access to the governing board for the purpose of proposing Bylaws amendments (inherently circumventing the MEC’s typical review of proposed amendments).
4. Two new EPs were added to coordinate with the requirements of the Centers for Medicare & Medicaid Services; one details requirements for histories and physicals and the second delineates Department Chairs’ duties and responsibilities.

Medical Staffs and their Bylaws Committees must review the revised Standard, determine what changes are required to existing Bylaws and Rules and Regulations, and then draft amended Bylaws and applicable Rules and Regulations to ensure compliance by the July 1, 2009 deadline. All of the EPs must still be contained in the Medical Staff Bylaws, but procedural details relating to EPs 26-33 (including the fair hearing process) may be relegated to the Rules and Regulations and need not be set forth in the Medical Staff Bylaws. Perhaps the greatest challenge will be to determine what revisions are needed to permit the Medical Staff as a whole to “take back” authority delegated to the MEC should the Medical Staff determine that the MEC is not addressing quality and other concerns of the Medical Staff.

For further information, please contact or Stephen T. Moore or your regular  Hinshaw attorney.

This alert has been prepared by Hinshaw & Culbertson LLP to provide information on recent legal developments of interest to our readers. It is not intended to provide legal advice for a specific situation or to create an attorney-client relationship.