On Monday, March 15, 2010, the Joint Commission announced revisions to Medical Staff Standard MS.01.01.01 relating to medical staff governance and accountability to the governing body for patient care quality and safety. Hospitals and their medical staff have until March 31, 2010 to comply with the revised standard. The revised standard is available for review here.
Standard MS.01.01.01 addresses the medical staff’s self-governance and its accountability to the governing body for the quality and safety of patient care. Intended by the Joint Commission to promote patient safety and quality of care through the support of a well-functioning, positive relationship between a hospital’s medical staff and governing body, the Standard recognizes that a hospital’s governing body is ultimately responsible for the quality and safety of care, but that collaboration among a hospital’s governing body, medical staff and administration.
Focusing on the key role that the definition of the medical staff’s organizational responsibilities and how the medical staff and governing body will work together in the medical staff bylaws, that Standard MS.01.01.01 outlines a detailed framework for constructing, writing and implementing bylaws that the Joint Commission believes best supports appropriate collaboration between the medical staff, the governing body and the administration to promote the safety and quality of care. These Standard address the allocation of responsibilities between the medical staff and the governing body for the development and adoption of medical staff bylaws, processes to be utilized to develop and implement bylaws and a detailed list of elements that medical staff bylaws are required to address to meet the Standard.
The new Medical Staff standard is only one of an expanding series of Joint Commission Standards focusing on medical staff regulation and performance to help promote quality that facilities and their medical staff must address to maintain accreditation. In addition to the revised Medical Staff Standard, for instance, health care facilities and their medical staffs also generally are working to address the Joint Commission’s Standards to Ongoing Professional Practice Evaluation, credentialing, peer review and disruptive conduct standards.
About The Author
If you need assistance with health industry human resources or other management, concerns, wish to inquire about compliance, risk management or training, or need legal representation on other matters please contact Cynthia Marcotte Stamer at cstamer@cttlegal.com or 214.270.2402.
Nationally and internationally recognized for more than 22 years of work with health industry and other organizations, publications, workshops and presentations and leadership Cynthia Marcotte Stamer has worked extensively with medical staffs, hospitals and other health care facilities, physician organizations and others on these and other medical staff bylaws and management, physician and other health industry staffing and credentialing, performance management and discipline, peer review; regulatory compliance and internal controls; risk management; quality assurance; operations; tax; reimbursement; public policy and other matters. The publisher of the Solutions Law Press Health Care Update, and Solutions Law Press Health Care Privacy & Technology Update and a former legal columnist for MD News, and Board Certified in Labor and Employment Law, Ms. Stamer also is a popular speaker and author of these and other health industry topics. She regularly speaks and conducts training for the ABA, American Health Lawyers Association (AHLA), Health Care Compliance Association, Institute of Internal Auditors, Harris County Medical Society, the Medical Group Management Association, SHRM, Southwest Benefits Association and many other organizations. Her many publications and programs regularly include “Monitoring & Managing Physician Performance, Standards For Ongoing Professional Practice Evaluation and Beyond,” “Sex, Drugs & Rock ‘n Role in Medicine,” “Medical Staff Bylaws That Help Medical Staff’s Work,” “Payment or Not For Never Events” “Physician Survival Training,” and a host of other continuing medical education and other health industry compliance, operations and risk management topics. Publishers of her many highly regarded writings on health industry and human resources matters include the Bureau of National Affairs, Aspen Publishers, ABA, AHLA, Spencer Publications, World At Work, SHRM, Business Insurance, James Publishing and many others. You can review other highlights of Ms. Stamer’s health care experience here, and employment experience here. Her insights on these and other matters appear in Managed Care Executive, Modern Health Care, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, MDNews, Kentucky Physician, and many other national and local publications.
Other Resources
If you found this information of interest, you also may be interested in reviewing other updates and publications by Ms. Stamer including:
- Stamer To Discuss “Health Care Reform’s Implications For Employers, Health Plans & Employee Benefits Practitioners” At May 5 Dallas Bar Association Meeting
- Stamer To Present “2010 Health Plan Checkup” At Annual DFW ISCEBS Employee Benefits Fundamentals Workshop
- Stamer To Speak About TPA & Other Plan Services Agreement Contracting Strategies For Managing Risks & Improving Effectiveness At 2010 Great Lakes Benefits Conference
- · Extension of Unemployment Benefits Signed Into Law & Immediately Effective As Filibuster Ends
- · COBRA Premium Subsidy Requirements Expanded & Extended Under Newly Signed Unemployment Extension Legislation
- · HRO Invites Comments On Project To Develop & Test Hospital Toolkit Intended To Guide Hospitals In Using AHRQ Quality Indicators
- NLRB Orders Union Elections In 31 California Health Care Facilities To Proceed
- IRS To Allow Medical Resident FICA Refund Claims
- HIPAA Heats Up: HITECH Act Changes Take Effect & OCR Begins Posting Names, Other Details Of Unsecured PHI Breach Reports On Website
- HHS Delays 2010 HHS Federal Poverty Rate Update To March 1, 2010
- Rising Enforcement and Changing Rules Require Prompt Review & Update of Health Plan Privacy & Data Security Policies & Procedures
- Retaliation For Filing HIPAA Complaint Recognized As Basis For State Retaliatory Discharge Claim
- Quest Diagnostics Inc. To Pay $688,000 In Overtime Back Wages Settlement After Misclassifying Systems Employees As Exempt
- Homecare Workers Exempt From FLSA
- Stamer Speaks To Chiefs of Staff About JCAHO Physician Performance Evaluation Requirements
- Pfizer To Pay $2.3 Billion For Fraudulent Marketing In Largest DOJ Health Care Fraud Settlement
- Maximum Penalty For Patient Protection Act Confidentiality Breaches To Rise To $11,000
- HHS Delays 2010 HHS Federal Poverty Rate Update To March 1, 2010
- OIG Special Fraud Alert Targets DME Telemarketing
- Federal HEAT & Other Federal Health Care Fraud Efforts Score More Than 15 Successes As OIG Claims $20.97 Billion Saved From Enforcement Activities In December
- HEAT Initiative Snares Health Fraud Related Guilty Pleas of Physical Therapist, Money Launderer and Patient Recruiter In Detroit
- Medicare Paid Physicians More Than $92 Million in Incentives for 2008 Under the Physician Quality Reporting Initiative
- Renal Dialysis Faculties Encouraged to Review Current Protocols for Administering Erthropoiesis-Stimulating Agents
- CMS Publishes Updated FY 2010 Inpatient Rehabilitation Facility Prospective Payment System Final Rule
- SouthWest Benefits e-Connections Highlights Stamer Article About Importance For Health Plans, Their Sponsors & Business Associates To Update HIPAA Policies, Practices & Agreements
- Health Plan Liability Heats Up As Plans & Businesses Face New Obligations, Costs & Exposures under New HIPAA Privacy Rules Effective 2/17 & Other Expanding Federal Health Plan Mandates
- Employers, Group Health Plans Subject To New CHIP/Medicaid Notice, Coordination of Benefits & Special Enrollment Requirements
- Health Plans & Business Associates Face 2/17 Deadline To Update Policies, Contracts & Procedures For HIPAA Privacy Rule Changes
- St. Louis Employer’s OSHA Violations Trigger Contempt Order and Penalties
- Labor Department Final H-2A Certification Procedures Tighten Requirements For Employment Of Temporary Agricultural Employment Of Workers
- COBRA, HIPAA, GINA, Mental Health Parity or Other Group Health Plan Rule Violations Trigger New Excise Tax Self-Assessment & Reporting Obligations
- Inapplicability of HIPAA Privacy To Disability Insurer Not License To Impose Unreasonable Claims Requirements
- New Mental Health Parity Regulations Require Health Plan Review & Updates
For More Information
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