Joint Commission Revises Medical Staff Bylaw Standard

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 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 hereHer 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:

For More Information

We hope that this information is useful to you.  If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here. To unsubscribe, e-mail here.

©2010 Cynthia Marcotte Stamer.  All rights reserved.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: