In a news release published on January 3, 2008, The Joint Commission announced that it had appointed a 16-member Task Force to "examine implementation issues" related to the controversial revised Medical Staff Standard 1.20 and identified the members of the Task Force.

Revised MS.1.20, in short, would require (1) that the medical staff as a whole (rather than the MEC) adopt all Medical Staff Bylaws, Manuals, and policies, (2) there to be process for the medical staff as a whole to override the MEC, and (3) that the Medical Staff Bylaws (not Manuals or other related documents) contain all provisions regarding most medical staff matters (organization, qualifications, privileging, etc.) and permit only “procedural details” on limited topics to be in Manuals or other related documents.

The Joint Commission is not yet indicating that changes will be made to revised MS.1.20. Rather, The Joint Commission states that the new Task Force will assist with the implementation of revised MS.1.20. The Joint Commission identified three functions of the Task Force:

  • The Joint Commission stated that the Task Force will "analyze the potential impact of implementing the revised standard through the examination of case examples and factual information and will suggest mitigating remedies that will support achievement of the objectives of the standard revision.” 
  • Further, The Joint Commission claimed the Task Force will "focus on gaining a better understanding of the practical implementation issues related to hospital compliance with the four concepts contained within the revised standard: 1) the flexibility allowed the organized medical staff and the governing body on the placement of documents in or outside of the medical staff by-laws, 2) the expectation that the decisions of the Medical Executive Committee reflect the wishes of the organized medical staff, 3) the expectation that organizations with productive working relationships among leadership will find the voting requirements of the organized medical staff reasonable to implement, and 4) the method to limit items requiring joint approval, thus not burdening the hospital."
  • Finally, The Joint Commission stated that an "additional aim of the task force is to allay concerns related to the amount of time and money required to meet the requirements of the revised standard within a well-functioning organization."

Revised MS.1.20 has received significant criticism from the healthcare industry. In a previous E-Mail Alert on this topic we noted the AHA's strong comments to revised MS.1.20 and predicted that we would see more changes prior to final implementation. We continue to doubt that the revised MS.1.20 will become effective in its present form. The Joint Commission states that it anticipates receiving the Task Force's report at The Joint Commission board meeting on February 29-March 1, 2008. We should know more once this report is released.

As a reminder, MS.1.20 does not become effective until July 1, 2009. We continue to believe it is premature at this time to make any revisions or changes based on revised MS.1.20. We will provide updates on this issue as additional information is available.