The Revised Standard affects the authority of organized medical staff in relation to the medical executive committee, and the development, implementation and revision of medical staff bylaws.


On July 10, 2007, The Joint Commission (formerly known as The Joint Commission on Accreditation of Healthcare Organizations) announced significant revisions to its Medical Staff Standard, MS.1.20, which describes the authority of the organized medical staff in relation to the medical executive committee, and the development, implementation and revision of medical staff bylaws. MS.1.20 with the new revisions is referred to herein as the "Revised Standard."

The Revised Standard is scheduled to become effective on July 1, 2009, as part of changes to the Comprehensive Accreditation Manual for Hospitals. The Joint Commission has stated that it expects all accredited hospitals to update their medical staff bylaws to bring them into compliance with the Revised Standard before the Revised Standard goes into effect.

The Revised Standard has proven to be highly controversial. Harold Bressler, The Joint Commission’s general counsel, and Paul Schyve, M.D., The Joint Commission’s senior vice president, attended a September 5, 2007, teleconference discussing the Revised Standard, sponsored by the American Health Lawyers Association. Although they declined to offer any substantive comment, both expressed a desire to better understand the concerns of the hospital community. They also indicated that The Joint Commission would offer further comment on the Revised Standard during a Joint Commission call with accredited organizations, currently scheduled for November 1, 2007. A brief summary of the Revised Standard and its impact is provided below. The full text of the Revised Standard may be accessed on The Joint Commission website .

Medical Staff Standards Recent History

MS.1.20 historically has focused on the relationships among the organized medical staff, the medical staff executive committee and the hospital, including the required components of medical staff bylaws, rules and regulations, policies and manuals. The Joint Commission’s 2004 proposed revisions to MS.1.20 aimed to indicate what provisions were required in medical staff bylaws and what provisions could be contained in other documents relating to the medical staff. In effect it delineated which provisions of the medical staff bylaws and other medical staff documents were subject to control by the hospital board or administration, or the medical executive committee, rather than by the entire organized medical staff.

Hospitals responded negatively to the 2004 proposed revision, and in 2006 The Joint Commission changed the proposed language of MS.1.20 to state that the contents of the medical staff bylaws and related documents would be left for the hospital and the medical staff to develop collaboratively. That 2006 revision was in addition to the existing language of MS.1.30, which provided that neither the organized medical staff nor the governing body had the authority to unilaterally amend the medical staff bylaws or rules and regulations.

Latest Revisions to MS.1.20

The Revised Standard is a significant and controversial reversal of The Joint Commission’s position in 2006. The Revised Standard specifies that "substantive" categories of the medical staff bylaws, including those relating to privileging, credentialing, medical staff hearings and elections, and the "process" for each of these areas, are required to be part of the medical staff bylaws that are approved by the hospital’s organized medical staff. Only "procedural details" describing how these processes will be executed may be relegated to other documents that are not necessarily subject to approval by the organized medical staff, such as medical staff or departmental rules and regulations and written policies. However, in the Revised Standard, The Joint Commission has provided little guidance on what differentiates a "process" from a "procedural detail," which potentially could lead to confusion regarding how the Revised Standard is to be implemented and surveyed by The Joint Commission.

Certain "Elements of Performance" for the Revised Standard specify what must be part of the medical staff bylaws approved by the organized medical staff. Separate credentialing policies and hearing materials no longer will be recognized. Under the Revised Standard, the medical staff bylaws must describe what authority the organized medical staff delegates to the medical executive committee and how such authority may be removed. The organized medical staff is specifically empowered to take action in the case of disagreement or a failure to act by the medical executive committee.

The Revised Standard not only affirms that the organized medical staff retains full authority to adopt the medical staff bylaws, rules and regulations, and policies, but also states that the organized medical staff may propose such documents directly to the hospital’s governing body, regardless of whether the content of such documents had previously been reviewed and approved by the medical executive committee.

Commentators who work extensively with organized medical staffs have noted that empowering the entire organized medical staff to propose or veto necessary amendments to the medical staff bylaws will not enhance harmony at the hospital. Instead, this approach appears likely to empower relatively small numbers of dissident but active medical staff members who are not on the medical executive committee, possibly allowing them to generate greater conflict.

The Revised Standard also fails to address what actions a hospital may take if it does not agree with actions taken by its medical executive committee or its organized medical staff with respect to medical staff rules and regulations. The Revised Standard merely refers to the guidance in a Leadership Standard, LD.2.40, which reviews general conflict management principles. Again, the Revised Standard appears to open up possibilities for increased conflict between the hospital and the organized medical staff, as well as between the organized medical staff and the medical executive committee, with no identified quality of patient care purpose.

Effect of the Revised Standard on Accredited Providers

The Joint Commission states that the Revised Standard was designed to support and reinforce a productive working relationship between the organized medical staff and the hospital’s governing body, and to increase efficiency. Assuming that the Revised Standard is not modified by The Joint Commission, it remains to be seen whether in practice the Revised Standard will promote a productive relationship, as predicted by The Joint Commission, or the heightened tensions and discord predicted by a number of accredited hospitals that have voiced opposition to the Revised Standard.

Publication of the Revised Standard well in advance of its January 1, 2009, implementation date provides an opportunity for accredited health care providers to review their medical staff bylaws, rules and regulations, policies and manuals to identify "process" matters that will need to be included in each of those documents, as well as identify what "procedural" details will need to be included in order to conform with the Revised Standard. The intervening months may permit providers to gather information on The Joint Commission’s interpretation of the Revised Standard, which seems to have the potential to create significant new rifts between hospitals and their medical staffs.