Action Alerts

JCAHO's Perspectives Highlights MS.1.20 - Medical Staff Bylaws
October 2004

On 9/29/04 a special release from JCAHO’s Perspectives publication regarding MS.1.20 (medical staff bylaws) was sent to subscribers. These requirements must be in place by 1/1/06.

Bricker and Eckler, LLP (B&E), our affiliated healthcare law firm based in Columbus, Ohio, released a bulletin on 10/11/04 regarding the impact of these new requirements. Please visit B&E website to review the Bulletin in its entirety.

QMCG asked JCAHO a few client questions regarding the new requirements. John Herringer, Associate Director of the Standards for Hospitals Section at JCAHO offered this insight on the new requirements:

"You have until 1/1/06 to review and make any necessary changes. We will be publishing further information on the requirements for the review in the next, hopefully, few days.”

Currently on the JCAHO website (www.jcaho.org), a statement entitled, “Revised EP Regarding Medical Staff Governance”, by R. Wise has very recently released the following information on these new requirements:

“A new element of performance (EP) for medical staff standard MS.1.20 in the hospital manual describes the process to define and limit the administrative procedures that can be placed in the medical staff rules and regulations. This change may necessitate a change to bylaws, including the defined processes for corrective action, fair hearing and appeal, credentialing, privileging and appointment. The EP is reflective immediately for all proposed new changes in the content of the medical staff bylaws and rules and regulations. Medical staffs and governing bodies have until January 1, 2006 to come into compliance with respect to the existing content of their medical staff bylaws and rules and regulations. Contact Robert Wise at, mailto:rwise@jcaho.org .“

QMCG and B&E recommend looking for JCAHO publications and clarifications on this issue. We will keep you posted as changes continue to be released. 

Please call QMCG at 614/227-4849 or email www.qmcg.com with any questions.