Joint Commission gives final OK to medical staff standard

The change aims to assure medical staff self-governance and give physicians a way to resolve differences with hospital administrators.

By — Posted April 6, 2010

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The Joint Commission has formally approved changes to a long-controversial standard governing relations between hospital administrators and organized medical staffs.

When it was first adopted in 2004, many physician organizations said the standard threatened medical staff self-governance. When the standard was revised in 2007 to address those concerns, some hospital officials said it required too many issues to be covered in medical staff bylaws and would make it too difficult for hospitals to change policies.

The new standard, approved in March, attempts to strike a balance for medical staff autonomy and maintain productive working relationships between physicians and hospital executives.

The standard "really supports patient safety and quality of care," said Jay A. Gregory, MD, chair of the governing council of the American Medical Association Organized Medical Staff Section. "It defines clearly that the organized medical staff is accountable to the [hospital] governing body to oversee the quality of care, treatment and services provided by the physicians."

Dr. Gregory served on a Joint Commission-convened task force with participants from organizations representing hospitals, physicians and dentists that met a dozen times between January 2008 and March 2009.

The new standard states that the organized medical staff has the primary job of assuring quality and patient safety in the hospital while laying out a mechanism for physicians, the hospital governing body and chief executive to resolve differences over rules, policies and procedures. By spelling out these respective roles and responsibilities, the standard aims to foster collaborative working relationships to improve the quality of care.

Medical staffs around the country will have to revise their bylaws in the next year to comply with the standard, but Dr. Gregory said the changes should give doctors more control over processes such as peer review.

"The general practicing physician won't have anything more to do than vote on the bylaws at medical staff meetings," he said. "But now [physicians] can rest assured once and for all that there will be peer review and by their peers. I hope we can get away from the sham peer review that's sometimes brought on by administrators and so forth. Now this is the responsibility of the organized medical staff, and they will have to live up to that responsibility."

As of late March, both the standard and frequently-asked-questions document about it were publicly available on the Joint Commission Web site (link).

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