Resources: Medical Staff Bylaws
Relevant Standards
- CMS:
- §482.12 – .22 (A-0045, A-0047, A-0049, A-0338-41, A-0347, A-0353-8, A-0363),
- §482.62(b)(2) TAG: B144
- TJC: MS.01.01.01
References & Tools1212
- Status Check: Are You Prepared to Meet Revised MS.01.01.01? Source, February, 2011 (Vol 9, #2) – Includes checklist of requirements [FTxt][REF: MDx, LDR, GB] [®]
- On March 31, 2011, the grace period for MS.01.01.01 ends and surveyors will begin scoring organizations on this standard again. If you have not already done so, it is critical that your organization/medical staff review EPs 12 to 36 to ensure compliance. Particular attention should be paid to EPs 12-16 as these are the items required to be in the bylaws by CMS. Remember you cannot just move things in and out of medical staff bylaws. You need to allow time for the proper approval/amendment process by the medical staff as well as any time they may need for deliberation about what details to include (or not). The article also contains a useful sidebar entitled “What’s Now Effective in Standard MS.01.01.01 on March 31”. A significant part of the changes involve greater communication possibilities and requirements between the medical staff, MEC, governing body and even individual physicians who may be concerned about a particular proposal related to their practice. In that context, it is important to pay attention to the aspect of EP 10 that requires organizations to have a process for managing conflict between the medical staff and the MEC. For those not sure how to handle this, the article provides the example that “the organization might require that the organized medical staff and the MEC work together to develop a joint proposal when there are conflicting proposals, or it might dictate that both proposals be forwarded to the governing body if the conflict cannot be resolved”. There is also a checklist (pages 4-5) of the “Information Required for Bylaws” to assist in the review process.
- MS.01.01.01 Overview Podcast (by R. Weiss x 5.5 min) [®]
- Sample: FPPE Draft Policy (Alabama)
Required Written Documents
- MS.01.01.01, EPs:
- 1: The medical staff develops bylaws, rules and regulations, and policies.
- 1: The medical staff develops bylaws, rules and regulations, and policies.
**Additional Clarifications & Compliance Strategies (Premier)**
[private Membership premier]
- The Joint Commission approves MS.01.01.01…Finally! Now what? from Medical Staff Leader Insider, March 18, 2010 x[®]
- Medical Staff Bylaws Standard Takes Effect March 31, 2011, from ABA Health eSource , January 2011, Volume 7 Number 5 [®]
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