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December 23, 2004Client Alert

JCAHO Issues Corrections to Hospital Standards Regarding Medical Staff Bylaws

Earlier this year the Joint Commission on Accreditation of Health Care Organizations (“JCAHO”) issued corrections to the 2005 accreditation standards for hospitals. JCAHO issued additional clarifications to the corrections on October 21, 2004. The corrections, as clarified, contain significant revisions to the standard regarding medical staff bylaws (“Bylaws”) and procedures for credentialing, privileging, corrective action, and fair hearings and appeals. Please note that Bylaws must comply not only with JCAHO standards but also with Medicare Conditions of Participation and applicable state law.

On September 29, 2004, the Joint Commission on Accreditation of Health Care Organizations (“JCAHO”) issued corrections to the 2005 accreditation standards for hospitals. JCAHO issued additional clarifications to the corrections on October 21, 2004. The corrections, as clarified, contain significant revisions to the standard regarding medical staff bylaws (“Bylaws”) and procedures for credentialing, privileging, corrective action, and fair hearings and appeals.

Please note that Bylaws must comply not only with JCAHO standards but also with Medicare Conditions of Participation and applicable state law.

History of JCAHO Medical Staff Bylaws Standards

JCAHO Standard MS.1.20 requires that Bylaws address medical staff governance and accountability to the governing body. Corresponding Elements of Performance set forth the items that must be included in the Bylaws, such as a definition of the criteria and qualifications necessary for appointment to the medical staff and a description of the roles and responsibilities of department chairs.

On December 23, 2003, JCAHO issued a clarification to the standards pertaining to Bylaws that permitted credentialing, privileging, appointment, and fair hearing and appeal processes to be referenced in the Bylaws and described in detail in other documents. In addition, the clarification noted that the approval process for these other documents could differ from the approval process for the Bylaws, which requires approval by a percentage of the entire medical staff. The clarification explicitly stated that, for example, the medical staff could delegate its authority to approve the other documents to the Medical Executive Committee (“MEC”), so that amendments to the other documents would require only MEC approval followed by governing body approval. Thus, pursuant to this clarification, JCAHO did not require that the full medical staff approve amendments to documents relating to credentialing, privileging, appointment, and fair hearing and appeal processes.

Corrections to Medical Staff Bylaws Standards

The September 29, 2004 corrections are embodied in a new Element of Performance for Standard MS.1.20:

“When administrative procedures, associated with processes described in the medical staff bylaws for corrective actions, fair hearing and appeal, credentialing, privileging, and appointment, are described in medical staff governance documents that supplement the bylaws (i.e., rules and regulations and policies):

  • The mechanism for the approval of the administrative procedures, which may be different from that for adoption and amendment of the medical staff bylaws, is described in the medical staff bylaws.
  • Criteria to identify those administrative procedures that can be in the supplementary documents are described in the bylaws.
  • The administrative procedures are approved by both the medical staff and the governing body through the bylaws-described mechanism.”

In addition to adding the Element of Performance described above, the September 29, 2004 corrections made other minor changes in the order of the Elements of Performance, scoring categories, and the language regarding the MEC’s function, size, and composition.

Clarifications: Definitions of “Processes” and “Procedures”

In the October 21, 2004 clarifications, JCAHO distinguishes between “processes” and “procedures.” Processes are composed of multiple steps: for example, the process for appointment to the medical staff contains certain steps, such as completion of an application; primary source verification; background and data bank checks; evaluation of the application by the department chair, the credentials committee, the medical executive committee; and governing body approval.

For each of the steps in a process, there are procedures in place. Each procedure has either a major or minor impact on the outcome of the process. JCAHO explains that procedures involving evaluative conclusions or decisions invariably have a major impact, while many administrative procedures often have only a minor impact. For example, the clerical procedure for conducting primary source verification of an applicant’s credentials has only a minor impact on whether an individual is appointed to the medical staff, while the credentials committee’s procedure for evaluating an applicant has a major impact on whether the individual is appointed.

Element of Performance 19 requires that procedures having a major impact on the outcome of a process must be fully described in the Bylaws themselves. Thus, procedures for the following matters, among others, must be included in the Bylaws: defining criteria for medical staff membership and clinical privileges, evaluating applicant-specific information in determining membership and clinical privileges, and decision-making associated with fair hearings and appeals, such as selection of the fair hearing panel.

In contrast, administrative procedures having only a minor impact on the outcome of a process may be described in supplemental medical staff documents, such as rules and regulations and policies. Examples of administrative procedures that may be contained in supplemental documents include procedures relating to soliciting information from the applicant, conducting primary source verification, and scheduling fair hearings and appeals. The Bylaws must describe the criteria used to make determinations as to whether particular procedures may be addressed in documents separate from the Bylaws.

Impact of Corrections and Clarifications

For many hospitals, the corrections, as clarified, affect the structure of documents governing the medical staff. Processes for credentialing, privileging, corrective action, and fair hearings and appeals must now be addressed in the Bylaws themselves, rather than in separate documents. Not only must these processes be incorporated into the Bylaws, criteria must be developed to indicate which administrative procedures related to these processes may be addressed in rules and regulations or policies separate from the Bylaws.

In addition, for many hospitals in Wisconsin, the corrections have a significant impact on the approval mechanism for processes relating to credentialing, privileging, corrective action, and fair hearings and appeals. Because the new Element of Performance requires that these processes be addressed in the Bylaws, and Wisconsin law requires that Bylaws be adopted by the medical staff and approved by the governing body, it is no longer acceptable for the medical staff to delegate approval of amendments to these processes to the MEC. Rather, because these processes and many related procedures must be addressed in the Bylaws themselves, the medical staff and governing body must approve all changes to these processes pursuant to Wisconsin law.

Administrative procedures that do not affect the outcome of processes related to credentialing, privileging, corrective action, and fair hearings and appeals may continue to be set forth in separate documents, apart from the medical staff Bylaws; and these documents may be approved by the medical staff in a different and more streamlined manner than that through which the Bylaws are approved. For example, the mechanism for approval of changes to administrative procedures could provide that such documents would be considered approved by the medical staff if they are distributed by email to all medical staff members and no objections are lodged within five days after such email distribution.

Effective Date of Changes

The correction is effective immediately for all new changes to Bylaws or related policies addressing credentialing, privileging, corrective action, and fair hearings and appeals. Therefore, any new changes must be approved by the medical staff and the governing body in accordance with the new Element of Performance. When such changes are made to Bylaws or related policies, the documents themselves (i.e., the Bylaws or policies) should also be amended to bring them into compliance with the new Element of Performance.

If no changes to the Bylaws or other documents are made in the remaining months of 2004 or in 2005, all existing content of the Bylaws and documents relating to administrative procedures for credentialing, privileging, corrective action, and fair hearings and appeals must be revised in accordance with the new Element of Performance by January 1, 2006. 

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