Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool.

Revisions to the Medical Staff Chapter

MS.1.20 Medical Staff Bylaws

Revisions addressing self-governance and accountability to the governing body go into effect July 2009. The revisions were designed to enhance the working relationship between the medical staff and the hospital's governing body. The revisions address:

·  situations when the medical staff does not agree with actions or decisions of the medical executive committee related to patient safety and quality of care;

·  expansion of the required processes that must be integrated into the content of the medical staff bylaws (procedures to enact these processes also must appear in either the medical staff bylaws, rules and regulations or policies); and

·  alignment of the Joint Commission standard with the Centers for Medicare and Medicaid Services requirements.

MS 4.30 Credentialing and Privileging

An addition to this standard is effective Jan. 1, 2008: Elements of Practice (EP) 1 will require a period of professional practice evaluation for all initially requested privileges. The time period and criteria for evaluation are defined by the organized medical staff.

Other revisions made to this chapter became effective January 2007. The following are among the changes.

Other Revisions Effective January 2007

MS 2.10 Management of Patient Care, Treatment and Services EP 2

Practitioners practice only within the scope of their privileges (moved from MS 4.40) as determined through mechanisms defined by the organized medical staff.

MS 4.30 Credentialing and Privileging

In the overview of this section, three new factors that impact competency assessment were introduced.

1. General competency, which includes six areas:

·  patient care - number of procedures performed, number of histories and physical exams completed;

·  medical/clinical knowledge - CME earned, number of procedures without complications;

·  practice-based learning and improvement - ACLS (with return demonstration), peer review;

·  interpersonal and communication skills - disruptive or good behavior, handwriting legibility;

·  professionalism - professional societies, participation in organizational committees; and

·  systems-based practice - best practice of CORE measures (grouped measurement sets that focus on clinical performance related to specific clinical groupings including heart failure, AMI, prevention of surgical infection, etc.).

2. Focused professional practice evaluation, which allows the medical staff to perform a focus evaluation on a specific aspect of a practitioner's performance when:

·  additional information is needed to confirm competence; and

·  questions arise regarding practice during the course of ongoing professional practice evaluation.

3. Ongoing professional practice evaluation, which enables early identification and intervention of performance problems. The process requires defined criteria resulting in evidence-based privilege renewal.

MS 4.00-MS 4.80 focus on assuring safe and effective patient care, treatment and services by:

·  the development of processes that assess current competency by continual review of practice/procedures;

·  consistent application of clearly defined evidence-based criteria used in the credentialing and privileging processes;

·  established processes that communicate decisions related to privileging to both the applicant and appropriate people with a need to know, such as staff who require knowledge as to whether a practitioner is privileged to perform a particular procedure; and

·  development of triggers that indicate the need for performance monitoring, and criteria for evaluating performance when issues affecting care are identified.

MS 4.100 EP 1 Temporary Privileges

A revision to this standard requires the medical staff bylaws to define the time period for which temporary privileges are granted.

MS 4.110 EP 5 Disaster Privileges

An addition to this standard identifies the minimum criteria needed to use volunteer licensed independent practitioners when emergency management plans have been activated and the hospital is unable to meet immediate patient needs.

The revisions to the Medical Staff chapter incorporate the new requirements of the Leadership chapter, as well as the ongoing focus of patient safety and the prevention of medical error through competency assessment and peer review.

Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ. She is skilled in developing and implementing programs to meet hospital regulatory agency requirements and has an excellent record in preparing organizations for licensing and accreditation surveys.