TJC Medical Staff Standard to Take Effect April 1, 2011

by Holly Hayes

The American Hospital Association (AHA) and the American Medical Association (AMA) sent a letter to hospital CEOs and medical staff presidents in November to remind them that The Joint Commission’s (TJC) recent revisions to hospital accreditation Standard MS.01.01.01 (formerly MS.1.20) will take effect April 1, 2011. The new standard is “designed to contribute to patient safety and quality of care through the support of a well-functioning, positive relationship between a hospital’s Medical Staff and Governing Body.”

Jane Reister Conard wrote a detailed post for Disputing earlier this year about the new standard and its Element of Performance (EP) 10 which states “there must be a conflict management system to address disputes that arise between the medical staff and the medical executive committee.” She wrote:

The inclusion of conflict management in the medical staff standard reaffirms The Joint Commission’s commitment to conflict management first set forth in the leadership standard (LD) 01.03.01, and more particularly stated in its EP 7. The leadership standard became effective January 1, 2009.

In December, 2008, the American Health Lawyers Association (AHLA) ADR Task Force published its Conflict Management Toolkit, to assist accredited facilities in addressing their need to develop conflict management systems in order to comply with The Joint Commission leadership standard. As part of its commitment to public service, the AHLA provides a complimentary download of the Toolkit available here.

While many of the Toolkit’s foundational principles and its conflict management guidance apply equally well to the development of a medical staff conflict management system for disputes between the medical staff and the executive medical staff committee, the medical staff should be wary of using a “cookie cutter” approach by accepting the transfer in total of a facility conflict management system based on LD 01.03.01, EP 7 to a medical staff conflict management system based on MS 01.01.01, EP 10.

Among other distinctions, a discerning medical staff member (or facility manager) would note that MS EP 10 addresses disputes among members of a unique entity, the medical staff, and its leadership. The medical staff may not be recognized as a distinct legal organization, may not have a separate business structure, and may not have sole control of its funds. Because of this looser structure, accommodations in processes in the broader facility conflict management system are necessary to account for individual physician’s concerns.

As mentioned above, the AHLA toolkit is an excellent resource for use by hospitals and medical staffs as medical staff bylaws are updated to accommodate MS.01.01.01.

Holly Hayes is a mediator at Karl Bayer, Dispute Resolution Expert where she focuses on mediation of health care disputes. Holly holds a B.A. from Southern Methodist University and a Masters in Health Administration from Duke University. She can be reached at holly@karlbayer.com.