How does one articulate the basic tenets of an effective working relationship between hospital governance, medical staff leadership, and the medical staff itself? The Joint Commission, in attempting to do just that, has in the past produced new versions of the standard addressing the issue, formerly known as MS 1.20 and now called MS 01.01.01. But these versions, when made available for comment, drew criticism from physicians and hospitals that pointed to the potential for substantial unintended consequences.
A new version, which is attached for your review, has been crafted by a special Task Force assembled by The Joint Commission in January 2008. The Task Force includes hospital executives, physician leaders, physician and hospital counsel, representatives of those who staff the medical staff functions, and others. Throughout its work, the Task Force was guided by three fundamental principles:
A well-functioning relationship between the governing body, hospital leadership, and the medical staff is essential to the delivery of high quality, safe care.
Effective communication is the lubricant that keeps relationships functioning well; it therefore is important that structures and processes support it.
Well-functioning relationships also depend on all parties knowing what is expected of them, and being able to live up to those expectations.
The Task Force worked with The Joint Commission staff to incorporate its suggestions into the revised language of MS 01.01.01. The American Hospital Association, American Medical Association, American College of Surgeons, American College of Physicians, American Dental Association, NAMSS, and other interested organizations believe this revised version appropriately articulates the elements of a productive relationship between a hospital and its medical staff. It also allows as much flexibility as possible in how and where a hospital and its medical staff choose to articulate these responsibilities.
The Joint Commission Board has approved distributing this version for field review.
NAMSS will be posting our comment letters on the NAMSS Homepage in the coming days to provide you with background on the proposed revision. We encourage all members to participate in this field review.
NAMSS has suggested that The Joint Commission offer substantial implementation time for this standard once it is finalized. During that period, NAMSS will work to bring you educational programs and materials to help you properly implement this standard.