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Comment Letter to The Joint Commission on the Proposed Modifications to MS.01.01.01 (formerly MS.1.20)
Quality and Patient Safety
Last Updated: 1/26/2010
January 26, 2010
The Joint Commission
Division of Standards & Survey Methods
MS.01.01.01 Field Engagement
One Renaissance Blvd.
Oakbrook Terrace, IL 60181
RE: Standard MS.01.01.01
Dear Sir/Madame,
The Hospital & Health System Association of Pennsylvania (HAP), on behalf of its Joint Commission accredited hospitals, appreciates the opportunity to provide comment on the proposed modifications to MS.01.01.01 (formerly MS.1.20). HAP has previously commented on prior revisions to the standard and elements of performance. In those comments, HAP expressed concerns about the lack of clarity and flexibility regarding what needed to be in medical staff bylaws versus other rules, regulations, or policies and procedures; unnecessary revision of medical staff bylaws that does not translate into improvements in the delivery of care; and the ability of the medical staff to circumvent the medical staff executive committee’s decisions and recommendations.
Although HAP recognizes the effort that The Joint Commission has taken to try to resolve the above mentioned concerns, HAP believes that the standard and elements of performance still do not resolve these issues. It is also worth noting that the Medicare Conditions of Participation do not address the issues of the format of the medical staff bylaws document, inclusion of bylaws topics, or the management of the organizational relationships as The Joint Commission seeks to do with the adoption of MS.01.01.01.
HAP believes the revised standard and elements of performance remained problematic and will potentially compromise a hospital and its leadership from ensuring the provision of high quality and safety patient care. Therefore, HAP continues to have the following concerns with the revised MS.01.01.01 standard and elements of performance:
- The proposed modifications do not recognize the governing body’s ultimate unilateral authority, which could interfere with its ability to adopt, implement, and enforce quality and safety requirements in the absence of full and uniform voluntary consensus from the medical staff.
- The proposal modification does not permit the kind of flexibility that accredited organizations should be afforded in determining what to include in its medical staff bylaws versus other supplemental documents and could potentially add increased expense and burden whenever requirements associated with qualifications, credentialing, privileging, and fair hearings need to be addressed.
- The proposed standard could diminish and weaken the role of the medical executive committee, which has historically served as the principle medical staff committee directly responsible to the governing body for quality and safety standards.
- The conflict resolution processes envisioned under the proposed modifications to the standards could further hinder hospital decision-making and take away the authority that the governing body might need to exercise in order to fulfill its essential obligations related to quality and patient safety.
- The proposed modifications to the standards appears to invest the organized medical staff with the sole authority to determine the qualifications, roles, and responsibilities of department chairs who serve a critical role in making sure the hospital achieves the provision of high quality care, pre-empting the responsibilities of the hospital governing body.
HAP believes that the revised standard and elements of performance creates a series of changes to the “organized medical staff” which could undermine hospital governance authority, and potentially compromise effective decision-making and action to ensure the provision of high quality care. HAP understands that The Joint Commission has invested considerable time and effort to try to address previous concerns expressed by the field, but believes that this standard and elements of performance still does not address previous articulated concerns. HAP recommends that The Joint Commission consider other ways to ensure that physician expertise and judgment is integrated into operational decision-making, yet unequivocally recognizes that ultimate leadership authority commensurate remains with its legal accountability with the governing body.
Thank you for the opportunity to express HAP’s concerns to this proposed MS.01.01.01. If you have any questions, you may contact Lynn Leighton, HAP’s vice president, health services (lgleighton@haponline.org) or 717-561-5308 or Kelly Thompson, HAP’s senior director, regulatory advocacy (kthompson@haponline.org) or 717-561-5325.
Sincerely,
Carolyn F. Scanlan
President and Chief Executive Officer
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