Wednesday, September 22, 2010
Co-sponsored by the Hospitals and Health Systems; Medical Staff, Credentialing, and Peer Review; and Physician Organizations Practice Groups
After much industry dialogue and debate leading to the creation of a Joint Commission Task Force that included representatives from various professional associations such as the AMA, AHA, FAH, and NAMSS, a new final Medical Staff Standard MS.01.01.01, formerly known as MS.1.20, has been adopted with an implementation date of March 31, 2011.
The goal of Part I of this two-part webinar series is to engage in a Q&A session and dialogue with senior members of The Joint Commission (TJC) to specifically address these required elements of performance (EPs) and other important questions which have been raised by various industry representatives and have been provided to TJC in advance so that the responses and discussions are cogent and on point. The program will include an attorney who principally represents hospitals and another who represents physicians and medical staffs so that there is a balanced approach to the program. Time will be reserved for additional questions from webinar participants.
This Standard, which is a combination of new, revised, and existing EPs, sets out the basic requirements for the following areas:
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The substantive provisions that need to be in the Medical Staff Bylaws as opposed to a rule, regulation, or policy.
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The need to establish a conflict management process when disputes arise between the organized medical staff (OMS) and the medical executive committee (MEC) and, if unresolved, the role of the board in reviewing this conflict.
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The need to develop a mechanism or threshold for determining when the conflict management process is triggered.
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Whether hospitals and medical staffs are able to maintain or adopt separate fair hearing plans and credentialing manuals under the new Standard.
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The ability of the OMS to propose changes to bylaws, rules, regulations, and policies directly to the board, and bypassing the bylaws committee and the MEC.
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Whether the MEC can propose and conditionally adopt “urgent amendments” to rules and regulations without prior OMS approval when the hospital is faced with an immediate legal mandate.
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The ability of the OMS to approve and reduce MEC authority and to remove members.
Learn more about Part II: An “In the Trenches” Discussion of Alternative Approaches.
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Gregory Abrams, Esquire
Partner
Pacific West Law Group LLP, Oakland, CA
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John Herringer, II, RN, MS
Associate Director, Standards Interpretation Group
The Joint Commission, Chicago, IL
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Charles Mowll, FACHE
The Joint Commission, Chicago, IL