MS.01.01.01 Background

• Background

– The proposed August, 2006, Medical Staff standards, which addressed which substantive provisions could be in the bylaws versus rules, regs and policies, largely deferred to medical staff and hospital.

– Standard also allowed the organized medical staff (“OMS”) to make direct recommendations to the Board under certain circumstances

– The Standard was generally found acceptable, at least to the hospital industry, and adoption as final was expected.

– In June, 2007, TJC took everyone by surprise when it published a substantially different standard as part of MS.1.20.

..Standard was very prescriptive yet confusing over what provisions must be in bylaws versus “supplemental” documents.

..Bylaw amendment process and who could amend was not clear.

..“Organized medical staff”, an undefined term, was given the authority to overturn or reject MEC recommendations, reduce MEC authority, remove MEC members and recommend bylaw changes directly to the Board and bypass the MEC.