MS 01.01.01 ADOPTED: Tune-up or Overhaul for Bylaws?

The Joint Commission adopted a new standard on medical staff self-governance and bylaws on March 12, 2010. Years in development, MS 01.01.01 (formerly numbered MS 1.20) will go into effect March 31, 2011. Medical staff bylaws amendments will be required, no matter how current your bylaws are, but to what degree? Here’s an estimate:


If the bylaws were broken apart into a hearing plan or an organization manual or a credentialing policy, or any combination thereof, extensive revision will likely be needed. The new standard lists 24 provisions and processes (Elements of Performance 12-36) that must be included in the medical staff bylaws, ranging from leadership selection and privileging to corrective action and hearings.


In some medical staffs, bylaws have not kept up with Medicare’s Conditions of Participation requirements that history and physicals be addressed, not in rules and regulations, but in medical staff bylaws. MS 01.01.01 as revised meets the Conditions, and so should well-maintained bylaws.


Most medical staffs will find that the bylaws will need a tune-up to comply with the new standard’s unique requirements. For example, medical staff bylaws now must include processes to manage conflicts between the medical staff and its medical executive committee, and provide for the medical staff and medical executive committee to communicate proposed rules, regulations and policies to each other. Few -if any- medical staffs have such processes already running.


I have completed revisions for several client medical staffs, and tuned-up model medical staff bylaws published by state medical societies to comply with MS 01.01.01. It can get a little technical, and there are opportunities for the medical staff to be steered wrong and delegate away its authority over its own governing documents. Do not put off taking your bylaws in for service--the standard goes into effect March 31, 2011.

© 2010 Elizabeth A. Snelson, Esq.
 Legal Counsel for the Medical Staff PLLC

Questions? Comments?
 Click icon below to email this article to a colleague.