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Wednesday 4:01 CST, February 10, 2016

Standards FAQ Details


Medical Staff (MS) (Critical Access Hospitals / Critical Access Hospitals)

MS 01.01.01
Current | March 10, 2011

Medical staff involvement in governing body decision making

Q.  Is it required that the medical staff representation participate in all governing body discussions related to hospital business/operation/management? 

A. Standard LD.01.03.01 EP 9 says “The governing body provides the organized medical staff with the opportunity to be represented at governing body meetings (through attendance and voice) by one or more of it members, as selected by the organized medical staff.”  The intent of this requirement is that the medical staff’s representative(s) participate in all governing body meetings.  The rationale for this representation is found in the “Introduction to the Leadership Structure,  Standards LD.01.01.01 through LD.01.07.01” section in the Leadership chapter of the Comprehensive Accreditation Manual for Hospitals, 2011, which outlines the need for a collaborative relationship between leadership groups.  Specifically:

“Many leadership responsibilities directly affect the provision of care, treatment, and services, as well as the day-to-day operations of the hospital.  In some cases, these responsibilities will be shared among leadership groups, and in other cases, a particular leader or leadership group has primary responsibility.  Regardless of the hospital’s structure, it is important that leaders carry out all their responsibilities.”

“How well leaders  work together is key to effective hospital performance, and the standards emphasize this.  Leaders from different groups—governance, senior management, and the organized medical staff—bring different skills, experiences, and perspectives to the hospital.  Working together means that leaders from all groups have the opportunity to participate in discussion and have their opinions heard.”

Defining a medical staff “leader” or “leaders” is the individual organization’s medical staff determination. For example the medical staff leader who may participate in governance meetings could be the Vice President for Medical Affairs (VPMA) in one organization. In another this responsibility may be assumed by the Chair of the Medical Executive Committee.

At times, the medical staff representative(s) may have a conflict-of-interest with regard to an issue discussed in a governing body meeting--as may any other attendee, including governing body members themselves. Therefore, Standard LD.02.02.01 requires organization leaders to define in writing conflicts of interest involving leaders and to have a policy that defines how conflicts of interest will be addressed.  This definition and policy should be applied when making the decision on whether the medical staff representative(s) (or any other attendee) should be recused during a specific discussion at the governing body meeting.

Obtaining Approval on medical staff bylaws and amendments thereto

.  Is a formal meeting of the organized medical staff required to obtain adoption/approval of the medical staff bylaws and revisions of amendments?

A:  There is no current medical staff standard requiring a meeting of the medical staff.  The old  standard that required the bylaws to include a “requirement for frequency of meetings and for attendance” was eliminated with the 2004 revision to the medical staff standards.

In the March 31, 2011 standard, EP 23 requires that the bylaws include “The process for adopting and amending the medical staff bylaws”.  EP 24 requires that the bylaws include “The process for adopting and amending the medical staff rules and regulations and policies”.  The EPs do not prescribe or limit the process that can be utilized.

Such processes could include, for example:

  • Defining the percent of the voting members of the organized medical staff needed for the adoption/amendment to be ratified, e.g., a simple majority
  • Defining the method of communicating proposals and member’s votes (e.g., letter via U.S. mail, email notification, a formal meeting, electronic voting)
  • Defining the deadline for the ballot return when using remote voting
  • Notifying the members that failure to respond by a defined date will be considered a vote for approval

 View additional MS 01.01.01 FAQ's