Beginning March 31, health care providers must be in compliance with The Joint Commission’s revised standard for effective working relationships between medical staff and hospital leadership.

Standard MS.01.01.01 (formerly MS.1.20) is designed to contribute to patient safety and quality of care through the support of a well-functioning, positive relationship between a hospital’s medical staff and its governing body.

Because many emergency physicians are now medical staff leaders, ACEP is encouraging its members to be aware of the upcoming revision to the hospital accreditation standards and to educate themselves about the changes.

“For all emergency physicians, it should be clear that this standard is all about improving care and leadership. There is no longer an excuse that ‘it is the hospital’s decision, not ours,’ ” said James Augustine, M.D., chair of the Professional Technical Advisory Committee of The Joint Commission.

According to The Joint Commission, the revised standard addresses the medical staff’s self-governance and its accountability to the governing body for the quality and safety of patient care. It also recognizes that while a hospital’s governing body is ultimately responsible for the quality and safety of care, the governing body, medical staff, and administration must collaborate to achieve this goal.

“The intent of these revisions is that the medical staff bylaws can both maintain the medical staff’s self-governance and enhance its collaboration with the hospital’s Governing Body, while optimizing the efficiency of maintaining the bylaws,” Robert Wise, M.D., who is vice president of the Division of Standards and Survey Methods for The Joint Commission, said in a press release.

An important element for achieving this collaboration is a written set of documents, known as medical staff bylaws, that describes the medical staff’s organizational responsibilities and how the medical staff and governing body will work together. Standard MS.01.01.01, which underwent an extensive field review with accredited organizations, physicians, and other interested parties, provides the framework for constructing, writing, and implementing these bylaws.

Find out more about the new standard at www.jointcommission.org/standard_ms010101.