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New JCAH standards affect medical staff, quality assurance
Insights
Recent hospital accreditation changes permit broader medical staff definitions, including nonphysician practitioners. Hospitals can customize credentialing processes and ethical standards, reducing liability risks.
Area of Science:
- Healthcare Administration
- Medical Staff Governance
- Accreditation Standards
Background:
- Joint Commission on Accreditation of Hospitals (JCAH) revised its Accreditation Manual for Hospitals.
- Revisions impact medical staff composition, credentialing, governance, and quality assurance.
- A key revision expands the medical staff definition to include nonphysician practitioners.
Purpose of the Study:
- To analyze the implications of the revised JCAH standards.
- To address the controversy surrounding the expanded definition of medical staff.
- To highlight changes in credentialing and ethical standards.
Main Methods:
- Analysis of the revised Joint Commission on Accreditation of Hospitals' Accreditation Manual for Hospitals.
- Examination of specific revisions concerning medical staff composition and credentialing.
- Review of changes in ethical standards and their impact on liability.
Main Results:
- The expanded medical staff definition is permissive, not mandatory for hospitals.
- Hospitals must develop hospital-specific credentialing criteria and processes for all providers.
- Ethical criteria, pledges, and standards have been removed, reducing institutional liability.
- The role and composition of the Medical Executive Committee (MEC) have been redefined.
Conclusions:
- Hospitals have increased flexibility in defining medical staff and credentialing processes.
- The revised standards allow for tailored approaches to provider assessment and privilege granting.
- Elimination of specific ethical requirements offers greater institutional latitude and reduced legal risk.
Abstract:
Medical staff composition, credentialing procedures, governance, and quality assurance are the major areas affected by recent revisions in the Joint Commission on Accreditation of Hospitals' Accreditation Manual for Hospitals. The most controversial revision expands the definition of the medical staff to include not only physicians and dentists but also other nonphysician practitioners. Much of this controversy is unwarranted, however, because the standard is purely permissive; no hospital is required to change its medical staff composition if it chooses not to. Institutions are now permitted, if not encouraged, to examine specific classes or categories of providers and to determine the appropriateness of their practice within the hospital setting. Criteria for granting staff membership or clinical privileges must be developed for each category. Mechanisms for appointing medical staff members and for granting clinical privileges must be "hospital-specific"; each hospital; even those within the same system, chain, or geographic area, must have separate and distinct policies and guidelines for decision making in the credentialing process. The credentialing mechanism also must be "described to each applicant." The phrases "ethical criteria," "ethical pledge," and "ethical standards" have been completely dropped from the accreditation requirements. The previous standards subjected both the JCAH and the hospital to liability hazards. The newer standards not only eliminate the potential liability associated with the adoption of a particular code of ethics but also give the hospital greater latitude in enforcement, since the institution is not limited to a particular codification of principles or religious ethics. The medical executive committee's (MEC's) role and composition have also been redefined.(ABSTRACT TRUNCATED AT 250 WORDS)