Changes to CAH standards allow for unified medical staff, hearings and appeal process in bylaws

By Karen Kondilis

Critical access hospitals (CAH) that are accredited by The Joint Commission (TJC) will now have the option to create a single, unified medical staff if they are part of a multihospital system. TJC has created a new standard in the Medical Staff chapter, MS.01.01.05, which states, “Multihospital systems can choose to establish a unified and integrated medical staff in accordance with state and local laws.”

The new standard aligns with CMS Conditions of Participation published in November 2022 as well as TJC standards for acute care hospitals, which also allow for a unified medical staff in a multihospital system. As with acute care hospitals that choose to create a unified and integrated medical staff, CAHs that choose to do so must look to the elements of performance (EP) to ensure:

• Each separately accredited CAH demonstrates that its medical staff members have voted by majority either to accept the unified and integrated medical staff structure or to opt out of such a structure and maintain a separate and distinct medical staff for their critical access hospital. (EP 1)
• The unified and integrated medical staff takes into account each member hospital’s unique circumstances and any significant differences in patient populations and services offered in each hospital, CAH, and rural emergency hospital. (EP 2)
• The unified and integrated medical staff establishes and implements policies and procedures to make certain that the needs and concerns expressed by members of the medical staff at each of its separately accredited hospitals, CAHs, and/or rural emergency hospitals, regardless of practice or location, are given due consideration. (EP 3)
• The unified and integrated medical staff has mechanisms in place to make certain that issues localized to particular hospitals, critical access hospitals, and/or rural emergency hospitals within the system are duly considered and addressed. (EP 4)

TJC also added new EPs to MS.01.01.01, which focuses on the self-governing medical staff and medical staff bylaws. The new EPs include the following:

• The medical staff bylaws include a description of those members of the medical staff who are eligible to vote (EP 17).
• The medical staff bylaws include the process for fair hearings and appeals. (EP 34)
• The medical staff bylaws include information on how a hospital can opt out of the unified and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their respective hospital. (EP 37).

These changes are effective June 1, 2023 and will be published with the August 2023 standards release. To see the full list of standard changes, click here.