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The Joint Commission ("TJC") is an independent nonprofit organization that accredits more than 17,000 healthcare organizations. It establishes Standards by which it assesses organizations' performance. This assessment is accomplished through periodic surveys of the healthcare organization. TJC accreditation is one means by which healthcare organizations may be "deemed" to meet Medicare "Conditions of Participation."
It's been almost three years since TJC adopted new Elements of Performance for its medical staff self-bylaws standard. "Elements of Performance" are the factors that TJC reviews to assess whether an organization's performance meets a TJC "Standard." At that time, MS 1.20 (as it was then known) caused quite a stir throughout the hospital/medical staff community. Such a stir, in fact, that TJC retrenched, forming a Task Force of industry experts to assist it in developing implementation guidelines. The Task Force, comprised of individuals representing hospital governance, administration, medical staff, and healthcare attorney constituencies began meeting in January 2008, at TJCs headquarters in Oak Park, Illinois. After the first full day of robust discussion, exploring the background, the intent, and the varying viewpoints of its potential impact, it became clear to all that more than implementation assistance would be needed. At the request of the Task Force, TJC staff requested and received TJC Board authorization to do more - to revisit and ultimately restructure the Elements of Performance altogether.
Over the next two years, the Task Force convened multiple times, and collectively hammered out revisions to the Elements of Performance ("EP"s or "Elements").
The Standard, now renamed MS. 01. 01. 01, thus consists of the Standard itself - "Medical staff bylaws address self-governance and accountability to the governing body" - as well as 36 different EPs that are deemed by TJC to reflect the characteristics of a self-governing medical staff and how it should account to the governing body. Its revised Elements were first endorsed by the organizations represented on the Task Force - American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, Federation of American Hospitals, and National Association of Medical Staff Services; they were disseminated for Field Review1 between December 2009 and January 2010; and ultimately approved, intact, by the TJC Board of Commissioners2 at its March 12-13, 2010 meeting,...