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Medical Staff Standard Includes Conflict Resolution Requirement

From the Disputing Blog of Karl Bayer, Victoria VanBuren, and Holly Hayes.

The Joint Commission Medical Staff Standard MS.01.01.01 has been approved and will go into effect March 31, 2011. See the Standard here.

American Medical News summarizes: “The new standard states that the organized medical staff has the primary job of assuring quality and patient safety in the hospital while laying out a mechanism for physicians, the hospital governing body and chief executive to resolve differences over rules, policies and procedures. By spelling out these respective roles and responsibilities, the standard aims to foster collaborative working relationships to improve the quality of care. Medical staffs around the country will have to revise their bylaws in the next year to comply with the standard.” Read more here.

With regard to the management of conflict, The Joint Commission introduction to the new standard states: “If conflict arises within the medical staff regarding medical staff bylaws, rules and regulations, or policies, it implements its process for managing internal conflict (see Element of Performance 10 — see below). If conflicts regarding the medical staff bylaws, rules and regulations, or policies arise between the governing body and the organized medical staff, the organization implements its conflict management processes, as set forth in the Leadership chapter.”

Element of Performance 10 states: “The organized medical staff has a process which is implemented to manage conflict between the medical staff and the medical executive committee on issues including, but not limited to, proposals to adopt a rule, regulation, or policy or an amendment thereto. Nothing in the foregoing is intended to prevent medical staff members from communicating with the governing body on a rule, regulation, or policy adopted by the organized medical staff or the medical executive committee. The governing body determines the method of communication.”

The Joint Commission recognition of the value of teamwork in the medical setting and the mandate for the development of a conflict resolution process is summarized as follows: “This collaborative relationship is critical to providing safe, high quality care in the hospital. While the governing body is ultimately responsible for the quality and safety of care at the hospital, the governing body, medical staff, and administration collaborate to provide safe, quality care. (Please see the Leadership chapter for more discussion of the relationship among the organized medical staff, administration, and governing body.)”

See our posts on the Leadership chapter here and here.

The requirement that “The organized medical staff has a process which is implemented to manage conflict…” validates the use of ADR techniques in health care. We welcome your comments to this new medical staff standard.


Holly Hayes

Holly Hayes Bovio received a Masters in Health Administration (MHA) from Duke University and her undergraduate degree from Southern Methodist University. She holds a certificate in mediation from Texas State.  Holly brings a strong hospital operations background to healthcare mediations including a focus on clinical quality.  Holly managed her own consulting… MORE >

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