QUESTION:    We are being surveyed by the Joint Commission and the physician surveyor has informed me that she is going to cite us for noncompliance with MS.01.01.01 because our bylaws do not include a reference to who can grant disaster privileges. We have a provision in our bylaws that deals with the granting of privileges, we have a policy on disaster credentialing, and we reference disaster privileges in our credentialing policy.  I pointed all of this out to the surveyor, but she wasn’t buying it.  Do we need more in our bylaws?

ANSWER:    It is hard to believe that this kind of issue is still being raised by Joint Commission surveyors, but it is. Several other clients said the same thing happened when they were surveyed by the Joint Commission. They were cited, despite the fact that they had a disaster privileging policy, because the medical staff bylaws did not specifically mention this term.

In our opinion, MS.01.01.01 does not require the medical staff bylaws to address disaster privileges, so long as you have a disaster privileging policy or address this issue in your credentials policy. The surveyor appears to be interpreting the Standards literally and without regard to the discretion which the Joint Commission said it would grant to hospitals and their medical staffs in determining what constitutes a “basic step” and must be in the bylaws, and what constitutes a “detail” and can be in a separate policy.

Notably, the language of MS.01.01.01 – the standard which delineates those matters which must be outlined in the “Bylaws” vs. other policies – says nothing about disaster privileges. While Standard EM.02.02.13, EOP 2 states that the Bylaws must identify the individuals responsible for granting disaster privileges, the Joint Commission itself, and others within the hospital industry, use the term “Bylaws” loosely, when referring to the Medical Staff Bylaws, credentialing policy, rules and regulations, and other medical staff policies. It is for this very reason that the Joint Commission took the opportunity, through MS.01.01.01, to outline the items which must be included in the “Bylaws” document.

Although we do not agree with the surveyor’s interpretation, some battles are not worth fighting. All you need to do to satisfy the surveyor is modify the “Basic Steps” in the bylaws to include a sentence on disaster privileges. We recommend the following language: “When the disaster plan has been implemented, the Chief Executive Officer or the President of the Medical Staff may use a modified credentialing process to grant disaster privileges after verification of the volunteer’s identity and licensure.”