Medical Staff Governance

Citation

TJC EM.12.02.03

The hospital has a staffing plan for managing all staff and volunteers during an emergency or...

The hospital must develop a staffing plan to manage personnel and volunteers during emergency incidents, including methods for contact and role integration.

Citation

TJC LD.11.01.01

The governing body is ultimately accountable for the safety and quality of care, treatment, a...

The governing body is responsible for the hospital's legal conduct, medical staff oversight, grievance processes, and quality assessment programs.

Citation

TJC LD.11.02.01

The hospital has an organized medical staff that is accountable to the governing body.

The hospital must maintain an organized medical staff that is accountable to the governing body for the quality of patient care.

Citation

TJC MM.14.01.01

Medication orders are clear and accurate.

The hospital must ensure medication orders are clear, accurate, and documented by authorized practitioners.

Citation

TJC MM.16.01.01

The hospital safely administers medications.

The standard addresses medication administration under law, practitioner orders, standards of practice, medical staff policies, and patient or caregiver self-administration procedures.

Citation

TJC MS.14.01.01

Medical staff bylaws address self-governance and accountability to the governing body.

The standard specifies required medical staff bylaw content for governance, membership, credentialing, privileging, examinations, committees, and fair hearing processes.

Citation

TJC MS.14.02.01

Neither the organized medical staff nor the governing body may unilaterally amend the medical...

The standard addresses limits on unilateral amendment of medical staff bylaws and processes for communication, conflict management, and urgent provisional amendments.

Citation

TJC MS.14.03.01

For hospitals that use Joint Commission accreditation for deemed status purposes:

Addresses conditions for separately accredited hospitals in a multihospital system to establish or opt out of a unified and integrated medical staff.

Citation

TJC MS.15.01.01

There is a medical staff executive committee.

Addresses the existence, composition, attendance, bylaw conformity, and governing body recommendations of the medical staff executive committee.

Citation

TJC MS.16.01.01

The organized medical staff oversees the quality of patient care, treatment, and services pro...

Addresses organized medical staff responsibility for care quality, privileges, patient safety, histories and physicals, emergency care policies, and selected radiology and nuclear medicine staff qualifications.

Citation

TJC MS.16.01.03

The management and coordination of each patient’s care, treatment, and services is the respon...

Addresses admission recommendations, continuous physician availability, and practitioner responsibility for Medicare patient care within privileges and licensure.

Citation

TJC MS.16.02.01

In hospitals participating in a professional graduate education program(s), the organized med...

Hospitals participating in professional graduate education programs must define medical staff supervision, role descriptions, order-writing limits, communications, and compliance with review committee citations.

Citation

TJC MS.16.03.01

The organized medical staff leads and participates in organizationwide performance improvemen...

The organized medical staff must lead and participate in performance improvement activities addressing care quality, patient safety, pain management, opioid prescribing, records, and practitioner competence.

Citation

TJC MS.17.01.01

Prior to granting a privilege, the hospital determines if the resources necessary to support...

Before granting a privilege, the hospital must determine whether sufficient space, equipment, staffing, and financial resources are available to support it.

Citation

TJC MS.17.01.03

The hospital collects information regarding each physician's or other licensed practitioner’s...

The hospital must collect and verify credentialing information for practitioners seeking privileges and, for deemed status hospitals, ensure qualified radiologist supervision of ionizing radiology services.

Citation

TJC MS.17.02.01

The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an o...

The standard requires objective, evidence-based criteria and procedures for granting, renewing, and documenting clinical privileges, including surgical and obstetrical privileges where applicable.

Citation

TJC MS.17.02.03

The organized medical staff reviews and analyzes all relevant information regarding each requ...

The standard requires the organized medical staff to review relevant practitioner qualifications and complete privileging decisions using health care quality-related criteria without specified discriminatory factors.

Citation

TJC MS.17.03.01

An expedited governing body approval process may be used for initial appointment and reappoin...

The standard permits expedited governing body approval for medical staff appointment, reappointment, and privileges when defined eligibility criteria are met.

Citation

TJC MS.17.04.01

Under certain circumstances, temporary clinical privileges may be granted for a limited perio...

The standard sets conditions, verification steps, approval roles, and duration limits for granting temporary clinical privileges.

Citation

TJC MS.18.01.01

Deliberations by the medical staff in developing recommendations for appointment to or termin...

Medical staff deliberations for appointment, termination, and clinical privilege decisions include peer recommendations addressing competence and professional attributes.

Citation

TJC MS.18.02.01

The organized medical staff defines the circumstances requiring monitoring and evaluation of...

The organized medical staff defines and implements criteria, triggers, monitoring plans, and resolution measures for evaluating practitioner performance.

Citation

TJC MS.18.02.03

Ongoing professional practice evaluation information is factored into the decision to maintai...

Ongoing professional practice evaluation information is used to determine whether existing clinical privileges should be continued, limited, revised, or revoked.

Citation

TJC MS.18.03.01

The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on repo...

The hospital and organized medical staff maintain a defined process for collecting, investigating, and addressing concerns about privileged practitioners’ clinical practice or competence.

Citation

TJC MS.18.04.01

There are mechanisms for a fair hearing and appeal process to address adverse decisions regar...

The organized medical staff must have a fair hearing and appeal process for adverse privilege and reappointment decisions related to quality of care issues.

Citation

TJC MS.18.05.01

The medical staff develops and implements a process to identify and manage matters of individ...

The medical staff must implement a confidential process to identify, refer, monitor, and respond to physician or practitioner health and impairment concerns separately from discipline.

Citation

TJC MS.19.01.01

All physicians and other licensed practitioners privileged through the medical staff process...

Privileged physicians and other licensed practitioners must participate in continuing education that is documented and considered in reappointment and privileging decisions.

Citation

TJC MS.20.01.01

Physicians or other licensed practitioners who are responsible for the care, treatment, and s...

The originating hospital must credential and privilege telemedicine practitioners or include specified safeguards when relying on distant-site credentialing and privileging decisions.

Citation

TJC MS.20.01.03

For originating and distant sites:

Medical staffs at originating and distant sites recommend which clinical services are appropriately delivered through a telemedicine link and ensure offered services align with accepted quality standards.

Citation

TJC NPG.01.06.02

The hospital marks the procedure site.

The standard addresses when and how procedure sites are marked, who may mark them, and alternative processes when marking is refused or impractical.

Citation

TJC NPG.02.01.01

The mission, vision, and goals guide the hospital’s actions.

The standard requires hospital governing, senior, and medical staff leaders to create and communicate mission, vision, and goals that guide leadership actions.

Citation

TJC NPG.02.02.01

The hospital addresses conflicts of interest and ethics.

The standard requires hospital leaders to define, disclose, and manage conflicts of interest and to provide a process for staff, patients, and families to address ethical issues.

Citation

TJC NPG.03.02.03

The hospital has a staffing plan for managing all staff and volunteers during an emergency or...

The standard addresses written emergency staffing procedures for staff, volunteers, volunteer licensed practitioners, disaster privileges, and staff support needs.

Citation

TJC NPG.10.02.01

Staff performing waived tests are competent.

Requires documented training and periodic competency assessment, using at least two specified methods, for staff performing waived tests, with limited credentialing-based alternatives for licensed practitioners.

Citation

TJC NPG.12.01.01

The hospital’s leadership team ensures that there is qualified ancillary staff required to me...

Hospital leadership ensures adequate qualified ancillary staff across service lines, including medical records, dietetic, pharmacy, infection prevention, and surgical services, with specified qualifications and supervision.

Citation

TJC NPG.12.02.01

The nurse executive directs the implementation of a nurse staffing plan(s).

Requires the nurse executive to direct nurse staffing, ensure 24/7 registered nurse coverage, and establish policies for outpatient department staffing.

Citation

TJC NPG.13.01.01

The hospital defines and verifies qualifications and education requirements for imaging servi...

Requires the hospital to define and verify qualifications, certifications, and ongoing education for CT technologists, medical physicists, and MRI technologists.

Citation

TJC NR.11.01.01

The nurse executive directs the implementation of nursing policies and procedures, nursing st...

Requires the nurse executive to direct nursing policies, standards, and staffing, with registered nurse assignment, supervision, and evaluation of nursing care.

Citation

TJC PC.12.01.01

The hospital provides care, treatment, and services as ordered or prescribed and in accordanc...

Requires the hospital to provide care, treatment, and services as ordered by licensed practitioners in accordance with law, regulation, and professional standards, with specific conditions for outpatient orders, blood transfusions, IV medications, and rehabilitation services.

Citation

TJC PC.12.01.09

The hospital makes food and nutrition products available to its patients.

Requires the hospital to make food and nutrition products available to patients in accordance with clinical practice guidelines and to maintain a current approved therapeutic diet manual.

Citation

TJC PC.13.01.01

The hospital plans operative or other high-risk procedures.

Requires the hospital to plan operative and high-risk procedures and to ensure anesthesia is administered only by specified qualified practitioners.

Citation

TJC PC.13.01.03

The hospital provides the patient with care before and after operative or other high-risk pro...

Requires preanesthesia assessment, intraoperative and postanesthesia documentation, preprocedural education, immediate postoperative care, and qualified discharge.

Citation

TJC PC.13.02.05

The hospital initiates restraint or seclusion based on an individual order.

The hospital requires individual physician orders for restraint or seclusion and mandates specific time limits and evaluation requirements for renewals.

Citation

TJC RC.11.02.01

Entries in the medical record are authenticated.

Requires that all medical record entries, including verbal orders, be dated, timed, and authenticated by the responsible authorized practitioner, with safeguards protecting authentication integrity and record security.

Citation

TJC RC.12.01.01

The medical record contains information that reflects the patient's care, treatment, and serv...

Specifies the demographic, clinical, consent, standing-order, and history-and-physical content that must be documented in the patient's medical record.

Citation

TJC RC.12.02.01

Qualified staff receive and record verbal orders.

Requires that only staff authorized by hospital policy and consistent with law accept and record verbal orders.

Citation

TJC TS.11.01.01

The hospital, with the medical staff’s participation, develops and implements written policie...

Requires the hospital, with medical staff participation, to develop and implement written policies and procedures for donating and procuring organs, tissues, and eyes, including OPO and tissue/eye bank agreements, donor family notification, and documentation of donation decisions.