On January 1, 2002, new Joint Commission on Accreditation of Hospital Organizations (JCAHO) accreditation standards for hospitals governing the supervision of residents became effective. JCAHO accredited hospitals may be required to modify their hospital bylaws, medical staff rules and regulations or policies in order to comply with the new standards.
Outlines of the standards are highlighted below. The full text of the standards may be viewed at http://www.jcaho.org/standards_frm.html.
Medical Staff Standard MS.2.5 was revised to require hospitals to specify in the rules, regulations and policies of the medical staff the process for supervision of participants in the professional graduate education program (residents) in accordance with new Medical Staff Standard 6.9.
Medical Staff Standard MS.6.9 requires hospitals to define (e.g., in a policy) the process for supervision of residents by licensed independent practitioners (LIP) with appropriate clinical privileges. LIP is defined as "any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges." (JCAHO Accreditation Manual for Hospitals Glossary)
The standard also requires the medical staff to ensure that each resident is supervised in his or her patient care responsibilities by an LIP who has been granted clinical privileges through the medical staff process. Other issues to be addressed include providing medical staff with written descriptions of the role, responsibilities and patient care activities of residents. In the written descriptions, hospitals must include the mechanisms by which the resident’s supervisor and the graduate education program director are to make decisions about the resident’s progressive involvement and independence in specific patient care activities. Finally, the rules require hospitals to identify in the medical staff rules, regulations and policies those individuals who may write patient care orders, the circumstances under which they may write such orders and what entries must be countersigned by a supervising LIP.
Medical Staff Standard MS.6.9.1 requires hospitals to institute a mechanism (e.g., in a policy) for effective communication between the hospital committee responsible for the professional graduate education program, the medical staff and the governing body. The standard also requires hospitals to ensure that the professional graduate education committee and the medical staff regularly communicate about the safety and quality of patient care provided by the residents and the educational and supervisory needs of the residents.
The standard requires hospitals to ensure that the professional graduate education committee and the governing body periodically communicate about the educational needs and performance of the residents. Hospitals must also ensure that any accredited professional graduate education programs (e.g., by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Dental Association’s Commission on Dental Accreditation (ADACDA) are able to demonstrate compliance with the appropriate accreditation standards.
Revised Governance Standard GO.2 provides that in addition to providing for the effective functioning of activities related to delivering quality patient care, performance improvement, risk management, medical staff credentialing and financial management, the governing body must also provide for the effective functioning of professional graduate medical education programs (e.g., by adopting policies and bylaw provisions).