Wednesday, August 20, 2008

How Long Will It Take?

There is a squabble going on at the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) having to do with standard number MS 1.20 (Modern Healthcare, June 23, 2008). The disagreement has something to do with the authority of the Executive Committee of the hospital’s medical staff to resolve medical staff bylaws issues without the approval of the medical staff as a whole.

The dispute calls to mind a contradiction between organizational principles that has existed in modern hospitals since their inception. One principle holds that a hospital’s board of trustees has jurisdiction over everything that goes on in it. Another holds that the medical staff is “self-governing.”

The contradiction is this: The medical staff plays an essential role in hospital operations. If it is self-governing, then it is not governed by the hospital’s trustees, in which case the trustees do not have jurisdiction over everything that goes on in the hospital. So both principles cannot hold.

This unresolved conflict goes far to explain the absence of accountability in health care. As is well known, there are issues of cost, safety and quality in hospitals. The medical staff cannot deal effectively with those issues because it does not have jurisdiction over hospital operations. The trustees and administration are similarly handicapped because they lack adequate jurisdiction over the chief medical decision-makers; i.e., the physicians.

There is little public awareness of this contradiction. One assumes this will change as the public becomes increasingly concerned about cost, safety and quality in health care.

Over the years, the need to deal with the increased complexity of health care has caused a gradual shift in power from the medical staff to the hospital. The dispute at JCAHO probably represents an attempt by organized medicine to stem the tide.

Eventually, the contradiction will be resolved by abandoning self-government in favor of an appropriate form of hospital control.

The only question is how long it will take.

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