California Law May Limit Hospitals’ Ability to Adopt The Joint Commission’s Revised Reappointment Timeframe Standards

In a move changing a decades-long practice, The Joint Commission extended its required timeframe for the reappointment of practitioners from every two years to every three years, unless law or regulation require shorter time periods.

The change became effective February 19, 2023, and applies to the Hospital, Critical Access Hospital, Ambulatory Health Care, Behavioral Health Care and Human Services, Nursing Care Centers, and Office-Based Surgery accreditation programs. For hospitals, the revisions are found in the elements of performance for practitioner reappointment in Standards MS.06.01.07 and MS.07.01.01.

Although adopting a three-year reappointment term offers potential administrative benefits to medical staffs and their members, don’t go changing your reappointment timeframes yet. Some states may have different rules regarding reappointment timelines. In California, for example, hospitals and medical staffs could unintentionally place physician licenses in jeopardy if they adopt a three-year reappointment cycle: Business and Professions Code Section 2282(a) provides that practicing at a hospital with appointment terms that exceed two years (if the hospital has at least five physicians on staff) constitutes unprofessional conduct. This means that, conceivably, the Medical Board of California could take action against physicians who are on staff at a hospital that adopts The Joint Commission’s extended reappointment period.

What about hospital licensing requirements? Again, hospitals should carefully examine their state’s law. In California, hospital licensing regulations may not stand in the way of extending the reappointment times. California Department of Public Health regulators recently suggested that Title 22, Section 70701(a)(7), which requires medical staffs to ensure that practitioners demonstrate their competency at least every two years, simply requires an assessment of competency, not reappointment, every two years. However, although Title 22 may not prevent California hospitals from adopting a three-year reappointment cycle, the Business and Professions Code may still stand as an effective bar unless the California Legislature amends the statute.  

Given that state laws may have specific timeframes for practitioner reappointment, health care organizations should exercise caution and consult legal counsel to anticipate potential legal issues and risks before shifting to a three-year reappointment term.


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