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Urgent Update: Joint Commission Approves Three Year Appointments


The Joint Commission has just issued a significant revision to its appointment timing standards. Medical Staffs may now appoint and reappoint applicants/members for a term not to exceed three years. This revision is effective immediately.

The Joint Commission revision is not mandatory. Medical Staffs may continue to use the two year cycle if desired but the change does present an excellent opportunity to save the time and effort involved in the current two year cycle. There will be a number of issues to consider in deciding whether or not to implement, and if so, how your organization implements the just-approved change. For example, CMS requirements for regular periodic appraisals (42 C.F.R. Section 482.22) and practical considerations in implementation should be considered.

Particularly important is the California regulation which requires that a medical staff review and establish competence “….at the time of original application for appointment to the staff and at least every two years thereafter.” 22 CCR Section 70701(a)(7). The language does not require appointment and reappointment on a two year schedule, but clarification will be needed as to whether reviews such as OPPE/FPPE on an ongoing basis can satisfy the regulatory requirement in the context of a three year cycle.

Hooper, Lundy, & Bookman’s Medical Staff Practice Group is assessing this change, and will provide updates. Given the significance, we wanted to bring it to clients/friends attention immediately.

For more information, please reach out to Jennifer Hansen in San Diego, Ruby Wood or Ross Campbell in San Francisco, or any other member of our Hooper, Lundy & Bookman team.


Ross E. Campbell
Of Counsel
San Francisco
Jennifer A. Hansen
San Diego
Ruby W. Wood
San Francisco