Chapter 3335-43 Medical Staff Members

3335-43-01 Medical staff name.

The board of trustees of the Ohio state university, by official action on September 13, 1963, established "the Ohio state university hospitals." In accordance with Chapters 3335-93-01 to 3335-93-03 and 3335-101-04 of the Administrative Code, the Ohio state university Wexner medical center board (herein called Wexner medical center board) has delegated to the medical staff of the Ohio state university hospitals the responsibility to prepare and recommend adoption of these bylaws. "The medical staff of the Ohio state university hospitals" shall be the name of the hospitals' medical staff organization.

Effective: 4/27/2015
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 03/20/1998, 02/04/2002, 08/06/2010

3335-43-02 Purpose.

The purpose of the self-governing, democratically organized medical staff, which is accountable to the Ohio state university Wexner medical center board for the quality of care provided to the patients of the Ohio state university hospitals, shall be:

(A) To strive to maintain quality standards of patient care for all patients admitted to the

Ohio state university hospitals, consistent with an active teaching environment, realizing that the care and treatment of the individual patient is the medical responsibility of the member of the attending, courtesy A, and community affiliate medical staff to whose care the patient is admitted or transferred.

(B) To support educational and research programs; elevate and advance the educational standards of our professions, including, but not limited to, pre- and post-M.D. students, nurse students, graduate nurse students, students of the allied medical professions, and students of other health professional colleges; and provide research programs to enhance and advance the educational and patient-care programs.

(C) To provide a means whereby medical problems may be reviewed; policies and procedures discussed; and to provide a means for establishing and maintaining standards of professional, medical and educational performance, organization, and discipline within the medical staff and harmonious cooperation and understanding among the units comprising the Ohio state university hospitals.

(D) To provide service, education and research programs to benefit the mental, physical, and environmental health of the citizens of the state of Ohio; dedicate itself to be responsive to the needs of its patients and to communicate effectively concerning matters of patient care; and encourage dissemination of medical knowledge to health professionals and the public, and conduct research for the prevention and treatment of disease.

Effective: 4/27/2015
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 07/01/1984, 01/31/1994, 06/15/1998, 02/04/2002, 08/19/2002, 03/26/2007, 01/20/2009, 06/06/2011

3335-43-03 Patients.

(A) The continuous care and treatment of individual patients is the medical responsibility of the member of the attending, courtesy A, and community affiliate medical staff to whose care the patient is admitted or transferred within the Ohio state university hospitals and to licensed health care professionals being granted clinical privileges under these bylaws.

(B) There shall be only one category or classification of patients in the Ohio state university hospitals, and those patients are the private patients of the medical staff under whose care they are admitted. Patients admitted to the Ohio state university hospitals who, at the time of admission, have not requested or selected a member of the medical staff to attend them shall be assigned by the chief of the appropriate clinical division or department or their designees, to a member of the medical staff for their care and treatment.

(C) All patients admitted to the Ohio state university hospitals should cooperate and be an integral part of the teaching program of the college of medicine. Should a patient, or on the behalf of the patient, the patient's representative, refuse to participate or cooperate in the teaching program of the Ohio state university hospitals or the college of medicine, the medical staff member responsible for the care and treatment of the patient will encourage participation in the Ohio state university's teaching programs, but will simultaneously inform patients, or when appropriate, the patient's representative, of their right to refuse participation. Students, including pre- and post-M.D., but not limited thereto, shall be under the direction and control of the members of the medical staff to whom the patient is assigned upon admission to the Ohio state university hospitals or transfer within the Ohio state university hospitals' services. The Ohio state university hospitals respect the patient's right to participate in decisions about his or her care, treatment and services, and further respects the patient's right to refuse care treatment and services, in accordance with law and regulation.

Effective: 4/27/2015
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 07/01/1984, 03/20/1998, 06/15/1998, 02/04/2002, 08/19/2002, 03/26/2007, 01/20/2009, 06/06/2011

3335-43-04 Membership.

(A) Qualifications.

(1) Membership on the medical staff of the Ohio state university hospitals is a privilege extended to doctors of medicine, osteopathic medicine, dentistry, and to practitioners of psychology and podiatry who consistently meet the qualifications, standards, and requirements set forth in the bylaws, rules and regulations of the medical staff, the medical center board and the board of trustees of the Ohio state university. Membership on the medical staff is available on an equal opportunity basis without regard to race, color, creed, religion, sexual orientation, national origin, gender, age, handicap, or veteran/military status. Doctors of medicine, osteopathic medicine, dentistry, and practitioners of psychology and podiatry in faculty and administrative positions who desire medical staff membership shall be subject to the same procedures as all other applicants for the medical staff.

(2) All members of the medical staff of the Ohio state university hospitals shall, except as specifically provided in these bylaws, be members of the faculty of the Ohio state university college of medicine, or in the case of dentists, of the Ohio state university college of dentistry, and shall, except for members of the limited staff, be duly licensed or certified to practice in the state of Ohio. Members of the limited staff shall possess a valid training certificate, or an unrestricted license from the applicable state board based on the eligibility criteria defined by that board. All members of the medical staff and limited staff shall comply with provisions of state law and the regulations of the state medical board. Only those physicians, dentists, and practitioners of psychology and podiatry who can document their education, training, experience, competence, adherence to the ethics of their profession, dedication to educational and research-goals, and ability to work with others with sufficient adequacy to assure the medical center board and the board of trustees of the Ohio state university that any patient treated by them at university hospitals will be given the high quality of medical care provided at university hospitals, shall be qualified for membership on the medical staff of the Ohio state university hospitals.

All applicants for membership and members of the medical staff must provide basic health information to fully demonstrate that the applicant or member has, and maintains, the ability to perform requested clinical privileges. The chief medical officer of the medical center, medical directors, the department chairperson, the credentialing committee, the medical staff administrative committee, the professional affairs committee of the Ohio state university medical center board, or the Ohio state university medical center board may initiate and request a physical or mental health evaluation of an applicant or member. Such request shall be in writing to the applicant. All members of the medical staff will comply with medical staff and the Ohio state university policies regarding employee and medical staff health and safety; uncompensated care; and will comply with appropriate administrative directives and policies to avoid disrupting those operations of the Ohio state university hospitals which adversely impact overall patient care or which adversely impact the ability of the Ohio state university hospitals employees or staff to effectively and efficiently fulfill their responsibilities. All members of the medical staff shall agree to comply with bylaws, rules and regulations, and policies and procedures adopted by the medical staff administrative committee and the medical center board, including but not limited to policies on professionalism, behaviors that undermine a culture of safety, annual education and training (list approved by the medical staff administrative committee and maintained in the chief medical officer's office), conflict of interest, HIPAA compliance, and access and communication guidelines. Medical staff members must also comply with the university integrity program requirements including but not limited to billing, self referral, ethical conduct and annual education.

(3) Exclusion of any medical staff member or licensed health care professional from participation in any federal or state government program or suspension from participation, in whole or part, in any federal or state government reimbursement program, shall result in immediate lapse of membership on the medical staff of the Ohio state university hospitals and the immediate lapse of clinical privileges at the Ohio state university hospitals as of the effective date of the exclusion or suspension. If the medical staff member's or licensed health care professional's participation in these programs is fully reinstated, the affected medical staff member or licensed health care professional shall be eligible to apply for membership and clinical privileges at that time. It shall be the duty of all medical staff members and licensed health care professionals to promptly inform the chief medical officer of any action taken, or the initiation of any process which could lead to such action taken by any of these programs.

(4) An applicant for membership shall at the time of appointment or reappointment, be and remain board certified in his or her primary are of practice at the Ohio state university hospitals. This board certification must be approved by at least one of the American board of medical specialties, or other applicable certifying boards, including certifying boards if applicable for doctors of osteopathy, podiatry, psychology, and dentistry. All applicants must be and remain certified within the specific areas for which they have requested clinical privileges. Applicants who are not board certified at the time of application but who have completed their residency or fellowship training within the last five years will be eligible for medical staff appointment. However, in order to remain eligible, those applicants must achieve board certification in their primary area of practice within five years from the date of completion of their residency or fellowship training. Applicants must maintain board certification and, to the extent required by the applicable speciality/subspeciality board, satisfy recertification requirements. Recertification will be assessed at reappointment. Failure to meet or maintain board certification shall result in immediate termination of membership on the medical staff of the Ohio state university hospitals. Waiver of this threshold eligibility criteria is as follows:

(a) A request for a waiver will only be considered if the applicant provides information sufficient to satisfy his or her burden of demonstrating that his or her qualification are equivalent to or exceed the criterion in question and that there are exceptional circumstances that warrant a waiver. The clinical department chief must endorse the request for waiver in writing to the credentialing committee.

(b) The credentialing committee may consider supporting documentation submitted by the prospective applicant, any relevant information from third parties, input from the relevant department chiefs, and the best interests of the hospital and the communities it serves. The credentialing committee will forward its recommendation, including the basis for such, to the medical staff administrative committee.

(c) The medical staff administrative committee will review the recommendation of the credentialing committee and make a recommendation to the professional affairs committee of the Ohio state medical center and the medical center board regarding whether to grant or deny the request for a waiver and the basis for its recommendation.

(d) The Ohio state medical center board's determination regarding whether to grant a waiver is final. A determination not to grant a waiver is not a "denial" of appointment or clinical privileges and does not give rise to a right to a hearing. The prospective applicant who requested the waiver in a particular case is not intended to set a precedent for any other applicant. A determination to grant a waiver does not mean that an appointment will be granted. Waivers of threshold eligibility criteria will not be granted routinely. No applicant is entitled to a waiver or to a hearing if a waiver is not granted.

(5) All applicants must demonstrate recent clinical activity in their primary area of practice during the last two years to satisfy minimum threshold criteria for privileges within their clinical departments.

(6) Any medical staff member whose membership has been terminated pursuant to paragraph (A)(3) or (A)(4) of this rule shall not be entitled to request a hearing and appeal in accordance with rule 3335-43-06 of the Administrative Code. Any licensed health care professional whose clinical privileges have been terminated pursuant to paragraph (A)(4) of this rule may not request an appeal in accordance with paragraph (H)(8)(j) of rule 3335-43-07 of the Administrative Code.

(7) No applicant shall be entitled to medical staff membership and or clinical privileges merely by the virtue of fulfilling the above qualifications or holding a previous appointment to the medical staff.

(B) Application for membership.

Initial application for medical staff membership for all categories of the medical staff shall be made by the applicant to the chief of the clinical department on forms prescribed by the medical staff administrative committee stating the qualifications and references of the applicant and giving an account of the applicant's current licensure, relevant professional training and experience, current competence and ability to perform the clinical privileges requested. All applications for appointment must specify the clinical privileges requested. Applications may be made only if the applicant meets the qualifications outlined in paragraph (A) of this rule. The application shall include written statements of the applicant to abide by the bylaws, rules and regulations and policies and procedures of the medical staff, the medical center board, and the board of trustees of the Ohio state university. The applicant shall produce a government-issued photo identification to verify his/her identity pursuant to hospital/medical staff policy. The applicant shall agree that membership on the medical staff requires participation in the peer review process of evaluating credentials, medical staff membership and clinical privileges, and that a condition for membership requires mutual covenants between all members of the medical staff to release one another from civil liability in this review process as long as the peer review was taken in the reasonable belief that it was in furtherment of quality health care based upon a reasonable review and appropriate procedural due process. In addition for community affiliate medical staff in order to optimize the clinical organization resource utilization and planning of the Ohio state university hospitals, the chief of the clinical department may require that the community affiliate medical staff member identify categories of diagnosis, extent of anticipated patient activity, and service areas to be utilized and may prepare a statement of participation for the applicant, which shall be made a part of the application for appointment. A separate record shall be maintained for each applicant requesting appointment to the medical staff.

(C) Terms of appointment. Initial appointment to the medical staff shall be for a period not to exceed twenty-four months. During the first six months of the initial appointment, except for medical staff appointments without clinical privileges, appointees shall be subject to focused professional practice evaluation (FPPE) in order to evaluate the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization pursuant to these bylaws. FPPE requires the evaluation by of the chief of the clinical department with oversight by the credentials committee and the medical staff administrative committee. Following the six-month FPPE period, the chief of the clinical department may:

(1) recommend the initial appointee to transition to ongoing professional practice evaluation (OPPE), which is described later in these bylaws to the medical staff administrative committee;

(2) extend the FPPE period, which is not considered an adverse action, for an additional six months not to exceed a total of twelve months for purposes of further monitoring and evaluation; or

(3) terminate the initial appointee's medical staff membership and clinical privileges. In the event that the medical staff administrative committee recommends that an adverse action be taken against an initial appointee, the initial appointee shall be entitled to the provisions of due process as outlined in these bylaws.

(D) Ethics and ethical relationship. The code of ethics as adopted, or as may be amended, by the American medical association, the American dental association, the American psychological association, American osteopathic association and the American podiatric medical association shall govern the professional ethical conduct of the respective members of the medical staff.

(E) Procedure for appointment.

(1) The written and signed application for membership on the medical staff shall be presented to the applicable chief of the clinical department. The applicant shall include in the application a signed statement indicating the following:

(a) If the applicant should be accepted to membership on the medical staff, the applicant agrees to be governed by the bylaws, rules and regulations of the medical staff, the medical center board and the board of trustees of the Ohio state university.

(b) The applicant consents to be interviewed in regard to the application.

(c) The applicant authorizes the Ohio state university hospitals to consult with members of the medical staffs of other hospitals with which the applicant has been or has attempted to be associated, and with others who may have information bearing on the applicant's competence, character and ethical qualifications.

(d) The applicant consents to the Ohio state university hospitals' inspection of all records and documents that may be material to the evaluation of the applicant's professional qualifications and competence to carry out the clinical and educational privileges for which the applicant is seeking as well as the applicant's professional ethical qualifications for medical staff membership.

(e) The applicant releases from any liability:

(i) All representatives of university hospitals for acts performed in connection with evaluating the applicant's credentials or releasing information to other institutions for the purpose of evaluating the applicant's credentials in compliance with these bylaws performed in good faith; and

(ii) All third parties who provide information, including otherwise privileged and confidential information, to members of the medical staff, the Ohio state university hospitals staff, Ohio state medical center board members and members of the Ohio state university board of trustees concerning the applicant's credentials performed in good faith.

(f) The applicant has an affirmative duty to disclose any prior termination, voluntary or involuntary, current loss, restriction, denial, or the voluntary or involuntary relinquishment of any of the following: professional licensure, board certification, DEA registration, membership in any professional organization or medical staff membership or privileges at any other hospital or health care facility.

(g) The applicant further agrees to disclose to the chief medical officer of the Ohio state university hospitals the initiation of any process which could lead to such loss or restriction of the applicant's professional licensure, board certification, DEA registration, membership in any professional organization or medical staff membership or privileges at any other hospital or health care facility.

(h) The applicant agrees that acceptance of membership on the medical staff of the Ohio state university hospitals authorizes the Ohio state university hospitals to conduct any appropriate health assessment including but not limited to drug or alcohol screens on a practitioner at any time during the normal pursuit of medical staff duties, based upon reasonable cause as determined by the chief of the practitioner's clinical department or the chief medical officer of the Ohio state university hospitals or their authorized designees.

(2) The purpose of the health assessment shall be to ensure that the member of the medical staff is able to fully perform and discharge the clinical, educational, administrative and research responsibilities which the member is permitted to exercise by reason of medical staff membership. If, at the time of the initial request for a health assessment, and at any time a medical staff member refuses to participate as needed in a health assessment, including but not limited to a drug or alcohol screening, this shall result in automatic lapse of membership, privileges, and prerogatives until remedied by compliance with the requested health assessment. Upon request of the medical staff administrative committee or medical center board, the applicant will provide documentation the applicant's physical and mental status with sufficient adequacy to demonstrate that any patient treated by the applicant will receive care of a generally professionally recognized level of quality and efficiency.

The conditions of this paragraph shall be deemed continuing and may be applicable to issues of continued good standing as a member of the medical staff.

(3) An application for membership on the medical staff shall be considered complete when all the information requested on the application form is provided, the application is signed by the applicant and the information is verified. A completed application must contain:

(a) Peer recommendation from at least three individuals with "first hand" knowledge about the applicant's clinical and professional skills.

(b) Evidence of required immunizations.

(c) Evidence of current professional medical malpractice liability coverage required for the exercise of clinical privileges.

(d) Satisfaction of ECFMG requirements, if applicable. If an individual receives a conceded eminence certificate or a clinical research faculty certificate from the state medical board of Ohio, the requirement for ECFMG certification may be waived at the discretion of the medical center board.

(e) Verification by primary source documentation of:

(i) Current and previous state licensure;

(ii) Faculty appointment (not required for community affiliate category);

(iii) DEA registration when required for exercise of clinical privileges;

(iv) Graduation from an accredited medical or professional school;

(v) Successful completion or record of post graduate medical or professional education; and

(vi) Board certification active candidacy for board certification (may not be required for community affiliate category). or applicant qualifies for a waiver pursuant to paragraph (A) (4) of rule 3335-43-04 of the Administrative Code.

(f) Information from the national practitioner data bank.

(g) Verification that the applicant has not been excluded from any federally funded health care program.

(h) Complete disclosure by applicant of all past and current claims, suits, and settlements, if any.

(i) Completion of criminal history check by Ohio state university medical center security department.

(j) Completion of Ohio state university medical center drug testing.

(k) Verification of completion of annual educational requirements approved by the medical staff administrative committee and maintained in the chief medical officer's office.

(l) Demonstration of recent active clinical practice during the last two years required for exercise of clinical privileges.

(m) Attestation of current Ohio automated Rx reporting system ("OARRS") account for all applicants who have a DEA registration.

(4) The chief of the applicable clinical department shall be responsible for investigating and verifying the character, qualifications, and professional standing of the applicant by making inquiry of the primary source of such information and shall within thirty days of receipt of the complete application, submit a report of those findings along with a recommendation on membership and clinical privileges to the chief medical officer of the Ohio state university hospitals.

(5) The chief medical officer shall receive all initial signed and verified applications from the chief of the clinical department and shall make an initial determination as to whether the application is complete. The credentials committee, the medical staff administrative committee, the professional affairs committee, and the medical center board have the right to render an application incomplete, and therefore not able to be processed, if the need arises for additional or clarifying information.

The chief medical officer shall forward all complete applications to the credentials committee. The applicant shall have the burden of producing information for an adequate evaluation of applicant's qualifications for membership and for the clinical privileges requested. If the applicant fails to complete the prescribed forms or fails to provide the information requested within sixty days of receipt of the signed application, processing of the application shall cease and the application shall be deemed to have been voluntarily withdrawn which action is not subject to hearing or appeal pursuant to rule 3335-43-06 of the Administrative Code.

If the chief of the applicable clinical department does not submit a report and recommendation on a timely basis, the completed application shall be forwarded to the chief medical officer for presentation to the credentials committee on the same basis as other applicants.

(6) Completed applications shall be acted upon as follows:

(a) By the credentials committee within thirty days after receipt of a completed application from the chief medical officer.

(b) By the medical staff administrative committee within thirty days after receipt of a completed application and the report and recommendation of the credentials committee.

(c) By the professional affairs committee through the expedited credentialing process or medical center board within sixty days after receipt of a completed application and the report and recommendation of the medical staff administrative committee.

All applications shall be acted upon by the Ohio state medical center board within one hundred twenty days of receipt of a completed application. These time periods are deemed guidelines only and do not create any right to have an application processed within these precise periods. These periods may be stayed or altered pending receipt and verification of further information requested from the applicant, or if the application is deemed incomplete at any time. If the procedural rights specified in rule 3335-43-06 of the Administrative Code are activated, the time requirements provided therein govern the continued processing of the application.

(7) The credentials committee shall review the application, evaluate and verify the supporting documentation, references, licensure, the chief of the clinical department's report and recommendation, and other relevant information. The credentials committee shall examine the character, professional competence, professional conduct, qualifications and ethical standing of the applicant and shall determine, through information contained in personal references and from other sources available to the credentials committee, including an appraisal from the chief of the clinical department in which clinical privileges are sought, whether the applicant has established and meets all of the necessary qualifications for the category of medical staff membership and clinical privileges requested. The credentials committee shall, within thirty days from receipt of a complete application, make a recommendation to the chief medical officer that the application be accepted, rejected, or modified. The chief medical officer shall forward the recommendation of the credentials committee to the medical staff administrative committee. The credentials committee or the chief medical officer may recommend to the medical staff administrative committee that certain applications for appointment be reviewed in executive session. The recommendation of the medical staff administrative committee regarding an appointment decision shall be made within thirty days of receipt of the credentials committee recommendation and shall be communicated by the chief medical officer, along with the recommendation of the chief medical officer to the professional affairs committee of the medical center board, and thereafter to the medical center board. When the Ohio state medical center board has acted, the chairperson of the board shall instruct the chief medical officer to transmit the final decision to the chief of the clinical department and applicant and, if appropriate, to the director of the applicable clinical division.

(8) At any time the medical staff administrative committee first recommends non-appointment of an initial applicant for medical staff membership or recommends denial of any clinical privileges requested by the applicant, the medical staff administrative committee shall require the chief medical officer to notify the applicant by certified return receipt mail that the applicant may request an evidentiary hearing as provided in paragraph (D) of rule 3335-43-06 of the Administrative Code. The applicant shall be notified of the requirement to request a hearing as provided by paragraph (B) of rule 3335-43-06 of the Administrative Code. If a hearing is properly requested, the applicant shall be subject to the rights and responsibilities of rule 3335-43-06 of the Administrative Code. If an applicant fails to properly request a hearing, the medical staff administrative committee shall accept, reject, or modify the application for appointment to membership and clinical privileges.

The final recommendation of the medical staff administrative committee shall be directly communicated to the medical center board by the chief medical officer, who shall make a separate recommendation to the medical center board.

When the Ohio state medical center board has acted, the chairperson of the board shall instruct the chief medical officer to transmit the final decision to the chief of the clinical department and applicant and, if appropriate, to the director of the applicable clinical division. The chairperson of the board shall also notify the dean of the college of medicine and the chief executive officer of the Ohio state university hospitals of the decision of the board.

(F) Procedure for reappointment

(1) At least ninety days prior to the end of the medical staff member's appointment period, the chief of the clinical department shall provide each medical staff member with an application for reappointment to the medical staff on forms prescribed by the medical staff administrative committee. The reappointment application shall include all information necessary to update and evaluate the qualifications of the medical staff member. The chief of the clinical department shall review the information available on each medical staff member, and the chief of the clinical department shall make recommendations regarding reappointment to the medical staff and for granting clinical privileges for the ensuing appointment period. The chief of the clinical department's recommendation shall be transmitted in writing along with the signed and completed reappointment forms to the chief medical officer at least forty-five days prior to the end of the medical staff member's appointment period. The terms of paragraphs (A), (B), (C), (D), (E)(1), and (E)(2) of this rule shall apply to all applicants for reappointment. Reappointment to the medical staff shall be done on a regular basis for a period not to exceed twenty-four months.

Only completed applications for reappointment shall be considered by the credentials committee. An application for reappointment is complete when all the information requested on the reappointment application form is provided, the reappointment form is signed by the applicant, and the information is verified, and no need for additional or clarifying Information is identified. A completed reappointment application form must contain:

(a) Evidence of required immunizations if applicable since last appointment.

(b) Evidence of current professional medical malpractice liability insurance required for the exercise of clinical privileges.

(c) Verification of primary source documentation of:

(i) State licensure;

(ii) Faculty appointment (not required for community affiliate category);

(iii) DEA registration when required for clinical privileges;

(iv) Successful completion or record of additional post graduate medical or professional education; and

(v) Board certification, re-certification, or continued active candidacy for certification (may not be required for community affiliate category) or applicant qualifies for a waiver pursuant to paragraph (A) (4) of rule 3335-43-04 of the Administrative Code.

(d) Information from the national practitioner data bank.

(e) Verification that the applicant has not been excluded from any federally funded health care program.

(f) Specific requests for any changes in clinical privileges sought at reappointment with supporting documentation as required by credentialing guidelines.

(g) Specific requests for any changes in medical staff category.

(h) A summary of the member's clinical activity during the previous appointment period.

(i) Patterns of care as demonstrated through quality assurance records.

(j) Verification of completion of annual educational requirements approved by the medical staff administrative committee and maintained in the chief medical officer's office.

(k) Complete disclosure by medical staff members of claims, suits, and settlements, if any.

(l) Continuing medical education and applicable continuing professional education activities. Documentation of category one CME that at least in part relates to the individual medical staff member's specialty or sub-specialty area and are consistent with the licensing requirements of the applicable Ohio state licensing board shall be required.

(m) Attestation of current OARRS account for all applicants who have a DEA registration.

(2) The member for reappointment shall be required to submit any reasonable evidence of current ability to perform the clinical privileges requested. The chief of the clinical department shall review and evaluate the reappointment application and the supporting documentation. The chief of the clinical department shall evaluate all matters relevant to recommendation, including the member's professional competence; clinical judgment; clinical or technical skills; ethical conduct; participation in medical staff affairs; compliance with the bylaws, rules and regulations of the medical staff, the medical center board, and the board of trustees of the Ohio state university; cooperation with the Ohio state university hospitals' personnel and the use of the Ohio state university hospitals' facilities for patients; relations with other physicians, other health professionals or other staff, and maintenance of a professional attitude toward patients; and the responsibility to the Ohio state university hospitals and the public.

(3) The chief medical officer shall forward the reappointment forms and the recommendations of the chief of the clinical department to the credentials committee. The credentials committee shall review the request for reappointment in the same manner, and with the same authority as an original application for medical staff membership. The credentials committee shall review all aspects of the reappointment application including source verification of the member's quality assurance record for continuing membership qualifications and for clinical privileges. The credentials committee shall review each member's performance-based profile to ensure that the same level of quality of care is delivered by all medical staff members with similar delineated clinical privileges across all clinical departments and across all categories of medical staff membership.

The credentials committee shall forward its recommendations to the chief medical officer at least thirty days prior to the end of the period of appointment. The chief medical officer shall transmit the completed reappointment application and the recommendation of the credentials committee to the medical staff administrative committee.

Failure of the member to submit a reappointment application shall be deemed a voluntary resignation from the medical staff and shall result in automatic expiration of membership and all clinical privileges at the end of the medical staff member's current appointment period, which action shall not be subject to a hearing or appeal pursuant to rule 3335-43-06 of the Administrative Code. A request for reappointment subsequently received from a member who has been automatically expired shall be processed as a new appointment.

Failure of the chief of the clinical department to act timely on an application for reappointment shall be the same as provided in paragraph (E)(5) of this rule.

(4) The medical staff administrative committee shall review each request for reappointment in the same manner and with the same authority as an original application for medical staff membership. The medical staff administrative committee shall accept, reject, or modify the request for reappointment in the same manner and with the same authority as an original application for medical staff membership. The recommendation of the medical staff administrative committee regarding reappointment of a member shall be communicated by the chief medical officer, along with the recommendation of the chief medical officer, to the professional affairs committee of the medical center board, and thereafter to the medical center board. When the Ohio state medical center board has acted, the chairperson of the board shall instruct the chief medical officer to transmit the final decision to the chief of the clinical department and applicant and, if appropriate, to the director of the applicable clinical division.

(5) When the decision of the medical staff administrative committee results in a decision of non-reappointment or reduction, suspension or revocation of clinical privileges, the medical staff administrative committee shall instruct the chief medical officer to give written notice to the affected member of the decision, the stated reason for the decision, and the member's right to a hearing pursuant to paragraphs (A) and (B) of rule 3335-43-06 of the Administrative Code. This notification and an opportunity to exhaust the appeal process shall occur prior to an adverse decision unless the provisions outlined in paragraph (D) of rule 3335-43-05 of the Administrative Code apply. The notice by the chief medical officer shall be sent certified return receipt mail to the affected member's last known address as determined by the Ohio state university records.

(6) If the affected member of the medical staff does not make a written request for a hearing to the chief medical officer within thirty-one days after receipt of the adverse decision, it shall be deemed a waiver of the right to any hearing or appeal as provided in rule 3335-43-06 of the Administrative Code to which the staff member might otherwise have been entitled on the matter (7) If a timely, written request for hearing is made, the procedures set forth in rule 3335-43-06 of the Administrative Code shall apply.

(G) Resumption of clinical activities following leave of absence.

(1) A member of the medical staff shall request a leave of absence in writing for good cause shown such as medical reasons, educational and research reasons or military service to the chief of clinical service and the chief medical officer. Such leave of absence shall be granted at the discretion of the chief of the clinical service and the chief medical officer provided, however, such leave shall not extend beyond the term of the member's current appointment. A member of the medical staff who is experiencing health problems that may impair his or her ability to care for patients has the duty to disclose such impairment to his or her chief of clinical department and the chief medical officer and the member shall be placed on immediate medical leave of absence until such time the member can demonstrate to the satisfaction of the chief medical officer that the impairment has been sufficiently resolved and can request for reinstatement of clinical activities. During any leave of absence, the member shall not exercise his or her clinical privileges, and medical staff responsibilities and prerogatives shall be inactive.

(2) The member must submit a written request for the reinstatement of clinical privileges to the chief of the clinical service. The chief of the clinical service shall forward his recommendation to the credentialing committee which, after review and consideration of all relevant information, shall forward its recommendation to the medical staff administrative committee and professional affairs committee of the medical center board. The credentials committee, the chief medical officer, the chief of the clinical service or the medical staff administrative committee shall have the authority to require any documentation, including advice and consultation from the member's treating physician or the committee for licensed independent practitioner health that might have a bearing on the medical staff member's ability to carry out the clinical and educational responsibilities for which the medical staff is seeking privileges. Upon return from a leave of absence for medical reasons the medical staff member must demonstrate his or her ability to exercise his or her clinical privileges upon return to clinical activity.

(3) All members of the medical staff who take a leave of absence for medical or non-medical reasons must be in good standing on the medical staff upon resumption of clinical activities. No member shall be granted leave of absence in excess or his or her current appointment and the usual procedures for appointment and reappointment, including deadlines for submission of application as set forth in this rule, will apply irrespective of the nature of the leave. Absence extending beyond his or her current term or failure to request reinstatement of clinical privileges shall be deemed a voluntary resignation from the medical staff, and in such event, the member shall not be entitled to a hearing or appeal.

Replaces: 3335-43-04

Effective: 2/21/2014
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 05/25/1991, 08/26/1991, 01/31/1994, 05/26/1995, 08/05/1996, 03/20/1998, 06/15/1998, 02/18/2000, 02/04/2002, 08/19/2002, 10/04/2002, 06/23/2003, 07/01/2003, 02/01/2005, 06/20/2005, 11/21/2005, 03/26/2007, 02/27/2008, 01/20/2009, 11/23/2009, 12/03/2009, 08/06/2010, 06/14/2011, 09/16/2012, 07/31/2013, 02/21/2014

3335-43-05 Peer review and corrective action.

(A) Informal peer review.

All medical staff members agree to cooperate in informal peer review activities that are solely intended to improve the quality of medical care provided to patients at the Ohio state university hospitals. Information indicating a need for informal review, including patient complaints, disagreements, questions of clinical competence, inappropriate conduct and variations in clinical practice identified by the clinical departments or divisions and medical staff committees shall be referred to the chair of the practitioner evaluation committee. The practitioner evaluation committee chair or his or her designee will consult with the affected medical staff member and obtain information or opinions from knowledgeable persons within the medical center as well as external peer review consultants pursuant to criteria outlined in these bylaws. Following the assessment by the practitioner evaluation committee chair or his or her designee, the practitioner evaluation committee may make recommendations for educational actions of additional training, sharing of comparative data or monitoring or provide other forms of guidance to the medical staff member to assist him or her in improving the quality of patient care. Such actions are not regarded as adverse, do not require reporting to any governmental or other agency, and do not invoke a right to any hearing. At the conclusion of the evaluation, the practitioner evaluation committee chair or his or her designee submits a report to the applicable clinical department chief and the chief medical officer. The chief of the clinical department and the chief medical officer shall evaluate the matter to determine the appropriate course of action. They shall make an initial written determination on whether:

(1) The matter warrants no further action;

(2) Informal resolution under this paragraph is appropriate. The chief of the clinical department and the chief medical officer shall determine whether to include documentation of the informal resolution in the medical staff member's file. If documentation is included in the member's file, the affected member shall have an opportunity to review it and may make a written response which shall also be placed in the file. Informal review under this paragraph is not a procedural prerequisite to the initiation of formal peer review under paragraph (B) of this rule; or

(3) Formal peer review under paragraph (B) of this rule is warranted.

In cases where the chief of the clinical department and chief medical officer cannot agree on the need for formal peer review, the matter shall be submitted for formal peer review and determined as set forth in paragraph (B) of this rule.

(B) Formal peer review.

(1) Formal peer review may be initiated when a member of the medical staff of the Ohio state university hospitals:

(a) Fails to adhere to standards of patient care and professional conduct appropriate for a physician practicing in an academic medical center as determined by the medical staff;

(b) Is disruptive to the operation of the Ohio state university hospitals;

(c) Violates the bylaws, rules and regulations of the medical staff, the Ohio state university Wexner medical center board, or the board of trustees of the Ohio state university;

(d) Violates state or federal law; or

(e) Is responsible for acts or omissions detrimental to patient safety or to the quality or efficiency of patient care within the Ohio state university hospitals; or

(f) Is responsible for acts or omissions damaging to the reputation of the medical staff of the Ohio state university hospitals.

Formal peer review may be initiated by a chief of a clinical department, the chief medical officer, any member of the medical staff, the chief executive officer of the Ohio state university hospitals, the dean of the college of medicine, any member of the board of the Ohio state university hospitals, or the vice president for health services. All requests for formal peer review shall be in writing, shall be submitted to the chief medical officer, and shall specifically state the conduct or activities which constitute grounds for the requested action.

(2) The chief medical officer shall promptly deliver a written copy of the request for formal peer review to the affected member of the medical staff, in a confidential manner. The chief medical officer shall then conduct a preliminary review to verify the facts related to the request for formal peer review, and within thirty days, make a written determination. If the chief medical officer decides that no further action is warranted, the chief medical officer shall notify the person(s) who filed the request for formal peer review and the member accused, in writing, that no further action will be taken.

(3) Whenever the chief medical officer determines that formal peer review is warranted, he or she shall refer the request for formal peer review to the formal peer review committee. The affected member of the medical staff shall be notified of the referral to the formal peer review committee, and be informed that these medical staff bylaws shall govern all further proceedings.

(4) The executive vice president for health sciences or designee shall exercise any or all duties or responsibilities assigned to the chief medical officer under these rules for implementing corrective action and appellate procedure if:

(a) The chief medical officer is the medical staff member charged;

(b) The chief medical officer has a financial interest or a relationship with any person that may have an improper effect on the exercise of his or her judgment in the matter, or may be perceived to have such an effect.

(5) The formal peer review committee shall investigate every request and shall deliver written findings and recommendations for action to the chief of the clinical department within thirty days. The formal peer review committee may recommend a reduction, suspension or revocation of the medical staff member's clinical privileges or other action as it deems appropriate. In making its recommendation the formal peer review committee may consider, relevant literature and clinical practice guidelines, the opinions and views expressed throughout the review process, information or explanations provided by the member under review, and other relevant information. Prior to making its report, the committee shall afford the medical staff member against whom the action has been requested an opportunity for an interview. At such interview, the medical staff member shall be informed of the specific actions or omissions alleged to constitute grounds for formal peer review and shall be given copies of any statements, reports, opinions or other information compiled at prior stages of the proceedings. The medical staff member may furnish written or oral information to the formal peer review committee at this time and shall be given an opportunity to discuss, explain, or refute the allegations and to respond to any statements, reports or opinions previously compiled in the proceedings. However, such interview shall not constitute a hearing, but shall be investigative in nature. The medical staff member shall not be represented by an attorney at this interview.

(6) Upon receipt of the written report and recommendation from the formal peer review committee, the chief of the clinical department shall, within seven days, make his or her own written recommendation for corrective action and forward that recommendation along with the findings and recommendations of the formal peer review committee to the chief medical officer.

(7) The chief medical officer shall have ten days to decide whether to accept, reject or modify the recommendation of the chief of the clinical department. If the chief medical officer decides the grounds are not substantiated, the chief medical officer will notify the formal peer review committee, the chief of the clinical department, the person(s) who filed the complaint and the affected medical staff member, in writing, that no further action will be taken.

If the chief medical officer finds the grounds for the requested corrective action are substantiated, the chief medical officer shall promptly notify the affected medical staff member of that decision and the corrective action that will be taken. This notice shall advise the affected medical staff member of his or her right to request a hearing before the medical staff administrative committee pursuant to rule 3335-43-06 of the Administrative Code and shall also include a statement that failure to request a hearing in the timeframe prescribed in this rule shall constitute a waiver of rights to a hearing and to an appeal on the matter and the affected medical staff member shall also be given a copy of the rule 3335-43-06 of the Administrative Code. This notification and an opportunity to exhaust the administrative hearing and appeal process shall occur prior to the imposition of the proposed corrective action unless the emergency provisions outlined in paragraph (D) of this rule apply. This written notice by the chief medical officer shall be sent certified return receipt mail to the affected medical staff member's last known address as determined by university records.

(8) If the affected member of the medical staff does not make a written request for a hearing to the chief medical officer within thirty-one days after receipt of the adverse decision, he or she shall be deemed to have waived the right to any review by the medical staff administrative committee to which the staff member might otherwise have been entitled on the matter.

(9) If a timely, written request for hearing is made, the procedures set forth in rule 3335-43-06 of the Administrative Code shall apply.

(C) Composition of formal peer review committee.

(1) When the determination that formal peer review is warranted is made, the chief of the clinical department shall select three members of the medical staff to serve on a formal peer review committee.

(2) Whenever the questions raised concern the clinical competence of the member under review, the chief of the clinical department shall select members of the medical staff to serve on the formal peer review committee who shall have similar levels of training and qualifications as the member who is subject to formal peer review.

(3) An external peer review consultant may serve as a member of the peer review committee whenever:

(a) A determination is made by the chief of the clinical department and the chief medical officer that the clinical expertise needed to conduct the review is not available on the medical staff;

(b) The objectivity of the review may be compromised; or

(c) Whenever the chief medical officer determines that an external review is otherwise advisable.

If an external reviewer is recommended, the chief of the clinical department shall make a written recommendation to the chief medical officer for selection of an external reviewer. The chief medical officer shall make the final selection of an external reviewer.

(D) Summary suspension.

(1) Notwithstanding the provisions of this rule, a member of the medical staff shall have all or any portion of his or her clinical privileges suspended or appointment terminated by the chief medical officer or the chief of the member's clinical department whenever such action must be taken immediately, when there is imminent danger to patients or to the patient care operations. Such summary suspension shall become effective immediately upon imposition and the medical staff member shall be subsequently notified in writing of the suspension by the chief medical officer. Such notice shall be issued by certified return mail to the affected medical staff member's last known address as determined by university records.

(2) A medical staff member whose privileges have been summarily suspended or whose appointment has been terminated shall be entitled to a hearing and appeal of the suspension pursuant to rule 3335-43-06 of the Administrative Code. If the affected member of the medical staff does not make a written request for a hearing to the chief medical officer within thirty-one days after receipt of the adverse decision, it shall be deemed a waiver of the right to any review by the medical staff administrative committee to which the staff member might otherwise have been entitled on the matter. If a timely, written request for a hearing is made, the procedures of rule 3335-43-06 of the Administrative Code shall apply.

(3) Immediately upon the imposition of a summary suspension, the chief medical officer or the appropriate chief of a clinical department shall have the authority to provide for alternative medical coverage for the patients of the suspended medical staff member who remain in the Ohio state university hospitals at the time of suspension. The wishes of the patient shall be considered in the selection of such alternative medical coverage. While a summary suspension is in effect, the member of the medical staff is ineligible for reappointment to the medical staff. Medical staff and hospital administrative duties and prerogatives are suspended during the summary suspension.

(E) Automatic suspension.

(1) Notwithstanding the provisions of this rule, a temporary lapse of a medical staff member's admitting privileges, effective until medical records are completed, may be imposed automatically by the chief medical officer after a warning, in writing, of delinquency for failure to complete medical records as defined by the rules and regulations of the medical staff. The chief medical officer shall notify the chief executive officer of the Ohio state university hospitals of the action taken.

(2) Action by the Ohio state boards of licensure revoking or suspending a medical staff member's license or placing the member upon probation shall automatically impose the same restrictions to that member's Ohio state university hospitals' privileges.

(3) Failure to maintain the minimum required type and amount of professional liability insurance with an approved insurer, shall result in immediate and automatic suspension of a medical staff member's appointment and privileges until such time as proof of appropriate insurance coverage is furnished. In the event such proof is not provided within ten days of such suspension, the medical staff member shall be deemed to have voluntarily terminated his or her appointment and privileges.

(4) Upon exclusion, debarment, or other prohibition from participation in any state or federal health care reimbursement program, or a federal procurement or non- procurement program, the medical staff member's appointment and privileges shall be immediately and automatically suspended until such time as the exclusion, debarment, or prohibition is lifted.

(5) If a medical staff member pleads guilty to or is found guilty of a felony which involves: violence or abuse upon a person, conversion, embezzlement, or misappropriation of property; fraud, bribery, evidence tampering, or perjury; or a drug offense, the medical staff member's appointment and privileges shall be immediately and automatically terminated.

(6) Whenever a medical staff member's drug enforcement administration (DEA) or other controlled substances number is revoked, he or she shall be immediately and automatically divested of his or her right to prescribe medications covered by the number.

(7) When a medical staff member's DEA or other controlled substances number is suspended or restricted in any manner, his or her right to prescribe medications covered by the number is similarly automatically suspended or restricted during the term of the suspension or restriction.

(8) No medical staff member shall be entitled to the procedural rights set forth in rule 3335-43-06 of the Administrative Code as a result of an automatic suspension or termination. As soon as practicable after the imposition of an automatic suspension, the medical staff administrative committee shall convene to determine if further corrective action is necessary. Any further action with respect to an automatic suspension must be taken in accordance with this rule.

(9) Resignation, termination, or non-reappointment to the faculty of the Ohio state university shall result in immediate termination of membership on the medical staff of the Ohio state university hospitals.

(F) Reporting responsibility.

When a decision on corrective action is taken which constitutes a "formal disciplinary action" as may be defined in Ohio state law, or as may be required to be reported pursuant to federal law, including the health care quality improvement act, the chief medical officer shall ensure that a report of said action is made in order to maintain compliance with applicable state or federal law or regulations. The chief medical officer shall ensure that such reports are amended as may be required to reflect subsequent actions taken under the hearing and appeal rights afforded in these bylaws.

When applicable, any recommendations or actions that are the result of a review or hearing and appeal shall be monitored by the chief medical officer on an ongoing basis through the Ohio state university hospitals' quality management activities.

Effective: 6/23/2016
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 03/13/1978, 05/21/1983, 01/31/1994, 03/20/1998, 02/04/2002, 08/19/2002, 06/20/2005, 02/27/2008, 01/20/2009, 11/23/2009, 08/06/2010, 06/06/2011, 4/27/2015

3335-43-06 Hearing and appeal process.

(A) Right to hearing and to an appeal.

(1) When a member of the medical staff who has exhausted all remedies under paragraphs (E) and (F) of rule 3335-43-04 of the Administrative Code on appointment or reappointments; or under rule 3335-43-05 of the Administrative Code for corrective action; or who has been summarily suspended under paragraph (D) of rule 3335-43-05 of the Administrative Code; or who receives notice of a proposed action that will adversely affect membership on the medical staff or the exercise of clinical privileges (see paragraph (A)(6) of rule 3335-43-04 of the Administrative Code), the staff member shall be entitled to an adjudicatory hearing.

(2) All hearings and appeals shall be in accordance with the procedural safeguards set forth in this rule to assure that the affected medical staff member is accorded all rights to which the member is entitled.

(B) Request for hearing.

(1) The request for a hearing shall be submitted in writing by the affected medical staff member to the chief medical officer within thirty days of notification by the chief medical officer of the intended action. The chief medical officer shall forward the request to the medical staff administrative committee along with instructions to convene a hearing.

(2) The failure of a medical staff member to request a hearing, to which the member is entitled by these bylaws within the time and in the manner herein provided, shall be deemed a waiver of the right to any review by the medical staff administrative committee. The chief medical officer shall then implement the decision and that action shall become and remain effective against the medical staff member in the same manner as a final decision of the Ohio state university Wexner medical center board as provided for in paragraph (F) of rule 3335-43-05 of the Administrative Code. The chief medical officer shall promptly inform the affected medical staff member that the proposed decision, which had entitled the medical staff member to a hearing, has now become final.

(C) Notice of hearing.

(1) After receipt of a timely request for hearing by the chief medical officer from a medical staff member entitled to such hearing, the medical staff administrative committee shall be notified of the request for hearing by the chief medical officer and shall at the next scheduled meeting take the following action:

(a) Instruct the chief medical officer and chief of staff to jointly appoint within seven days a hearing committee, consisting of five members of the medical staff who are not members of the medical staff administrative committee, are not direct competitors, do not have a conflict of interest, and who have not previously participated in the formal peer review of the matter under consideration.

(b) Instruct the hearing committee to schedule and arrange for a hearing which hearing shall be conducted not less than thirty days nor more than sixty days from the date of the receipt of the request for hearing by the chief medical officer; provided, however, that a hearing for a medical staff member who is under suspension, which is then in effect, shall be held as soon as arrangements may be reasonably made.

(2) The medical staff member shall be given at least ten days prior notice of the scheduled hearing, provided that this notice may be waived in writing by the medical staff member. Notice shall be by certified return receipt mail to the staff member at the staff member's last known address as reflected by university records. The notice of hearing shall state in concise language the acts or omissions with which the medical staff member is charged; a list of representative medical records or documents being used; names of potential witnesses to be called; and any other reason or evidence that may be considered by the hearing committee during the hearing.

(D) Conduct of hearing.

(1) The hearing committee shall select a chairperson from the committee to preside over the hearing. The chairperson may require a representative for the individual and for the medical staff administrative committee (or the Wexner medical center board) to participate in a pre-hearing conference. At the pre-hearing conference, the chairperson shall resolve all procedural questions, including any objections to exhibits or witnesses, the role of legal counsel, and determine the time to be allotted to each witness's testimony and cross-examination.

The hearing committee shall have benefit of Ohio state university legal counsel. The hearing committee may grant continuances, recesses, and the chairperson may excuse a member of the hearing committee from attendance temporarily for good cause, provided that there shall be at no time less than four members of the hearing committee present unless the affected staff member waives this requirement.

All members of the hearing committee must be present to deliberate and vote. No member may vote by proxy. The person who has taken action from which the affected staff member has requested the hearing shall not participate in the deliberation or voting of the hearing committee. The hearing shall be a de novo hearing, although evidence of the prior recommendations and decisions may be presented.

(2) An accurate record of the hearing shall be kept. The mechanism for taking the record shall be by the use of a professional stenographer. This record shall be available to the affected member of the medical staff upon request at the member's expense.

(3) The personal presence of the medical staff member for whom the hearing has been scheduled shall be required. A medical staff member who fails without good cause to appear and proceed at such hearing shall be deemed to have waived all rights to appear and to have a hearing before the medical staff administrative committee in the same manner as provided in paragraph (B) of this rule, and to have accepted the adverse recommendation or decision involved and the same shall therein become and remain in effect as provided in paragraph (B) of this rule. The medical staff administrative committee may, in its own discretion, order the hearing committee to proceed with the hearing without the medical staff member and impose a sanction which is greater or lesser than that originally imposed.

(4) The hearing need not be conducted strictly according to the rules of law related to the examination of witnesses or presentation of evidence. Any relevant matters upon which responsible persons customarily rely in the conduct of serious affairs shall be considered, regardless of the existence of any common law or statutory rule which might make evidence inadmissible over objection in civil or criminal action. The member of the medical staff for whom the hearing is being held shall, prior to, or during the hearing, be entitled to submit memoranda concerning any issues of procedure or of fact and such memoranda shall become a part of the hearing record.

(5) The affected medical staff member shall have the following rights: to be represented by an attorney at law and to call and examine witnesses; to introduce evidence; to cross-examine any witnesses on any matter relevant to the issue of the hearing; and to challenge any witness and to rebut any evidence. If the medical staff member does not testify in his or her own behalf, the staff member may be called and examined as if under cross-examination.

(6) The hearing committee shall request the person who has taken the action from which the affected staff member has requested the hearing to present evidence to the hearing committee in support of the adverse recommendation. The hearing committee may proceed to hear evidence and testimony from either party in whatever order the hearing committee deems appropriate. The hearing committee may call its own witnesses, may recall any parties witnesses, and may question witnesses as it deems appropriate. All parties shall be responsible to secure the attendance of their own witnesses. All witnesses and evidence received by the hearing committee shall be open to challenge and cross-examination by the parties. Witnesses shall not be placed under oath. At the close of the evidence the hearing committee may request each party to make summary statements, either oral or written. The hearing committee may request legal representation from the Ohio state university.

(7) The hearing committee may, without special notice, recess the hearing and reconvene the same for the convenience of the participants or for the purpose of obtaining new or additional evidence or consultation. The hearing committee shall make its best effort to expeditiously determine the issues presented. The hearing committee may elect to limit its proceedings when sufficient material has been received. The parties may be required by the hearing committee to provide evidence in oral or written form. Upon conclusion of the presentation of oral and written evidence, the hearing shall be closed. The committee may thereupon, at a time convenient to itself, conduct its deliberations outside the presence of the medical staff member for whom the hearing was convened.

(8) Within sixty days after its appointment, the hearing committee shall forward its written report and recommendation together with the transcript of the hearing and all other documentation provided by the parties to the medical staff administrative committee. The affected medical staff member shall be notified of the recommendation of the hearing committee including a statement of the basis for the recommendation. The medical staff administrative committee shall accept, reject, or modify the recommendation of the hearing committee. The medical staff administrative committee may conduct further hearings as it deems necessary or may remand the matter back to the hearing committee for further action as directed. The medical staff administrative committee may impose a greater or lesser sanction than that recommended by the hearing committee.

(9) The medical staff administrative committee shall submit a written report, including its recommendation to the chairperson of the Wexner medical center board within fourteen days of the final vote by the medical staff administrative committee. An adverse action which must be reported to the state medical board or the federal government, including the national practitioner data bank, shall entitle an affected medical staff member to the procedures of this rule. The affected member of the medical staff shall be notified of the decision of the medical staff administrative committee by the chief medical officer.

(10) The decision and record of the medical staff administrative committee shall be transmitted to the quality and professional affairs committee of the Wexner medical center board, which shall, subject to the affected member's right to appeal and implementation of paragraph (E) of this rule, consider the matter at its next scheduled meeting, or at a special meeting to be held no less than thirty days following receipt of the transmittal. The quality and professional affairs committee may accept, reject, or modify the decision of the medical staff administrative committee. The quality and professional affairs committee may remand that matter back to the medical staff administrative committee for further action as directed.

(11) The recommendation of the quality and professional affairs committee shall be promptly considered by the Wexner medical center board, at its next scheduled meeting. The Wexner medical center board may accept, reject, or modify the recommendation of the quality and professional affairs committee. The Wexner medical center board may remand the matter back to the medical staff administrative committee for further action as directed.

(12) A copy of the Wexner medical center board decision shall be sent certified return receipt mail to the affected medical staff member at the member's last known address as determined by university records.

(E) Appeal process.

(1) Within thirty days after receipt of a notice by an affected medical staff member of the decision of the medical staff administrative committee, the member may, by written notice to the chairperson of the Ohio state university Wexner medical center board, request an appeal. The appeal shall only be held on the record before the medical staff administrative committee.

(2) If an appeal is not requested within thirty days, the affected medical staff member shall be deemed to have:

(a) Waived the member's right to appeal, and

(b) Accepted the adverse decision.

(3) The appeal shall be conducted by the quality and professional affairs committee of the Wexner medical center board.

(4) The affected medical staff member shall have access to the reports and records, including transcripts, if any, of the hearing committee and of the medical staff administrative committee and all other material, favorable or unfavorable, that has been considered by the medical staff administrative committee. The staff member shall then submit a written statement indicating those factual and procedural matters with which the member disagrees, specifying the reasons for such disagreement. This written statement may cover any matters raised at any step in the procedure to which the appeal is related, and legal counsel may assist in its preparation. Such written statement shall be submitted to the quality and professional affairs committee no later than seven days following the date of the affected member's notice of appeal.

(5) New or additional matters not raised during the hearing or in the medical staff administrative committee hearings shall only be considered on appeal at the sole discretion of the quality and professional affairs committee.

(6) Within fourteen days following submission of the written statement by the affected medical staff member, the quality and professional affairs committee shall recommend to the Ohio state university Wexner medical center board that the adverse decision be affirmed, modified or rejected, or to refer the matter back to the medical staff administrative committee for further review and recommendation. Such referral to the medical staff administrative committee may include a request for further investigation.

(7) Any final decision by the Wexner medical center board shall be communicated by the chief medical officer and by certified return receipt mail to the affected medical staff member at that member's last known address as determined by university records. The chief medical officer shall also notify in writing the executive vice president for health sciences, the dean of the college of medicine, the chief executive officer of the Ohio state university hospitals and the vice president for health services, chief of staff, the chief of the clinical department, and the person(s) who initiated the request for formal peer review. The chief medical officer shall take immediate steps to implement the final decision.

Effective: 6/23/2016
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 03/13/1978, 05/21/1983, 01/31/1994, 03/20/1998, 02/04/2002, 08/19/2002, 06/20/2005, 02/27/2008, 01/20/2009, 11/23/2009, 08/06/2010, 06/06/2011, 4/29/2015

3335-43-07 Categories of the medical staff.

The medical staff of the Ohio state university hospitals shall be divided into seven categories: physician scholar medical staff; attending medical staff; courtesy A medical staff; courtesy B medical staff; community affiliate medical staff; consulting medical staff; and limited staff. Medical staff members who do not wish to obtain any clinical privileges shall be exempt from the requirements of medical malpractice liability insurance, DEA registration, demonstration of recent active clinical practice during the last two years and specific annual education requirements as outlined in the list maintained in the chief medical officer's office, but are otherwise subject to the provisions of these bylaws.

(A) Physician scholar medical staff.

(1) Qualifications: The physician scholar medical staff shall be composed of those faculty members of the colleges of medicine and dentistry who are recognized for outstanding reputation, notable scientific and professional contributions, and high professional stature. This medical staff category includes but is not limited to emeritus faculty members. Nominations may be made to the chair of the credentialing committee who shall present the candidate to the medical staff administrative committee for approval.

(2) Prerogatives: Members of the physician scholar medical staff shall have access to the Ohio state university hospitals and shall be given notice of all medical staff activities and meetings. Members of the physician scholar medical staff shall enjoy all rights of an attending medical staff member except physician scholar members shall not possess clinical privileges.

(B) Attending medical staff.

(1) Qualifications: The attending medical staff shall consist of those faculty members of the colleges of medicine and dentistry to whom clinical teaching responsibilities are assigned in the Ohio state university hospitals and who satisfy the requirements and qualifications for membership set forth in rule 3335-43-04 of the Administrative Code. The assignment of teaching responsibility is the prerogative of the chief of the clinical department or the chief's designee.

(2) Prerogatives:

An attending medical staff member may:

(a) Admit patients consistent with their clinical privileges and the balanced teaching and patient care responsibilities of the Ohio state university hospitals. When, in the judgment of the chief of the clinical department, a balanced teaching program is jeopardized, following consultation with the dean of the college of medicine and the Ohio state university hospitals' chief executive officer, and with the concurrence of a majority of the medical staff administrative committee, the chief of the clinical department may restrict an attending medical staff member's ability to admit patients. Imposition of such restrictions shall not entitle the attending medical staff member to a hearing or appeal pursuant to rule 3335-43-06 of the Administrative Code.

(b) Be free to exercise such clinical privileges as are granted pursuant to these bylaws.

(c) Vote on all matters presented at general and special meetings of the medical staff and of the department and committees of which he or she is a member unless otherwise provided by resolution of the medical staff, clinical department, or committee and approved by the medical staff administrative committee.

(d) Hold office in the medical staff organization and in the clinical department and committees of which he or she is a member, unless otherwise provided by resolution of the medical staff, clinical department, or committee and approved by the medical staff administrative committee.

(3) Responsibilities:

Each member of the attending medical staff with clinical privileges shall:

(a) Meet the basic responsibilities set forth in rules 3335-43-02 and 3335-43-03 of the Administrative Code.

(b) Retain responsibility within the member's area of professional competence for the continuous care and supervision of each patient in the Ohio state university hospitals for whom the member is providing care, or arrange a suitable alternative for such care and supervision.

(c) Actively participate in such quality evaluation and monitoring activities as required by the medical staff, and discharge such medical staff functions as may be required from time to time.

(d) Satisfy the requirements set forth in rule 3335-43-11 of the Administrative Code for attendance at staff and departmental meetings and meetings of those committees of which he or she is a member and for payment of membership dues.

(e) Supervise members of the limited staff in the provision of patient care in accordance with accreditation standards and policies and procedures of approved clinical training programs. It is the responsibility of the attending physician to authorize each member of the limited staff to perform only those services which the limited staff member is competent to perform under supervision.

(f) Supervise other licensed healthcare professionals as necessary in accordance with accreditation standards and state law. It is the responsibility of the attending physician to authorize each licensed healthcare professional to perform only those services which the licensed healthcare professional is privileged to perform.

(g) Take call as assigned by the chief of the clinical department.

(C) Courtesy A medical staff.

(1) Qualifications: The courtesy A medical staff shall consist of those faculty members of the colleges of medicine and dentistry who do not qualify for attending medical staff appointment. This category includes community physicians who routinely admit patients to the Ohio state university hospitals and who actively participate in teaching programs.

(2) Prerogatives:

The courtesy A medical staff may:

(a) Exercise such clinical privileges as are granted pursuant to these bylaws.

(b) Admit, consistent with their clinical privileges, patients who complement the clinical teaching program.

(c) Attend meetings as a member of the medical staff and the clinical department of which he or she is a member and any medical staff or the Ohio state university hospitals education programs. The courtesy A medical staff member may vote for and be eligible to hold a position on the medical staff administrative committee reserved for the representative of the courtesy A or community affiliate medical staff as set forth in paragraph (D) of rule 3335-43-09 and paragraph (C) of rule 3335-43-10 of the Administrative Code. Members of the courtesy A medical staff may serve on non-elected medical staff committees as provided by these bylaws.

(3) Responsibilities: Each member of the courtesy A medical staff with clinical privileges shall be required to discharge the basic responsibilities specified in paragraph (B)(3) of this rule.

(D) Courtesy B medical staff.

(1) Qualifications: The courtesy B medical staff shall consist of those faculty members of the colleges of medicine and dentistry who do not qualify for attending medical staff appointment. This category is comprised of referring physicians who desire to be associated with the Ohio state university hospitals to refer and follow patients. Courtesy B medical staff members shall not possess clinical privileges, shall not be eligible to vote on medical staff policies, rules and regulations, or bylaws, and shall not be eligible to hold office.

(2) Prerogatives:

Courtesy B medical staff members may:

(a) Have access to the Ohio state university hospitals and shall be given notice of all medical staff activities and meetings.

(b) Attend meetings as a member of the medical staff and the clinical departments of which he or she is a member and any medical staff or the Ohio state university hospitals education programs.

(3) The grant of courtesy B medical staff appointment to physicians is a courtesy only, and may be terminated by the Wexner medical center board upon recommendation of the medical staff administrative committee without the right to a hearing or appeal.

(E) Limited staff.

Limited staff are not considered full members of the medical staff, do not have delineated clinical privileges and do not have the right to vote in general medical staff elections. Except where expressly stated, members of the limited staff are bound by the terms of these bylaws, the rules and regulations of the medical staff, and the limited staff agreement.

(1) Qualifications:

(a) The limited staff shall consist of doctors of medicine, osteopathic medicine, dentists and practitioners of podiatry or psychology who are accepted in good standing by a program director into a post-doctoral graduate medical education program and appointed to the limited staff in accordance with these bylaws.

(b) The limited staff shall maintain compliance with the requirements of state law, including regulations adopted by the Ohio state university medical board, or the limited staff member's respective licensing board.

(c) Members of the limited staff shall possess a valid training certificate or an unrestricted Ohio license from the applicable state board based on eligibility criteria defined by that state board. All members of the limited staff shall be required to successfully obtain an Ohio training certificate prior to beginning training within a program.

(2) Responsibilities:

Each member of the limited staff shall:

(a) Be responsible to respond to all questions and to complete all forms as may be required by the credentials committee.

(b) Participate fully in the teaching programs, conferences, and seminars of the clinical department in which he or she is appointed in accordance with accreditation standards and policies and procedures of the graduate medical education committee and approved clinical training programs.

(c) Participate in the care of all patients assigned to the limited staff member under the appropriate supervision of a designated member of the attending or courtesy A medical staff in accordance with accreditation standards and policies and procedures of the clinical training programs. The clinical activities of the limited staff shall be determined by the program director appropriate for the level of education and training. Limited staff shall be permitted to perform only those services that they are authorized to perform by the member of the attending or courtesy A medical staff based on the competence of the limited staff to perform such services. The limited staff may admit or discharge patients only when acting on behalf of the attending or courtesy A medical staff. The limited staff member shall follow all rules and regulations of the service to which the limited staff member is assigned, as well as the general rules of the Ohio state university hospitals pertaining to limited staff. Specifically, a limited staff member shall consult with the attending or courtesy A member of the medical staff responsible for the care of the patient before the limited staff member undertakes a procedure or treatment that carries a significant, material-risk to the patient unless the consultation would cause a delay that would jeopardize the life or health of the patient.

(d) Serve as a member of various medical staff committees in accordance with established committee composition as described in these bylaws and/or the rules and regulations of the medical staff. The limited staff member shall not be eligible to vote or hold elected office in the medical staff organization but may vote on committees to which the limited staff member is assigned.

(e) Be expected to make regular satisfactory professional progress including anticipated certification by the respective specialty or sub-specialty program of post-doctoral training in which the limited staff member is enrolled. Evaluation of professional growth and appropriate humanistic qualities shall be made on a regular schedule by the clinical departmental chief, program director, teaching faculty or evaluation committee in accordance with accreditation standards and policies and procedures of the approved training programs.

(f) Appeal by a member of the limited staff of probation, lack of reappointment, suspension or termination for failure to meet expectations for professional growth or failure to display appropriate humanistic qualities or failure to successfully complete any other competency as required by the accreditation standards of an approved training program will be conducted and limited in accordance with written guidelines established by the respective department or training program and approved by the medical director and the Ohio state university hospitals graduate medical education committee as delineated in the limited staff agreement.

Alleged misconduct by a member of the limited staff, for reasons other than failure to meet expectations of professional growth as outlined above, shall be handled in accordance with rules 3335-43-05 and 3335-43-06 of the Administrative Code.

(3) Failure to meet reasonable expectations.

Failure to meet reasonable expectations may result in sanctions including but not limited to probation, lack of reappointment, suspension or termination. Termination of limited staff member status shall result in automatic termination of the limited staff member's residency or fellowship appointment pursuant to these bylaws.

(4) Temporary appointments.

(a) Limited staff members who are Ohio state university faculty may be granted an early commencement or an extension of appointment upon the recommendation of the chief of the clinical department, with prior concurrence of the associate dean for graduate medical education, when it is necessary for the limited staff member to begin his or her training program prior to or extend his or her training program beyond a regular appointment period. These appointments shall not exceed sixty days.

(b) Temporary appointments may be granted upon the recommendation of the chief of the clinical department, with prior concurrence of the medical directors, for limited staff members who are not Ohio state university faculty but who, pursuant to education affiliate agreements approved by the university, need to satisfy approved graduate medical education clinical rotation requirements. These appointments shall not exceed a total of one hundred twenty days in any given post-graduate year. In such cases, the mandatory requirement for a faculty appointment may be waived. All other requirements for limited staff member appointment must be satisfied.

(5) Supervision.

Limited staff members shall be under the supervision of an attending or courtesy A medical staff member. Limited staff members shall have no privileges as such but shall be able to care for patients under the supervision and responsibility of their attending or courtesy A medical staff member. The care they extend will be governed by these bylaws and the general rules and regulations of each clinical department. The practice of care shall be limited by the scope of privileges of their attending or courtesy A medical staff member. Any concerns or problems that arise in the limited staff member's performance should be directed to the attending or courtesy A medical staff member or the director of the training program.

(a) Limited staff members may write orders for the care of patients under the supervision of the attending or courtesy A medical staff member.

(b) All records of limited staff member cases must document involvement of the attending or courtesy A medical staff member in the supervision of the patient's care to include co-signature of the history and physical operative report, and discharge summary.

(F) Community affiliate medical staff.

This is a closed medical staff category that was created as a one-time grandfathering category for medical staff members of the Ohio state university hospitals east prior to July 1, 2007.

(1) Qualifications: Community affiliate medical staff shall consist of those doctors of medicine, osteopathic medicine, dentists and practitioners of podiatry or psychology who:

(a) Do not qualify for an attending medical staff appointment; and

(b) Are community affiliate members seeking reappointment; and

(c) Satisfy the requirements and qualifications set forth in rule 3335-43-04 of the Administrative Code and are already appointed to the community affiliate medical staff pursuant to these bylaws.

A community affiliate medical staff member shall meet and maintain the same standards for quality patient care applicable to all members of the medical staff. Community affiliate medical staff members shall be subject to these bylaws and the rules and regulations of the medical staff except as provided in this paragraph. The community affiliate medical staff member shall not be required to obtain appointment to the faculty of the Ohio state university. The community affiliate medical staff member shall not be subject to the requirement for board certification within the community affiliate medical staff member's respective area of practice if that requirement was waived when he or she became a member of the Ohio state university east medical staff. Teaching and research accomplishments shall not be required in determining the qualifications of applicants to this category of the medical staff.

To optimize the clinical organization, resource utilization, and planning of the hospitals, the chief of the clinical department may require that the applicant for community affiliate medical staff membership to identify categories of diagnosis, extent of anticipated patient activity, and service areas to be utilized and may prepare a statement of participation for the applicant which will be made a part of the application for appointment.

(2) Prerogatives:

A community affiliate medical staff member may:

(a) Admit patients consistent with the limitations of bed and service allocations established by the medical directors and approved by the medical staff administrative committee, and the Wexner medical center board. If, in the judgment of the medical directors, a balanced teaching program is jeopardized, following consultation with the chief of the clinical department, and with the concurrence of a majority of the medical staff administrative committee, the medical director may restrict admissions of members of the community affiliate medical staff. Patients admitted under the care of the community affiliate medical staff will not be required to participate in the educational mission of the Ohio state university hospitals. Ordinarily, no coverage by the limited medical staff will be afforded, with the exception of emergency medical services.

(b) Exercise the clinical privileges granted, have access to all medical records, and be entitled to utilize the facilities of the Ohio state university hospitals incidental to the clinical privileges granted pursuant to these bylaws.

(c) Attend teaching and educational conferences approved by the Ohio state university, attend medical staff social functions, and participate as providers in the Ohio state university or the Ohio state university hospitals affiliated health plans.

(3) Responsibilities:

Each member of the community affiliate medical staff shall:

(a) Participate in the management of and represent the interests of the clinical department for which he or she is granted clinical privileges. The community affiliate medical staff member shall comply with all provisions of these bylaws and rules and regulations of the medical staff, unless expressly exempted under this rule. The community affiliate medical staff member shall comply with all the Ohio state university hospitals' policies and accreditation standards, and shall be subject to the same quality evaluation, monitoring, and resource management requirements as other members of the medical staff.

(b) Be responsible within the member's area of professional competence for the continuous care and supervision of each patient in the Ohio state university hospitals for whom the member is providing care, or arrange a suitable alternative for such care and supervision.

(c) Not be eligible to vote on medical staff policies, rules and regulations, or bylaws or to hold office. Members of the community affiliate medical staff may serve on non-elected medical staff committees as provided by these bylaws.

(d) Be subject to payment of medical staff dues or assessments as approved by the medical staff.

(G) Temporary medical staff appointment.

(1) External peer review. When peer review activities are being conducted by someone other than a current member of the medical staff, the chief medical officer may admit a practitioner to the medical staff for a limited period of time. Such membership is solely for the purpose of conducting peer review in a particular evaluation and this temporary membership automatically expires upon the member's completion of duties in connection with such peer review. Such appointment does not include clinical privileges, and is for a limited purpose.

(2) Proctoring. Temporary privileges may be extended to visiting medical faculty for special clinical or educational activities as provided by the Ohio state medical or dental board. When medical staff members require proctoring for the purposes of gaining experience to become credentialed to perform a procedure, a visiting physician may apply for temporary privileges per the prescribed medical staff proctoring policy.

(H) Consulting medical staff.

(1) Qualifications. The consulting medical staff shall consist of those faculty members of the colleges of medicine and dentistry who:

(a) Satisfy the requirements and qualifications for membership set forth in rule 3335-43-04 of the Administrative Code.

(b) Are consultants of recognized professional ability and expertise who provide a service not readily available from the attending medical staff.

These practitioners provide services at the Ohio state university hospitals only at the request of attending or courtesy A members of the medical staff.

(c) Demonstrate participation on the active medical staff at another accredited hospital requiring performance improvement/quality assessment activities similar to those of the Ohio state university hospitals. The practitioner shall also hold at such other hospital the same privileges, without restriction, that he/she is requesting at the Ohio state university hospitals. An exception to this qualification may be made by the Wexner medical center board provided the practitioner is otherwise qualified by education, training and experience to provide the requested service.

(2) Prerogatives:

Consulting medical staff members may:

(a) Exercise the clinical privileges granted for consultation purposes on an occasional basis when requested by an attending or courtesy A medical staff member.

(b) Have access to all medical records and be entitled to utilize the facilities of the Ohio state university hospitals incidental to the clinical privileges granted pursuant to these bylaws.

(c) Not admit patients to the Ohio state university hospitals.

(d) Not vote on medical staff policies, rules and regulations, or bylaws, and may not hold office.

(e) Must actively participate in such quality evaluation and monitoring activities as required by the medical staff and as outlined in the medical staff policy entitled "Consulting medical staff member policy."

(f) Attend medical staff meetings, but shall not be entitled to vote at such meetings or hold office.

(g) Attend department meetings, but shall not be entitled to vote at such meetings or serve as chief of a clinical department.

(h) Serve as a non-voting member of a medical staff committee; provided, however, that he/she may not serve as a committee chair or as a member of the medical staff administrative committee.

(3) Responsibilities.

Each member of the consulting medical staff shall:

(a) Meet the basic responsibilities set forth in rules 3335-43-02 and 3335-43-03 of the Administrative Code.

(b) Be exempt from all medical staff dues.

(I) Clinical privileges.

(1) Delineation of clinical privileges:

(a) Every person practicing at the Ohio state university hospitals by virtue of medical staff membership, faculty appointment, contract or under authority granted in these bylaws shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically applied for and granted to the staff member or other licensed health care professional by the Ohio state university Wexner medical center board after recommendation from the medical staff administrative committee.

Each clinical department shall develop specific clinical criteria and standards for the evaluation of clinical privileges with emphasis on invasive or therapeutic procedures or treatment which present significant risk to the patient or for which specific professional training or experience is required. Such criteria and standards are subject to the approval of the medical staff administrative committee and the Wexner medical center board.

(b) Requests for the exercise and delineation of clinical privileges must be made as part of each application for appointment or reappointment to the medical staff on the forms prescribed by the medical staff administrative committee. Every person in an administrative position who desires clinical privileges shall be subject to the same procedure as all other applicants. Requests for clinical privileges must be submitted to the chief of the clinical department in which the clinical privileges will be exercised. Clinical privileges requested other than during appointment or reappointment to the medical staff shall be submitted to the chief of the clinical department and such request must include documentation of relevant training or experience supportive of the request.

(c) The chief of the clinical department shall review each applicant's request for clinical privileges and shall make a recommendation regarding clinical privileges to the chief medical officer. Requests for clinical privileges shall be evaluated based upon the applicant's education, training, experience, demonstrated competence, references, and other relevant information, including the direct observation and review of records of the applicant's performance by the clinical department in which the clinical privileges are exercised. Whenever possible the review should be of primary source information. The applicant shall have the burden of establishing the applicant's qualifications and competency in clinical privileges requested and shall have the burden of production of adequate information for the proper evaluation of qualifications.

(d) The applicant's request for clinical privileges and the recommendation of the chief of the clinical department shall be forwarded to the credentials committee and shall be processed in the same manner as applications for appointment and reappointment pursuant to rule 3335-43-04 of the Administrative Code.

(e) Medical staff members who are granted new or initial privileges are subject to FPPE, which is a six-month period of focused monitoring and evaluation of practitioners' professional performance. Following FPPE medical staff members with clinical privileges are subject to ongoing professional practice evaluation (OPPE), which information is factored into the decision to maintain existing privileges, to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal. FPPE and OPPE are fully detailed in medical staff policies that were approved by the medical staff administrative committee and the Wexner medical center board.

(f) Upon resignation, termination or expiration of the medical staff member's faculty appointment or employment with the university for any reason, such medical staff appointment and clinical privileges of the medical staff member shall automatically expire.

(g) Medical staff members authorize the Ohio state university hospitals and clinics to share credentialing, quality and peer review information pertaining to the medical staff member's clinical competence and/or professional conduct. Such information may be shared at initial appointment and/or reappointment and at any time during the medical staff member's medical staff appointment to the medical staff of the Ohio state university hospitals.

(h) Medical staff members authorize the Ohio state university hospitals to release information, in good faith and without malice, to managed care organizations, regulating agencies, accreditation bodies and other health care entities for the purposes of evaluating the medical staff member's qualifications pursuant to a request for appointment, clinical privileges, participation or other credentialing or quality matters.

(2) Temporary privileges:

(a) Temporary privileges may be extended to a doctor of medicine, osteopathic medicine, dental surgery, psychologist, podiatry or to a licensed health care professional upon completion of an application prescribed by the medical staff administrative committee, upon recommendation of the chief of the clinical department, and approval by the chief medical officer. The chief medical officer, acting as a member and on behalf of the Wexner medical center board, has been delegated responsibility by the Wexner medical center board to grant approval of temporary privileges. The temporary privileges granted shall be consistent with the applicant's training and experience and with clinical department guidelines. Prior to granting temporary privileges, primary source verification of licensure and current competence shall be required. Temporary privileges shall be limited to situations which fulfill an important patient-care need, and shall be granted for a period not to exceed one hundred twenty days.

(b) Temporary privileges may be extended to visiting medical faculty or for special activity as provided by the Ohio state medical or dental board.

(c) Temporary privileges granted for locum tenens may be exercised for a maximum of ninety days, consecutive or not, any time during the twenty-four month period following the date they are granted.

(d) Practitioners granted temporary privileges will be restricted to the specific delineations for which the temporary privileges are granted. The practitioner will be under the supervision of the chair of the clinical department while exercising any temporary privileges granted.

(e) Special privileges. Upon receipt of a written request for specific temporary privileges and the approval of the clinical department chief and the chief medical officer, an appropriately licensed practitioner of documented competence, who is not an applicant for medical staff membership, may be granted special privileges for the care of one or more specific patients. Such privileges shall be exercised in accordance with the conditions specified in these bylaws.

(f) Practitioners exercising temporary privileges shall abide by these medical staff bylaws, rules and regulations, and hospital and medical staff policies.

(g) The temporary and special privileges must be in conformity with accrediting bodies' standards and the rules and regulations of the professional boards of Ohio.

(3) Expedited privileges.

If the Wexner medical center board is not scheduled to convene in a timeframe that permits the timely consideration of the recommendation of a complete application by the medical staff administrative committee, applicants may be granted expedited privileges by the quality and professional affairs committee of the Wexner medical center board. Certain restrictions apply to the appointment and granting of clinical privileges via the expedited process. These include but are not limited to: an involuntary termination of medical staff membership at another hospital, involuntary termination of medical staff membership at another hospital, involuntary limitation, or reduction, denial or loss of clinical privileges, a history of professional liability actions resulting in a final judgment against the applicant or a challenge by a state licensing board.

(4) Podiatric privileges:

(a) Practitioners of podiatry may admit patients to the Ohio state university hospitals if such patients are being admitted solely to receive care that a podiatrist may provide without medical assistance, pursuant to the scope of the professional license of the podiatrist. Practitioners of podiatry must, in all other circumstances, co-admit patients with a member of the medical staff who is a doctor of medicine or osteopathic medicine. A member of the medical staff who is a doctor of medicine or osteopathy shall be responsible for any medical problems that the patient has while an inpatient of the Ohio state university hospitals.

(b) A member of the medical staff who is a doctor of medicine or osteopathy:

(i) Shall be responsible for any medical problems that the patient has while an inpatient of the Ohio state university hospitals; and

(ii) Shall confirm the findings, conclusions and assessment of risk prior to high-risk diagnosis or therapeutic interventions defined by the medical staff.

(c) Practitioners of podiatry shall be responsible for the podiatric care of the patient including the podiatric history and physical examination and all appropriate elements of the patient's record.

(d) The podiatrist shall be responsible to the chief of the department of orthopaedics.

(5) Psychology privileges.

(a) Psychologists shall be granted clinical privileges based upon their training, experience and demonstrated competence and judgment consistent with their license to practice. Psychologists shall not prescribe drugs, or perform surgical procedures, or in any other way practice outside the area of their approved clinical privileges or expertise, unless otherwise authorized by law.

(b) Psychologists may not admit patients to the Ohio state university hospitals, but may diagnose and treat a patient's psychological illness as part of the patient's comprehensive care while hospitalized. All patients admitted for psychological care shall receive the same medical appraisal as all other hospitalized patients. A member of the medical staff who is a doctor of medicine or osteopathic medicine shall admit the patient and shall be responsible for the history and physical and any medical care that may be required during the hospitalization, and shall determine the appropriateness of any psychological therapy based on the total health status of the patient. Psychologists may provide consultation within their area of expertise on the care of patients within the Ohio state university hospitals.

In outpatient settings, psychologists shall diagnose and treat their patients' psychological illness. Psychologists shall ensure that their patients receive referral for appropriate medical care.

(c) Psychologists shall be responsible to the chief of the clinical department in which they are appointed.

(6) Dental privileges.

(a) Practitioners of dentistry, who have not been granted clinical privileges as oral and maxillofacial surgeons, may admit patients to the Ohio state university hospitals if such patients are being admitted solely to receive care which a dentist may provide without medical assistance, pursuant to the scope of the professional license of the dentist. Practitioners of dentistry must, in all other circumstances co-admit patients with a member of the medical staff who is a doctor of medicine or osteopathic medicine. A member of the medical staff who is a doctor of medicine or osteopathy shall be responsible for any medical problems that the patient has while an inpatient of the Ohio state university hospitals.

(b) A member of the medical staff who is a doctor of medicine or osteopathy:

(i) Shall be responsible for any medical problems that the patient has while an inpatient of the Ohio state university hospitals; and

(ii) Shall confirm the findings, conclusions and assessment of risk prior to high-risk diagnosis or therapeutic interventions defined by the medical staff.

(c) Practitioners of dentistry shall be responsible for the dental care of the patient including the dental history and physical examination and all appropriate elements of the patient's record.

(7) Oral and maxillofacial surgical privileges.

All patients admitted to the Ohio state university hospitals for oral and maxillofacial surgical care shall receive the same medical appraisal as all other hospitalized patients. Qualified oral and maxillofacial surgeons shall admit patients, shall be responsible for the plan of care for the patients, shall perform the medical history and physical examination, if they have such privileges, in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedure(s), and shall be responsible for the medical care that may be required at the time of admission or that may arise during hospitalization.

(8) Other licensed health care professionals.

(a) Clinical privileges may be exercised by licensed health care professionals who are duly licensed in the state of Ohio, and who are either:

(i) Members of the faculty of the Ohio state university, or

(ii) Employees of the Ohio state university whose employment involves the exercise of clinical privileges, or

(iii) Employees or members of the medical staff.

(b) A licensed health care professional as used herein, shall not be eligible for medical staff membership but shall be eligible to exercise those clinical privileges granted pursuant to these bylaws and in accordance with applicable Ohio state law. If granted such privileges under this rule and in accordance with applicable Ohio state law, other licensed health care professionals may perform all or part of the medical history and physical examination of a patient. Licensed health care professionals with privileges are subject to FPPE and OPPE.

(c) Licensed health care professionals shall apply and re-apply for clinical privileges on forms prescribed by the medical staff administrative committee and shall be processed in the same manner as provided in rule 3335-43-04 of the Administrative Code subject to the provisions of paragraph (G)(8) of this rule.

(d) Licensed health care professionals are not members of the medical staff, but may write admitting orders for patients of the Ohio state university hospitals when granted such privileges under this rule and in accordance with applicable Ohio state law. If such privileges are granted, the patient will be admitted under the medical supervision of the responsible medical staff member. Licensed health care professionals shall not be eligible to hold office, vote on medical staff affairs, or serve on standing committees of the medical staff unless specifically authorized by the medical staff administrative committee.

(e) Each licensed health care professional shall be individually assigned to a clinical department and shall be sponsored by one or more members of the medical staff. The licensed health care professional's clinical privileges are contingent upon the sponsoring medical staff member's privileges. In the event that the sponsoring medical staff member loses privileges or resigns, the licensed health care professionals whom he or she has sponsored shall be placed on administrative hold until another sponsoring medical staff member is assigned. The new sponsoring medical staff member must be assigned in less than thirty days.

(f) Licensed health care professionals must comply with all limitations and restrictions imposed by their respective licenses, certifications, or legal credentials as required by Ohio law, and may only exercise those clinical privileges granted in accordance with provisions relating to their respective professions.

(g) Only applicants who can document the following shall be qualified for clinical privileges as a licensed health care professional:

(i) Current license, certification, or other legal credential required by Ohio law.

(ii) Certificate of authority, standard care agreement, or utilization plan.

(iii) Education, training, professional background and experience, and professional competence.

(iv) Patient care quality indicators definition for initial appointment. This data will be in a format determined by the licensed health care professional subcommittee and the quality management department.

(v) Adherence to the ethics of the profession for which an individual holds a license, certification, or other legal credential required by Ohio law.

(vi) Evidence of required immunization.

(vii) Evidence of good personal and professional reputation as established by peer recommendations.

(viii) Satisfactory physical and mental health to perform requested clinical privileges.

(ix) Ability to work with members of the medical staff and the Ohio state university hospitals employees.

(h) The applicant shall have the burden to produce documentation with sufficient adequacy to assure the medical staff and the Ohio state university hospitals that any patient cared for by the licensed health care professional seeking clinical privileges shall be given quality care, and that the efficient operation of the Ohio state university hospitals will not be disrupted by the applicant's care of patients in the Ohio state university hospitals.

(i) By applying for clinical privileges as a licensed health care professional, the applicant agrees to the following terms and conditions:

(i) The applicant has read the bylaws and rules and regulations of the medical staff of the Ohio state university hospitals and agrees to abide by all applicable terms of such bylaws and any applicable rules and regulations, including any subsequent amendments thereto, and any applicable Ohio state university hospitals policies that the Ohio state university hospitals may from time to time put into effect.

(ii) The applicant releases from liability all individuals and organizations who provide information to the Ohio state university hospitals regarding the applicant and all members of the medical staff, the Ohio state university hospitals staff, the Ohio state university Wexner medical center board and the Ohio state university board of trustees for all acts in connection with investigating and evaluating the applicant.

(iii) The applicant shall not deceive a patient as to the identity of any practitioner providing treatment or service in the Ohio state university hospitals.

(iv) The applicant shall not make any statement or take any action that might cause a patient to believe that the licensed health care professional is a member of the medical staff.

(v) The applicant shall not perform any patient care in the Ohio state university hospitals that is not permitted under the applicant's license, certification, or other legal credential required under Ohio law.

(vi) The applicant shall obtain and continue to maintain professional liability insurance in such amounts required by the medical staff.

(j) Licensed health care professionals shall be subject to quality review and corrective action as outlined in this paragraph for violation of these bylaws, their certificate of authority, standard of care agreement, utilization plan, or the provisions of their licensure, including professional ethics. Review may be requested by any member of the medical staff, a chief of the clinical department, or by the chief quality officer or his or her designee. All requests shall be in writing and shall be submitted to the chief quality officer. The chief quality officer shall appoint a three-person committee to review and make recommendations concerning appropriate action. The committee shall consist of at least one licensed health care professional and one medical staff member. The committee shall make a written recommendation to the chief quality officer, who may accept, reject, or modify the recommendation. The chief quality officer forwards his or her recommendation to the chief medical officer for final determination.

(k) Appeal process.

(i) A licensed health care professional may submit a notice of appeal to the chairperson of the quality and professional affairs committee within thirty days of receipt of written notice of any adverse corrective action pursuant to these bylaws.

(ii) If an appeal is not so requested within the thirty-day period, the licensed health care professional shall be deemed to have waived the right to appeal and to have conclusively accepted the decision of the chief medical officer.

(iii) The appellate review shall be conducted by the chief of staff, the chair of the licensed health care professionals subcommittee and one medical staff member from the same discipline as the licensed health care professional under review. The licensed health care professional under review shall have the opportunity to present any additional information deemed relevant to the review and appeal of the decision.

(iv) The affected licensed health care professional shall have access to the reports and records, including transcripts, if any, of the hearing committee and of the medical staff administrative committee and all other material, favorable or unfavorable, that has been considered by the chief quality officer. The licensed health care professional shall submit a written statement indicating those factual and procedural matters with which the member disagrees, specifying the reasons for such disagreement. This written statement may cover any matters raised at any step in the procedure to which the appeal is related, and legal counsel may assist in its preparation. Such written statement shall be submitted to the review committee no later than seven days following the date of the licensed health care professional's notice of appeal.

(v) New or additional matters shall only be considered on appeal at the sole discretion of the quality and professional affairs committee.

(vi) Within thirty days following submission of the written statement by the licensed health care professional, the chief of staff shall make a final recommendation to the chair of the quality and professional affairs committee of the Wexner medical center board. The quality and professional affairs committee of the Wexner medical center board shall determine whether the adverse decision will stand or be modified and shall recommend to the Ohio state university Wexner medical center board that the adverse decision be affirmed, modified or rejected, or to refer the matter back to the review committee for further review and recommendation. Such referral to the review committee may include a request for further investigation.

(vii) Any final decision by the Wexner medical center board shall be communicated by the chief quality officer and by certified return receipt mail to the last known address of the licensed health care professional as determined by university records. The chief quality officer shall also notify in writing the executive vice president for health sciences, the dean of the college of medicine, the chief executive officer of the Ohio state university hospitals and the vice president for health services and the chief of the applicable clinical department or departments. The chief medical officer shall take immediate steps to implement the final decision.

(9) Emergency privileges.

In case of an emergency, any member of the medical staff to the degree permitted by the member's license or certification and regardless of department or medical staff status shall be permitted to do everything possible to save the life of a patient using every facility of the Ohio state university hospitals necessary, including the calling for any consultation necessary or desirable. After the emergency situation resolves, the patient shall be assigned to an appropriate member of the medical staff. For the purposes of this paragraph, an "emergency" is defined as a condition which would result in serious permanent harm to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger.

(10) Disaster privileges.

Disaster privileges may be granted in order to provide voluntary services during a local, state, or national disaster in accordance with hospital/medical staff policy and only when the following two conditions are present: the emergency management plan has been activated and the hospital is unable to meet immediate patient needs. Such privileges may be granted by the chief medical officer or his or her designee to fully licensed or certified, qualified individuals who at the time of the disaster are not members of the medical staff. These privileges will be limited in scope and will terminate once the disaster situation subsides or at the discretion of the chief medical officer.

(11) Telemedicine.

Telemedicine involves the use of electronic communication or other communication technologies to provide or support clinical care at a distance. Diagnosis and treatment of a patient may now be performed via telemedicine link.

(a) A member of the medical staff who wants to render care via telemedicine must so indicate on his or her application for clinical privileges.

(b) A member of the medical staff may request to exercise via telemedicine the same clinical privileges he or she has already been granted. The credentials committee, the chief of the clinical service, the chief medical officer, the medical staff administrative committee, and the Wexner medical center board shall have the prerogative of requiring documentation or making a determination of the appropriateness for the exercise of a particular specialty/sub-specialty via telemedicine.

Effective: 6/23/2016
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 0701/1984, 11/29/1987, 02/02/1992, 01/31/1994, 05/26/1995, 03/20/1998, 06/15/1998, 02/18/2000, 02/04/2002, 08/19/2002, 10/04/2002, 07/01/2003, 02/01/2005, 06/20/2005, 11/21/2005, 03/26/2007, 02/27/2008, 01/20/2009, 11/23/2009, 08/06/2010, 06/14/2011, 09/16/2012, 07/31/2013, 4/29/2015

3335-43-08 Organization of the medical staff.

(A) Each member of the attending medical, courtesy A and B medical, community affiliate medical, limited, and physician scholar medical staff shall be assigned to a clinical department and division, if applicable, upon the recommendation of the applicable chief of the clinical department.

(B) Names of clinical departments and divisions.

(1) Anesthesiology

(2) Emergency medicine

(3) Family medicine

Sports medicine

(4) Internal medicine. The following divisions are designated:

Cardiovascular medicine

Dermatology

Endocrinology, diabetes and metabolism

Gastroenterology, hepatology and nutrition

General internal medicine and geriatrics

Hematology

Hospital medicine

Human genetics

Infectious diseases

Medical oncology

Nephrology

Pulmonary, allergy, critical care and sleep medicine

Rheumatology - immunology

(5) Neurological surgery

(6) Neurology

Cognitive neurology

Electrodiagnostics

Epilepsy

General neurology

Multiple sclerosis and neuroimmunology

Neuromuscular disease

Neurooncology

Sleep

Stroke

(7) Obstetrics and gynecology. The following divisions are designated:

General obstetrics and gynecology

Maternal - fetal medicine

Female pelvic medicine and reconstructive surgery

Gynecologic oncology

Reproductive endocrinology and infertility

(8) Ophthalmology

(9) Orthopaedics. The following divisions are designated:

Hand

Orthopaedic oncology

Podiatry

Sports medicine

Trauma

(10) Otorhinolaryngology

(11) Pathology. The following divisions are designated:

Anatomic pathology

Clinical pathology

(12) Pediatrics. The following divisions are designated:

Ambulatory pediatrics

Adolescent medicine

Allergy

Biochemical disorders

Cardiology

Clinical genetics

Dermatology

Endocrinology/metabolism

Gastroenterology

General pediatrics

Handicapped child

Hematology/oncology

Infectious diseases

Neonatology

Nephrology

Neurology

Nutrition

Pediatric education/research and evaluation

Pharmacology/toxicology

Psychology

Pulmonary

(13) Physical medicine and rehabilitation. The following division is designated:

Pediatric physical medicine and rehabilitation

Rehabilitation psychology

(14) Plastic surgery.

(15) Psychiatry. The following divisions are designated:

General psychiatry

Child and adolescent psychiatry

Geriatric psychiatry

Health psychology

(16) Radiation oncology.

Pediatric radiation oncology

(17) Radiology. The following divisions are designated:

Diagnostic radiology

Nuclear medicine

(18) Surgery. The following divisions are designated:

Cardiac surgery

Colon and rectal surgery

General and gastrointestinal surgery

Pediatric surgery

Surgical oncology

Thoracic surgery

Transplant

Trauma, critical care and burn

Vascular diseases and surgery

(19) Urology.

(20) Dentistry. The following divisions are designated:

General dentistry

Oral and maxillofacial surgery

(C) The directors of the divisions in the Ohio state university hospitals shall be appointed by the chiefs of the clinical departments in the Ohio state university hospitals in which the divisions are included. Clinical divisions may be added or deleted upon the recommendation of the chief of the clinical department with the concurrence of a majority of the medical staff administrative committee.

(D) Qualifications and responsibilities of the chief of the clinical department.

The academic department chairperson shall ordinarily serve also as the chief of the clinical department. Each chief of the clinical department shall be qualified by education and experience appropriate to the discharge of the responsibilities of the position. Each chief of the clinical department must be board certified by an appropriate specialty board or must establish comparable competence. The chief of the clinical department must be a medical staff member at the Ohio state university hospitals. Such qualifications shall be judged by the respective dean of the college of medicine or dentistry. Qualifications for chief of the clinical department generally shall include: recognized clinical competence, sound judgment and well-developed administrative skills.

(1) Procedure for appointment and reappointment of the chief of the clinical department.

Appointment or reappointment of chief of the clinical department shall be made by the dean of the respective college of medicine or dentistry in consultation with elected representatives of the medical staff and the chief medical officer.

(2) Term of appointment of the chief of the clinical department.

The term of appointment of the chief of the clinical department shall be concurrent with the chief's academic appointment but shall be no longer than four years. Prior to the end of said four-year term, a review shall be conducted by the dean of the college of medicine and such review shall serve as the basis for the recommendation for reappointment pursuant to paragraph (D)(1) of this rule.

(3) Duties of the chief of the clinical department.

Each chief of the clinical department is responsible for the following:

(a) Clinically related activities of the department;

(b) Administratively related activities of the department, unless otherwise provided by the hospital;

(c) Continuing surveillance of the professional performance of all practitioners in the department who have delineated clinical privileges;

(d) Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department;

(e) Recommending clinical privileges for each practitioner of the department based on relevant training and experience, current appraised competence, health status that does not present a risk to patients, and evidence of satisfactory performance with existing privileges;

(f) Assessing and recommending to the relevant hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the hospital;

(g) The integration of the department or service into the primary functions of the hospital, developing services that complement the medical center's mission and plan for clinical program development;

(h) The coordination and integration of interdepartment and intradepartmental services;

(i) The development and implementation of policies and procedures that guide and support the provision of care, treatment, and services. This includes the development, implementation, enforcement and updating of departmental policies and procedures that are consistent with the hospital's mission. The clinical department chief shall make such policies and procedures available to the medical staff;

(j) The recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services, including ensuring that call coverage provides for continuous high quality and safe care;

(k) The determination of the qualifications and competence of department or service personnel who are not licensed independent practitioners and who provide patient care, treatment, and services;

(l) The continuous assessment and improvement of the quality of care, treatment, and services;

(m) The maintenance of quality control programs, as appropriate;

(n) The orientation and continuing education of all persons in the department or service;

(o) Recommending space and other resources needed by the department or service; and

(p) Hold regular clinical department meetings and ensure open lines of communication are maintained in the clinical department. The agenda for the meetings shall include, but not be limited to, a discussion of the clinical activities of the department and communication of the decisions of the medical staff administrative committee. Minutes of departmental meetings, including a record of attendance, shall be electronically available and/or distributed to all medical staff members in the clinical department, and such minutes shall be kept in the clinical department.

Replaces: 3335-43-08

Effective: 2/21/2014
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 04/27/1986, 08/18/1986, 08/10/1987, 05/25/1991, 02/02/1992, 01/31/1994, 05/26/1995, 03/20/1998, 06/15/1998, 12/04/1998, 02/04/2002, 08/19/2002, 10/04/2002, 06/23/2003, 02/01/2005, 06/20/2005, 11/21/2005, 04/24/2006, 03/26/2007, 11/30/2007, 01/20/2009, 11/23/2009, 12/03/2009, 03/15/2011, 06/14/2011, 09/16/2012, 02/21/2014

3335-43-09 Elected officers of the medical staff of the Ohio state university hospitals.

(A) Chief of staff.

The chief of staff shall:

(1) Serve on those committees of the Ohio state university Wexner medical center board as appointed by the chairperson of that board.

(2) Serve as vice chairperson of the medical staff administrative committee.

(3) Provide for communication between the medical staff and the Ohio state university Wexner medical center board in matters of quality of care, education, and research.

(4) Serve as liaison between the Ohio state university hospitals administration, medical administration, and the medical staff in all matters of mutual concern within the Ohio state university hospitals. In consultation with the medical directors and the chief medical officer, seek to ensure that the medical staff is represented and participates as appropriate in any Ohio state university hospitals deliberation which affects the discharge of medical staff responsibilities.

(5) Call, preside, and be responsible for the agenda of all general medical staff meetings.

(6) Make medical staff committee appointments jointly with the medical directors and chief of staff-elect in consultation with the chief executive officer of the Ohio state university hospitals and with the approval of the Wexner medical center board, with the exception of the members of the medical staff administrative committee and nominating committee.

(7) Be spokesperson for the medical staff in its external professional and public relations.

(8) Serve as chairperson of the nominating committee of the medical staff.

(9) Hold meetings of the elected medical staff officers, representatives from medical staff committees, the chief executive officer, the chief nursing officer and medical directors.

(B) Chief of staff-elect.

The chief of staff-elect shall:

(1) Serve on those committees of the Ohio state university Wexner medical center board as appointed by the chairperson of the Wexner medical center board.

(2) Carry out all the duties of the chief of staff when the chief of staff is unable to do so.

(3) Oversee the inclusion of changes in the bylaws, rules and regulations of the medical staff.

(C) Representatives of the medical staff elected at-large.

There shall be three medical staff representatives elected at-large. Each representative shall be a member of the medical staff administrative committee and shall serve on those committees of the Ohio state university Wexner medical center board as appointed by the chairperson of the Wexner medical center board.

(D) Qualifications of officers.

(1) Officers must be members of the attending staff at the time of their nomination and election and must remain members in good standing during the term of their office. Failure to maintain such status shall immediately create a vacancy in the office involved.

(2) The medical director, associate medical directors, assistant medical directors and chiefs of the clinical departments shall not be eligible to serve as chief of staff or chief of staff-elect unless they are replaced in their Ohio state university hospitals administrative role during the period of their term of office.

(E) Election of officers.

(1) All officers (other than at-large officers) shall be elected by a majority of those voting by written or electronic ballot of the attending staff.

(2) The nominating committee shall be composed of five members. The chief of staff shall serve on the committee and shall select four other members for the committee. The chief of staff shall be its chairperson.

(3) Nominations for officers shall be accepted from any member of the medical staff and shall be submitted either electronically or in writing to the nominating committee.

(4) The committee's nominees shall be submitted to all voting members of the attending staff no later than March first of the election year.

(5) Candidates for the office of chief of staff-elect shall be listed and each attending staff member shall be entitled to cast one vote. Candidates for the at-large positions shall be voted upon as a group. Each voting member of the attending staff shall be entitled to vote for three at-large candidates. The three candidates with the highest number of votes shall be elected. A majority of the votes shall not be necessary.

(6) Automatic removal shall be for failure to meet those responsibilities assigned within these bylaws, failure to comply with medical staff rules and regulations, policies and procedures of the medical staff, for conduct or statements that damage the reputation of the Ohio state university Wexner medical center, its goals and missions, or programs, or an automatic termination or suspension of clinical privileges that lasts more than thirty days.

(F) Term of office.

(1) The chief of staff and chief of staff-elect shall each serve two years in office beginning on July first. The chief of staff-elect shall be elected in the odd numbered years. A former chief of staff may not succeed the immediately preceding chief of staff-elect.

(2) The at-large representatives shall each serve two years, beginning July first. The at-large representatives may succeed themselves for three successive terms (six years total), if so elected. Upon completion of the three successive terms, the representative may not serve again without a period of two years out of office as an at-large representative. The representative may be elected chief of staff-elect at any time.

(G) Vacancies in office.

(1) A vacancy in the office of chief of staff shall be filled by the chief of staff-elect.

If the unexpired term is one year or less, the new chief of staff shall serve out the remaining term in office and shall then serve as chief of staff for the term for which elected. If the unexpired term is more than one year, the new chief of staff shall serve out the remaining term only.

(2) Vacancies in the office of chief of staff-elect shall be filled by a special election held within sixty days of the vacancy by the nominating and election process set forth in paragraph (F) of this rule. The new chief of staff-elect shall become chief of staff at the end of the term of the incumbent.

(3) Vacancies in the at-large representatives medical staff positions shall be filled by appointment by the chief of staff.

Effective: 9/18/2016
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 07/01/1984, 08/10/1987, 01/31/1994, 05/26/1995, 06/15/1998, 02/04/2002, 08/19/2002, 06/23/2003, 07/01/2003, 11/21/2005, 03/26/2007, 01/20/2009, 11/23/2009, 08/06/2010, 06/14/2011, 09/16/2012, 04/27/2015

3335-43-10 Administration of the medical staff of the Ohio state university hospitals.

(A) Chief medical officer.

The chief medical officer is the senior medical officer for the medical center with the responsibility and authority for all health and medical care delivered at the medical center. The chief medical officer is responsible for overall quality improvement and clinical leadership throughout the medical center, physician alignment, patient safety and medical staff development. The appointment, scope of authority, and responsibilities of the chief medical officer shall be as outlined in the Ohio state medical center board bylaws.

(B) Chief quality officer.

The chief quality and patient safety officer of the Ohio state university medical center is referred to herein these bylaws as the chief quality officer. The chief quality officer reports to the chief medical officer for administrative and operational issues and has an independent reporting relationship to the senior vice president for health sciences regarding quality data and patient safety events. The chief quality officer works collaboratively with clinical leadership of the medical center, including the director of medical affairs for the James cancer hospital, nursing leadership and hospital administration. The chief quality officer provides leadership in the development and measurement of the medical center's approach to quality, patient safety and reduction of adverse events. The chief quality officer communicates and implements strategic, operational and programmatic plans and policies to promote a culture where patient safety is an important priority for medical and hospital staff (C) Medical directors.

(C) Medical directors.

The medical directors of the hospitals of the Ohio state university report to the chief executive officer or the executive director of the respective hospital and chief medical officer. Each medical director will collaborate with the chief quality officer, the chief medical officer and the clinical department chiefs to develop, execute and monitor the quality and safety programs of the hospital. The appointment, scope of authority, and responsibilities of the medical directors for the Ohio state university hospitals shall be further outlined in the Ohio state medical center board bylaws.

(D) Medical staff committees.

(1) Appointments:

Appointments to all medical staff committees except the medical staff administrative committee, nominating committee and all health system committees, shall be made jointly by the chief of staff, chief of staff-elect, and the medical directors with medical staff administrative committee ratification. Representatives from the Ohio state university hospitals to health system committees shall be appointed jointly by the chief medical officer of the health system and the medical director. Unless otherwise provided by these bylaws, all appointments to medical staff committees shall be for one year and may be renewed. The chief of staff, chief medical officer, medical director, and the chief executive officer of the Ohio state university hospitals may serve on any medical staff committee as an ex-officio member without vote.

(2) Meetings:

Each medical staff committee shall meet at the call of its chairperson and at least quarterly. Committees shall maintain records of proceedings and minutes of meetings and shall forward all recommendations and actions taken to the chief medical officer who shall promptly communicate them to the medical staff administrative committee. The chairperson shall control the committee agenda, attendance of staff and guests, and conduct of the proceedings. A simple majority of appointed voting members shall constitute a quorum.

(3) Peer review committees:

The medical staff as a whole and each committee provided for by these medical staff bylaws is hereby designated as a peer review committee in accordance with the laws of the state of Ohio. The medical staff through its committees shall be responsible for evaluating, maintaining and/or monitoring the quality and utilization of patient care services provided by the Ohio state university hospitals.

(E) Medical staff administrative committee.

(1) Composition.

(a) This committee shall consist of the following voting members: chief of staff, chief of staff-elect, chiefs of the clinical departments, three medical staff representatives elected at large, the chief medical officer, and the chief executive officer of the Ohio state university hospitals. Additional members may be appointed to the medical staff administrative committee at the recommendation of the dean or the chief medical officer of the medical center subject to the approval of the medical staff administrative committee and subject to review/renewal on a yearly basis. Any members may be removed from the medical staff administrative committee at the recommendation of the dean, the senior vice president for health sciences or the chief medical officer of the medical center and subject to the review and approval of the medical staff administrative committee. A replacement will be appointed as outlined above to maintain the medical staff administrative committee's constituency. The chief medical officer shall be the chairperson and the chief of staff shall be vice-chairperson.

(b) Any member of the committee who anticipates absence from a meeting of the committee may appoint as a temporary substitute another member of the same category of the medical staff to represent him or her at the meeting. The temporary substitute shall have all the rights of the absent member. The chief executive officer of the Ohio state university hospitals may invite any member of the chief executive officer's staff to represent him or her at a meeting or to attend any meeting.

(c) All members of the committee shall attend, either in person or by proxy, a minimum of two-thirds of all committee meetings.

(2) Duties.

(a) To represent and to act on behalf of the medical staff, subject to such limitations as may be imposed by these bylaws, by the bylaws of the Ohio state medical center board, the bylaws or rules of the board of trustees of the Ohio state university.

(b) To have primary authority for activities related to self-governance of the medical staff. Action approved by the medical staff administrative committee can be reviewed by the professional affairs committee pursuant to rule 3335-43-13 of the Administrative Code.

(c) To receive and act upon committee reports.

(d) To delegate appropriate staff business to committees while retaining the right of executive responsibility and authority over all medical staff committees. This shall include but is not limited to review of and action upon medical staff appointments and reappointments whenever timely action is necessary. To approve and implement policies of the medical staff

(e) To approve and implement policies of the medical staff

(f) To provide a liaison between the medical staff, medical director, chief executive officer, and the medical center board.

(g) To recommend action to the medical directors and chief executive officer of the Ohio state university hospitals on matters of medico-administrative nature.

(h) To fulfill the medical staff's accountability to the medical center board and the board of trustees of the Ohio state university for medical care rendered to patients in the Ohio state university hospitals, and for the professional conduct and activities of the medical staff, including recommendations concerning:

(i) Medical staff structure;

(ii) The mechanism to review credentials and to delineate clinical privileges;

(iii) The mechanism by which medical staff membership may be terminated;

(iv) Participation in the Ohio state university hospitals' performance improvement activities; and

(v) Corrective action and hearing procedures applicable to medical staff members and other licensed health care professionals granted clinical privileges.

(i) To ensure the medical staff is kept abreast of the accreditation process and informed of the accreditation status of the Ohio state university hospitals.

(j) To review and act on medical staff appointments, reappointments, and requests for delineation of clinical privileges. Whenever there is doubt of an applicant's ability to perform the privileges requested, the medical staff administrative committee shall have the authority to request an evaluation of the applicant's clinical activities relevant to requested privileges.

(k) To report to the medical staff all actions affecting the medical staff.

(l) To inform the medical staff of all changes in committees, and the elimination of such committees as circumstances shall require.

(m) To create committees (for which membership is subsequently appointed pursuant to rule 3335-43-09 of the Administrative Code) to meet the needs of the medical staff and comply with the requirements of accrediting agencies.

(n) To establish and maintain rules and regulations governing the medical staff.

(o) To perform other functions as are appropriate.

(3) Meetings. The committee shall meet monthly and shall keep detailed minutes which shall be distributed to each committee member and to the medical center board through the professional affairs committee.

(4) Voting. At a properly constituted meeting, voting shall be by a simple majority of members present except in the case of termination or non-reappointment of medical staff membership or permanent suspension of clinical privileges, wherein a two-thirds vote of members present shall be required.

(F) Credentialing committee of the hospitals of the Ohio state university:

(1) Composition:

The credentialing responsibilities of medical staff are delegated to the credentialing committee of the hospitals of the Ohio state university, the composition of which shall include representation from the medical staff of each health system hospital.

The credentialing committee of the hospitals of the Ohio state university shall be appointed by the chief medical officer of the health system. The chief of staff and director of medical affairs or medical director of each health system hospital shall make recommendations to the chief medical officer for representation on the credentialing committee of the hospitals of the Ohio state university.

The credentialing committee of the hospitals of the Ohio state university shall meet at the call of its chair, who shall be appointed by the chief medical officer of the health system.

(2) Duties:

(a) To review all applications for medical staff and licensed health care professional appointment and reappointment, as well as all requests for delineation, renewal, or amendment of clinical privileges in the manner provided in these medical staff bylaws, including applicable time limits. During its evaluation, the credentialing committee of the hospitals of the Ohio state university will take into consideration the appropriateness of the setting where the requested privileges are to be conducted;

(b) To review biennially all applications for reappointment or renewal of clinical privileges;

(c) To review all requests for changes in medical staff membership;

(d) To assure, through the chairperson of the committee, that all records of formal peer review activity taken by the committee, including committee minutes, are maintained in the strictest of confidence in accordance with the laws of the state of Ohio. The committee may conduct investigations and interview applicants as needed to discharge its duties. The committee may refer issues and receive issues as appropriate from other medical staff committees;

(e) To make recommendations to the medical staff administrative committee through the chief medical officer regarding appointment applications and initial requests for clinical privileges. Such recommendations shall include the name, status, department (division), medical school and year of graduation, residency and fellowships, medical-related employment since graduation, board certification and recertification, licensure status as well as all other relevant information concerning the applicant's current competence, experience, qualifications, and ability to perform the clinical privileges requested;

(f) To recommend to the medical staff administrative committee that certain applications for appointment be reviewed in executive session;

(g) The committee, after review and investigation, may make recommendations to the chief medical officer, chief of staff or the chief of a clinical department, regarding the restriction or limitation of a member's clinical privileges for noncompliance or any other matter related to its responsibilities;

(h) To review all grants of special or temporary privileges; and

(i) To review requests made for clinical privileges by other licensed health care professionals as set forth in these bylaws.

(j) To recommend eligibility criteria for the granting of medical staff membership and privileges.

(k) To develop, recommend, and consistently implement policy and procedures for all credentialing and privileging activities.

(l) To review, and where appropriate take action on, reports that are referred to it from other medical staff committees and medical staff members.

(m) To perform such other functions as requested by the medical staff administrative committee, the professional affairs committee or medical center board.

(3) Licensed health care professionals subcommittee.

(a) Composition:

This subcommittee shall consist of other licensed health care professionals who have been appointed in accordance with paragraph (A)(6) of rule 3335-43-09 of the Administrative Code. The subcommittee shall be chaired by a director of nursing who shall serve as chair of the subcommittee.

(b) Duties:

(i) To review, within thirty days of receipt, all completed applications as may be referred by the credentialing committee of the hospitals of the Ohio state university.

(ii) To review and investigate the character, qualifications and professional competence of the applicant.

(iii) To review the applicant's patient care quality indicator definitions on initial granting of clinical privileges and the performance based profile at the time of renewal.

(iv) To verify the accuracy of the information contained in the application.

(v) To request a personal interview with the applicant if deemed appropriate.

(vi) To forward, following review of the application, a written recommendation for clinical privileges to the credentialing committee of the hospitals of the Ohio state university for review at its next regularly scheduled meeting.

(vii) To develop relevant policies and procedures regarding the scope of service and scope of practice to be granted to each licensed health care professional specialty. These policies and procedures shall be ratified by the credentialing committee and medical staff administrative committee, and be approved by the medical center board.

(G) Committee for licensed independent practitioner health.

(1) Composition:

The committee shall consist of medical staff members appointed in accordance with paragraph (A)(6) of rule 3335-43-09 of the Administrative Code.

(2) Duties:

(a) To consider issues of licensed independent practitioner health or impairment whenever a self referral or referral is requested by an affected member or another member or committee of the medical staff, the Ohio state university hospitals staff, or any other individual.

(b) To educate the medical staff and the Ohio state university hospitals staff about illness and impairment recognition issues, including at-risk criteria, specific to licensed independent practitioners.

(c) To provide appropriate counsel, referral and monitoring until the rehabilitation is complete and periodically thereafter, if required, to enable the medical staff member to obtain appropriate diagnosis and treatment, and to provide appropriate standards of care.

(d) To consult regularly with the chief of staff, chief medical officer and medical director of the Ohio state university hospitals.

(e) To advise credentials or other appropriate medical staff committees on the credibility of any complaint, allegation or concern, including those affecting the quality and safety of patient care.

(f) To assure, through the chairperson of the committee, that all proceedings and records, including the identity of the person referring the case, are handled and maintained in the strictest confidence in accordance with the laws of the state of Ohio.

(g) To initiate appropriate actions when a licensed practitioner fails to complete the required rehabilitation program.

(H) Medical staff bylaws committee.

(1) Composition:

The committee shall consist of those members appointed in accordance with paragraph (A)(6) of rule 3335-43-09 of the Administrative Code. The chairperson shall always be the chief of staff-elect.

(2) Duties:

(a) To review and recommend amendments, as appropriate, to these medical staff bylaws to the medical staff administrative committee at least every two years.

(b) To receive from members of the medical staff or the medical staff administrative committee any suggestions that may necessitate amendment of these bylaws.

(I) Infection prevention committee.

(1) Composition:

The medical staff members of the committee shall consist of those members appointed in accordance with paragraph (A)(6) of rule 3335-43-09 of the Administrative Code. The committee shall also include representatives of nursing, environmental services, and hospital administration as may be invited from time to time by the chief of staff. The chairperson shall be a physician member of the medical staff with experience or training in infectious diseases.

(2) Duties:

(a) To oversee surveillance and institute any recommendations necessary for the investigation, prevention, containment of nosocomial and clinical infectious diseases of both patients and staff at all facilities owned, operated, or controlled by the Ohio state university hospitals and subject to JCAHO standards.

(b) To take necessary action through the chairperson of the committee, and the Ohio state university hospitals' epidemiologist, in consultation with the medical director of the Ohio state university hospitals, to prevent and control emerging spread or outbreaks of infections; isolate communicable and infectious patients as indicated; and obtain all necessary cultures in emergent situations when the responsible medical staff member is unavailable.

(J) Ethics committee.

(1) Composition:

The committee shall consist of members of the medical staff, nursing, hospital administration, and other persons who by reason of training, vocation, or interest may make a contribution. Members shall be appointed as provided in these bylaws. The chairperson shall be a medical staff member who is a clinically active physician.

(2) Duties:

(a) To make recommendations for the review and development of guidelines or policies regarding ethical issues.

(b) To provide ethical guidelines and information in response to requests from members of the medical staff, patients, patient's family or other representative, and staff members of the Ohio state university hospitals.

(c) To provide a support mechanism for primary decision makers at the Ohio state university hospitals. To provide educational resources on ethics to all health care providers at the Ohio state university hospitals.

(d) To provide educational resources on ethics to all health care providers at the Ohio state university hospitals

(e) To provide and enhance interaction between hospitals administration and staff, departmental ethics committees, pastoral care services, and members of the medical staff.

(K) Practitioner evaluation committee.

(1) Composition.

This multi-disciplinary peer review committee is composed of clinically-active practitioners. If additional expertise is needed, the practitioner evaluation committee may request the assistance from any medical staff member or recommend to the chief medical officer an external review.

(2) Duties:

(a) To meet and keep minutes, which describe issues, opportunities to improve patient care, recommendations and actions to the chief quality officer and chair of the clinical department, responsible parties, and expected completion dates. The minutes are maintained in the quality and operations improvement office.

(b) To ensure that ongoing and systematic monitoring, evaluation, and process improvement is performed in each clinical department.

(c) To develop and utilize objective criteria in practitioner peer review activities.

(d) To ensure that the medical staff peer review process is effective.

(e) To maintain confidentiality of its proceedings. These issues are not to be handled outside of PEC by any individual, clinical department, division, or committee.

(L) Leadership council for clinical quality, safety and service.

(1) Composition:

The leadership council shall consist of members appointed in accordance with paragraph (A)(6) of rule 3335-43-09 of the Administrative Code, and shall include the senior vice president for health sciences, the dean of the college of medicine and the chairperson of the professional affairs committee of the medical center board as ex-officio members without a vote. The chief quality officer shall be the chairperson of the leadership council.

(2) Duties:

(a) To design and implement systems and initiatives to enhance clinical care and outcomes throughout the integrated health care delivery system.

(b) To serve as the oversight council for the clinical quality management and patient safety plan.

(c) To establish goals and priorities for clinical quality, safety and service on an annual basis.

(3) Clinical quality and patient safety committee.

(a) Composition:

The members of this group shall be appointed pursuant to these bylaws and shall include medical staff members from various clinical departments and support services, and shall include the director of the clinical quality management policy group, and representatives of nursing and hospitals administration. The chairperson of the policy group shall be a physician member of the medical staff.

(b) Duties:

(i) To coordinate the quality management related activities of the clinical departments, the medical information management department, utilization review, infection control, pharmacy and therapeutics and drug utilization committee, transfusion and isoimmunization, and other medical staff and the Ohio state university hospitals committees.

(ii) To implement clinical improvement programs to achieve the goals of the Ohio state university hospitals quality management plan, as well as assure optimal compliance with accreditation standards and governmental regulations concerning performance improvement.

(iii) To review, analyze, and evaluate on a continuing basis the performance of the medical staff and other health care providers; and advise the clinical department clinical quality sub-committees in defining, monitoring, and evaluating quality indicators of patient care and services.

(iv) To serve as liaison between the Ohio state university and the Ohio peer review organizations through the chairperson of the policy group and the director of clinical quality.

(v) To make recommendations to the medical staff administrative committee on the establishment of and the adherence to standards of care designed to improve the quality of patient care delivered in the Ohio state university hospitals.

(vi) To hear and determine issues concerning the quality of patient care rendered by members of the medical staff and the Ohio state university hospitals staff and make appropriate recommendations and evaluate action plans when appropriate to the chief medical officer, the medical director, the chief of a clinical department, or the Ohio state university hospitals administration.

(vii) To appoint ad-hoc interdisciplinary teams to address the Ohio state university hospitals-wide quality management plan.

(viii) To annually review and revise as necessary the Ohio state university hospitals-wide clinical quality management plan.

(ix) To report and coordinate with the leadership council for clinical quality, safety and service of all quality improvement initiatives.

(4) Clinical resource utilization policy group

(a) Composition:

The members shall be appointed in accordance with paragraph (A)(6) of rule 3335-43-09 of the Administrative Code and shall include medical staff members from various clinical departments and support services the directors of clinical quality and case management, and representatives of nursing and hospitals administration. The chairperson of the policy group shall be a physician member of the medical staff.

(b) Duties:

(i) To promote the most efficient and effective use of the hospitals of the Ohio state university health system facilities and services by participating in the review process and continued stay reviews on all hospitalized patients.

(ii) To formulate and maintain a written resource management review plan for the hospitals of the Ohio state university health system consistent with applicable governmental regulations and accreditation requirements.

(iii) To conduct resource management studies by clinical department or divisions, or by disease entity as requested or in response to variation from benchmark data would indicate.

(iv) To report and recommend to the leadership council for clinical quality, safety and service changes in clinical practice patterns in compliance with applicable governmental regulations and accreditation requirements, and when the opportunity exists to improve the resource management.

(v) To oversee evaluation and cost effective utilization of clinical technology.

(vi) To oversee the activities of the utilization management committee of the hospitals of the Ohio state university health system. This oversight will include the annual review and approval of the utilization management plan.

(5) Evidence-based practice policy group.

(a) Composition: The members shall be appointed in accordance with paragraph (A)(6) of rule 3335-43-09 of the Administrative Code, and shall include medical staff members from various clinical departments and support services, representatives of nursing, pharmacy, information systems, hospitals administration, and the chair of the clinical quality and management policy group. The chairperson of the policy group shall be a physician member of the medical staff.

(b) Duties:

(i) To oversee the planning, development, approval, implementation and periodic review of evidence-based medicine resources (i.e., clinical practice guidelines, quick reference guides, clinical pathways, and clinical algorithms) for use within the Ohio state university hospitals and its affiliated institutions. Planning should be based on the prioritization criteria approved by the leadership council for clinical quality, safety and service and review should focus on incorporating recent medical practice, literature or developments. Annual review should be done in cooperation with members of the medical staff with specialized knowledge in the field of medicine related to the guideline.

(ii) To report and recommend to the leadership council for clinical quality, safety and service specific process and outcomes measures for each evidence-based medicine resource.

(iii) To oversee ongoing education of medical staff (including specifically limited staff) and other appropriate Ohio state university hospitals staff regarding the fundamental concepts and value of evidence-based practice and outcomes measurement and its relation to quality improvement.

(iv) To initiate and support research projects when appropriate in support of the objectives of the leadership council for clinical quality, safety and service.

(v) To oversee the development, approval and periodic review of the clinical elements of computerized ordersets and clinical rules to be used within the information system of the Ohio state university hospitals and its affiliated institutions. Computerized ordersets and clinical rules related to specific practice guideline should be forwarded to the leadership council for clinical quality, safety and service for approval. All other computerized ordersets and clinical rules should be forwarded to the leadership council for clinical quality, safety and service for information.

(vi) To regularly report a summary of all actions to the leadership council for clinical quality, safety and service.

(M) Professionalism consultation committee.

(1) Composition.

This multi-disciplinary peer review committee is composed of clinically-active practitioners and other individuals with expertise in professionalism.

(2) Duties.

(a) Receive and review validity of complaints regarding concerns about professionalism of credentialed practitioners;

(b) Treat, counsel and coach practitioners in a firm, fair and equitable manner;

(c) Maintain confidentiality of the individual who files a report unless the person who submitted the report authorizes disclosure or disclosure is necessary to fulfill the institution's legal responsibility;

(d) Ensure that all activities be treated as confidential and protected under applicable peer review and quality improvement standards in the Ohio Revised Code;

(e) Forward all recommendations to the clinical department chief, the chief medical officer or his/her designee and, if applicable, to the chief nursing officer.

Replaces: 3335-43-10

Effective: 2/21/2014
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 08/05/1985, 09/06/1985, 08/26/1991, 10/21/1991, 01/31/1994, 03/20/1998, 06/15/1998, 09/28/2000, 02/04/2002, 08/19/2002, 10/04/2002, 06/23/2003, 07/01/2003, 02/01/2005, 06/20/2005, 11/21/2005, 03/26/2007, 02/27/2008, 01/20/2009, 11/23/2009, 12/03/2009, 06/14/2011, 09/16/2012, 08/12/2013, 02/21/2014

3335-43-11 History and physical.

(A) History and physical examination.

(1) A history and physical appropriate to the patient and/or the procedure to be completed shall be documented in the medical record of all patients either:

(a) Admitted to the hospital

(b) Undergoing outpatient/ambulatory procedures

(c) Undergoing outpatient/ambulatory surgery

(d) In a hospital-based ambulatory clinic

(2) For patients admitted to the hospital, the history and physical examination shall include at a minimum:

(a) Date of admission

(b) History of present illness, including chief complaint

(c) Past medical and surgical history

(d) Relevant past social and family history

(e) Medications and allergies

(f) Review of systems

(g) Physical examination

(h) Test results

(i) Assessment or impression

(j) Plan of care

(3) For patients undergoing outpatient/ambulatory procedures or outpatient/ambulatory surgery, the history and physical examination shall include at a minimum:

(a) Indications for procedure or surgery

(b) Relevant medical and surgical history

(c) Medications and allergies or reference to current listing in the electronic medical record

(d) Focused review of systems, as appropriate for the procedure or surgery

(e) Pre-procedure assessment and physical examination

(f) Assessment/impression and treatment plan

(4) For patients seen in a hospital-based ambulatory clinic, the history and physical shall include at a minimum:

(a) Chief complaint

(b) History of present illness

(c) Medications and allergies

(d) Problem-focused physical examination

(e) Assessment or impression

(f) Plan of care

(5) Deadlines and sanctions.

(a) A history and physical examination must be performed by a member of the medical staff, his/her designee or other licensed health care professional, who is appropriately credentialed by the hospital, and be signed, timed and dated.

(b) Patients admitted to the hospital: If the history and physical is performed by the medical staff member's designee or other licensed health care professional who is appropriately credentialed by the hospital, the history and physical must be countersigned by the responsible medical staff member.

(c) The complete history and physical examination shall be dictated, written or updated no later than twenty-four hours after admission for all inpatients.

(d) Admitted patients or patients undergoing a procedure or surgery, the history and physical examination may be performed or updated up to thirty days prior to admission or the procedure/ surgery or the visit. If completed before admission or the procedure/ surgery or patient's initial visit, there must be a notation documenting an examination for any changes in the patient's condition since the history and physical was completed. The updated examination must be completed and documented in the patient's medical record within twenty-four hours after admission or before procedure/surgery, whichever occurs first. It must be performed by a member of the medical staff, his/her designee, or other licensed health care professional who is appropriately credentialed by the hospital, and be signed, timed and dated. In the event the history and physical update is performed by the medical staff member's designee or other licensed health care professional who is appropriately credentialed by the hospital, it shall be countersigned, timed and dated by the responsible medical staff member.

(i) For patients undergoing an outpatient procedure or surgery, regardless of whether the treatment, procedure or surgery is high or low risk, a history and physical examination must be performed by a member of the medical staff, his/her designee, or other licensed health care professional who is appropriately credentialed by the hospital and must be signed or countersigned when required, timed and dated.

(ii) If a licensed health care professional is appropriately credentialed by the hospital to perform a procedure or surgery independently, a history and physical performed by the licensed health care professional prior to the procedure or surgery is not required to be countersigned.

(e) Hospital-based ambulatory clinic: If a history and physical examination is performed by a licensed health care professional who is appropriately credentialed by the hospital to see patients independently, the history and physical is not required to be countersigned.

(f) When the history and physical examination, including the results of indicated laboratory studies and x-rays, is not recorded in the medical record before the time stated for a procedure or surgery, the procedure or surgery cannot proceed until the history, and physical is signed or countersigned when required, by the responsible medical staff member, and indicated test results are entered into the medical record. In cases where such a delay would likely cause harm to the patient, this condition shall be entered into the medical record by the attending responsible medical staff member, his/her designee or other licensed health care professional, who is appropriately credentialed by the hospital, and the procedure or surgery may begin. When there is a disagreement concerning the urgency of the procedure, it shall be adjudicated by the medical director or the medical director's designee.

(g) Ambulatory patients must have a history and physical at the initial visit as outlined in paragraph (A)(4) of this rule.

(h) For psychology, psychiatric and substance abuse ambulatory sites, if no other acute or medical condition is present on the initial visit, a history and physical examination may be performed either:

(i) Within the past six months prior to the initial visit,

(ii) At the initial visit, or

(iii) Within thirty days following the initial visit.

Effective: 6/23/2016
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 12/04/2009, 09/16/2012, 02/21/2014, 4/27/2015

3335-43-12 Meetings and dues.

(A) Meetings The medical staff of the Ohio state university hospitals shall conduct scheduled meetings twice yearly. Notice of the meeting shall be sent to all medical staff at least two weeks prior to the meeting. Attendance is encouraged, but shall not be a requirement for continued medical staff membership and clinical privileges. Special meetings of the medical staff may be called at the option of the medical staff administrative committee.

(B) Dues.

The medical staff, by two-thirds vote of those in attendance at a regularly scheduled meeting, may establish dues. Payment of dues is a requirement for continued staff membership.

Replaces: 3335-43-12

Effective: 12/3/2009
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 04/27/1986, 05/25/1991, 01/31/1994, 02/04/2002, 10/04/2002, 12/03/2009

3335-43-13 Amendments and adoption.

(A) Medical staff responsibility.

The medical staff bylaws committee shall have the initial responsibility to formulate, review at least biennially, and recommend to the professional affairs committee of the medical center board any medical staff bylaws, rules, regulations, policies, procedures, and amendments as needed. Amendments to the bylaws shall be effective when approved by the university board of trustees. Amendments to the rules and regulations shall be effective when approved by the medical center board.

Such responsibility shall be exercised in good faith, in a timely manner and in accordance with applicable laws and regulatory standards. This applies as well to the review, adoption, and amendment of the related rules, policies, and protocols developed to implement the various sections of these bylaws.

The organized medical staff shall also have the ability to propose amendments to the medical staff bylaws, rules and regulations, and policies and procedures and propose them directly to the professional affairs committee of the medical center board.

If the voting members of the organized medical staff propose to adopt amendments to the bylaws, rules and regulations or policies, they must first communicate the proposal to the medical staff administrative committee. When the medical staff administrative committee proposes to adopt amendments to the bylaws, rules and regulations or policies, it communicates the proposal to the organized medical staff.

Conflict between the organized medical staff and the medical staff administrative committee will be managed by allowing communication directly from the medical staff to the professional affairs committee of the medical center board on issues including, but not limited to amendments to the bylaws and the adoption of new rules and regulations or policies. Medical staff members may communicate with the professional affairs committee of the medical center board by submitting their communication in writing to the chief of staff, who shall then communicate on their behalf to the professional affairs committee of the medical center board at its next regularly scheduled meeting for final determination.

In cases of urgent need to update the medical staff bylaws or rules and regulations in order to comply with law, statute, federal regulation, or accreditation standard, the medical staff administrative committee and the professional affairs committee of the medical center board may provisionally approve an urgent amendment without prior notification to the medical staff. The medical staff shall be immediately notified by the medical staff administrative committee. The medical staff shall have the opportunity for review of and vote on the provisional amendment. If the medical staff votes in favor of the provisional amendment, it shall stand. If there is conflict over the provisional amendment, process for resolving conflict between the organized medical staff and the medical staff administrative committee shall be implemented.

(B) Methods of adoption and amendment to these bylaws.

Proposed amendments to these bylaws may be originated by the medical staff bylaws committee, medical staff administrative committee or by a petition signed by twenty-five per cent of attending medical staff members.

Each attending medical staff member will be eligible to vote on the proposed amendment via printed or secure electronic ballot in a manner determined by the medical staff administrative committee. All attending medical staff members shall receive at least thirty days advance notice of the changes to be adopted:

(1) The medical staff receives a simple majority of the votes cast by those members eligible to vote.

(2) Amendments so adopted shall be effective when approved by the university board of trustees.

(C) Methods of adoption and amendment to medical staff rules, regulations and policies.

The medical staff may adopt additional rules, regulations and policies as necessary to carry out its functions and meet its responsibilities under these bylaws.

Proposed amendments to the rules, regulations and policies may be originated by the medical staff bylaws committee or the medical staff administrative committee.

The medical staff administrative committee shall vote on the proposed language changes at a regular meeting, or at a special meeting called for such purpose. Following an affirmative vote by the medical staff administrative committee, rules and regulations may be adopted, amended or repealed, in whole or in part and such changes shall be effective when approved by the organized medical staff, and the medical center board. Policies and procedures will become effective upon approval of the medical staff administrative committee.

In addition to the process described in this rule the organized medical staff itself may recommend directly to the professional affairs committee of the medical center board an amendment to any rule, regulation, or policy by submitting a petition signed by twenty-five percent of the members of the attending medical staff category. Upon presentation of such petition, the adoption process outlined in this rule will be followed.

(D) The medical staff administrative committee may adopt such amendments to these bylaws, rules, regulations, and policies that are, in the committee's judgment, administrative, technical or legal modifications or clarifications. Such modifications may include reorganization or renumbering, punctuation, spelling, or other errors of grammar or expression. Such amendments need not be approved by the entire medical center board but must be approved by the vice president of health services. Neither the organized medical staff nor the medical center board may unilaterally amend the medical staff bylaws or rules and regulations.

The medical staff bylaws, rules and regulations, medical center board bylaws, and relevant policies shall not conflict. The medical staff bylaws committee shall assure that there is no conflict.

Replaces: 3335-43-13

Effective: 6/14/2011
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 06/14/2011

3335-43-14 Rules of construction.

(A) "Shall" as used herein is to be construed as mandatory.

(B) These bylaws should be construed to be gender neutral.

Replaces: 3335-43-14

Effective: 6/14/2011
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 12/03/2009, 06/14/2011