Rule 3335-43-10 | Administration of the medical staff of the Ohio state university hospitals.
(A) Chief medical officer.
The chief clinical officer functions as the chief medical officer as referred to herein university bylaws. 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 university Wexner medical center board bylaws.
(B) Chief quality officer.
The chief quality and patient safety officer of the Ohio state university Wexner medical center is referred to herein university bylaws as the chief quality officer. The chief quality officer reports to the chief medical officer. 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 centers 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.
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 university Wexner 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 hospital 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 university bylaws, all appointments to medical staff committees shall be for two years 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 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 biennial basis. Any members may be removed from the medical staff administrative committee at the recommendation of the dean, the executive 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 in this paragraph to maintain the medical staff administrative committees 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 university bylaws, by the bylaws of the Ohio state university Wexner 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 quality and 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 Wexner medical center board.
(g) To recommend action to the medical directors and chief executive officer of the Ohio state university hospitals on matters of medical-administrative nature.
(h) To fulfill the medical staff's accountability to the Wexner 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.
(vi) To ensure the medical staff is kept abreast of the accreditation process and informed of the accreditation status of the Ohio state university hospitals.
(i) To review and act on medical staff appointments, reappointments, and requests for delineation of clinical privileges. Whenever there is doubt of an applicants ability to perform the privileges requested, the medical staff administrative committee shall have the authority to request an evaluation of the applicants clinical activities relevant to requested privileges.
(j) To report to the medical staff all actions affecting the medical staff.
(k) To inform the medical staff of all changes in committees, and the elimination of such committees as circumstances shall require.
(l) 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.
(m) To establish and maintain rules and regulations governing the medical staff.
(n) To perform other functions as are appropriate.
(3) Executive session.
Upon the recommendation of the credentialing committee, the medical staff administrative committee may vote to hold a portion of a regular, special or emergency meeting in executive session with participation limited to voting members of the medical staff administrative committee. Other individuals may be invited to attend any or all portions of an executive session as deemed necessary by the committee chair.
(4) Meetings. The committee shall meet monthly and shall keep detailed minutes which shall be distributed to each committee member and to the Wexner medical center board through the quality and professional affairs committee.
(5) 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. The chief of staff, director of medical affairs and medical directors of each 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 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 triennially 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 chairperson of the credentialinng committee 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 members 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 university 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 quality and professional affairs committee or Wexner 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 applicants 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. University policies and procedures shall be ratified by the credentialing committee and medical staff administrative committee, and be approved by the Wexner medical center board.
(G) Committee for 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 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 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 university 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 university 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) Quality leadership council.
(1) Composition:
The quality 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 executive vice president for health sciences, the dean of the college of medicine and the chairperson of the quality and professional affairs committee of the Wexner medical center board as ex-officio members without a vote. The chief quality officer shall be the chairperson of the quality leadership council.
(2)
(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.
(M) Clinical quality and patient safety committee.
(1) Composition:
The members of this group shall be appointed pursuant to university 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.
(2) Duties:
(a) 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.
(b) 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.
(c) 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.
(d) 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.
(e) 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.
(f) 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.
(g) To appoint ad-hoc interdisciplinary teams to address the Ohio state university hospitals-wide quality management plan.
(h) To annually review and revise as necessary the Ohio state university hospitals-wide clinical quality management plan.
(i) To report and coordinate with the leadership council for clinical quality, safety and service of all quality improvement initiatives.
(N) Clinical resource utilization policy group
(1) 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.
(2) Duties:
(a) 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.
(b) 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.
(c) 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.
(d) 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.
(e) To oversee evaluation and cost effective utilization of clinical technology.
(f) 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.
(O) Clinical practice guideline committee.
(1) 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.
(2) Duties:
(a) 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.
(b) 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.
(c) 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.
(d) To initiate and support research projects when appropriate in support of the objectives of the leadership council for clinical quality, safety and service.
(e) 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 guidelines 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.
(f) To regularly report a summary of all actions to the leadership council for clinical quality, safety and service.
(P) 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 institutions 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.
Last updated April 9, 2024 at 8:57 AM
Supplemental Information
Amplifies: 3335.08
Prior Effective Dates: 5/21/1983, 8/5/1985, 9/6/1985, 8/26/1991, 10/21/1991, 1/31/1994, 3/20/1998, 6/15/1998, 9/28/2000, 2/4/2002, 8/19/2002, 10/4/2002, 6/23/2003, 7/1/2003, 2/1/2005, 6/20/2005, 11/21/2005, 3/26/2007, 2/27/2008, 1/20/2009, 11/23/2009, 12/3/2009, 6/14/2011, 9/16/2012, 8/12/2013, 2/21/2014, 4/29/2015, 6/23/2016, 9/18/2016, 11/12/2020, 12/29/2023