Chapter 3335-97 Committees of the University Wexner Medical Center

3335-97-01 University Wexner medical center board standing committees.

The university Wexner medical center board shall approve the appointment of a finance committee and a quality and professional affairs committee. The chair of the university Wexner medical center board shall appoint the members of the board's committees. The chair of each committee of the university Wexner medical center board shall be selected from the voting members of the university Wexner medical center board. The board or the chair of the board may designate guidelines for the selection and participation of non-trustee members of committees.

Replaces: 3335-97-01

Effective: 10/4/2013
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 10/04/2013

3335-97-02 Professional affairs committee.

(A) Responsibilities. The professional affairs committee shall be responsible for the following specific duties:

(1) Overseeing all patient care activity in all facilities that are a part of the medical center, including, but not limited to, the hospitals, clinics, ambulatory care facilities, and physicians' office facilities.

(2) Monitoring quality assurance performance in accordance with the standards set by the university Wexner medical center for all programs identified in paragraph (A)(1) of this rule.

(3) Receiving reports from the university hospitals medical staff administrative committee and the James cancer hospital medical staff administrative committee regarding credentialing and recommending action on these reports to the university Wexner medical center board.

(4) Monitoring the achievement of accreditation and licensure requirements.

(5) Reviewing and recommending to the university Wexner medical center board medical staff bylaws changes and changes to medical staff rules and regulations.

(6) Approving membership and granting appropriate clinical privileges for the expedited credentialing of such practitioners that are eligible by satisfying minimum approved criteria as determined by the university Wexner medical center board and are recommended for membership and clinical privileges by the university hospitals medical staff administrative committee and the James cancer hospital medical staff administrative committee.

(7) Reviewing and approving reinstatement of clinical privileges for a practitioner after a leave of absence from clinical practice.

(8) Conducting peer review activities and recommending professional review actions to the university Wexner medical center board.

(9) Reviewing and resolving any petitions by the medical staffs for amendments to any rule, regulation or policy presented by the chief of staff on behalf of the medical staff pursuant to the medical staff bylaws and communicating such resolutions to the university hospitals medical staff administrative committee and the James cancer hospital medical staff administrative committee for further dissemination to the medical staffs.

(10) Such other responsibilities as assigned by the chair of the university Wexner medical center board.

(B) Composition. The committee shall consist of : four board members, appointed annually by the chair of the university Wexner medical center board, one of whom shall be appointed as chair of the committee; the chief medical officer of the medical center; the director of medical affairs of the James cancer hospital; the medical director of credentialing for the James cancer hospital; the chief of the medical staff of the university hospitals; and the chief of the medical staff of the James cancer hospital. With respect to items coming before the committee as detailed in paragraph (A) of this rule, at least two voting members of the university Wexner medical center board must be present; and the chief medical officer of the medical center and chief of the medical staff of university hospitals shall vote only with respect to those items involving the university hospitals, and the director of medical affairs of the James cancer hospital; the medical director of credentialing for the James cancer hospital and chief of the medical staff of the James cancer hospital shall vote only with respect to those items involving the James cancer hospital.

(C) Meetings. The professional affairs committee shall meet during the months the university Wexner medical center board does not have a regular meeting scheduled or at the call of the chair and shall advise the university Wexner medical center board of its activities as the board requests. The professional affairs committee shall act on behalf of the university Wexner medical center board in order to maintain the continuity of operations of the hospitals of the Ohio state university and the university hospitals and James cancer hospital medical staffs; to review and to approve medical staff membership and to grant appropriate clinical privileges for practitioners in accordance with applicable laws, accreditation requirements, bylaws and rules established by the university board of trustees, university Wexner medical center board and university hospitals and James medical staffs.

Effective: 7/31/2013
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 5/22/2009, 12/3/2010

3335-97-03 Quality and professional affairs committee.

(A) Responsibilities. The quality and professional affairs committee shall be responsible for the following specific duties:

(1) Reviewing and evaluating the patient safety and quality improvement programs of the university Wexner medical center;

(2) Overseeing all patient care activity in all facilities that are a part of the university Wexner medical center, including, but not limited to, the hospitals, clinics, ambulatory care facilities, and physicians' office facilities;

(3) Monitoring quality assurance performance in accordance with the standards set by the university Wexner medical center;

(4) Monitoring the achievement of accreditation and licensure requirements;

(5) Reviewing and recommending to the university Wexner medical center board changes to the medical staff bylaws and medical staff rules and regulations;

(6) Reviewing and approving clinical privilege forms;

(7) Reviewing and approving membership and granting appropriate clinical privileges for the credentialing of practitioners recommended for membership and clinical privileges by the university hospitals medical staff administrative committee and the James medical staff administrative committee;

(8) Reviewing and approving membership and granting appropriate clinical privileges for the expedited credentialing of such practitioners that are eligible by satisfying minimum approved criteria as determined by the university Wexner medical center board and are recommended for membership and clinical privileges by the university hospitals medical staff administrative committee and the James medical staff administrative committee;

(9) Reviewing and approving reinstatement of clinical privileges for a practitioner after a leave of absence from clinical practice;

(10) Conducting peer review activities and recommending professional review actions to the university Wexner medical center board;

(11) Reviewing and resolving any petitions by the medical staffs for amendments to any rule, regulation or policy presented by the chief of staff on behalf of the medical staff pursuant to the medical staff bylaws and communicating such resolutions to the university hospitals medical staff administrative committee and the James medical staff administrative committee for further dissemination to the medical staffs; and

(12) Such other responsibilities as assigned by the chair of the university Wexner medical center board.

(B) Composition. The committee shall consist of: no fewer than four voting members of the university Wexner medical center board, appointed annually by the chair of the university Wexner medical center board, one of whom shall be appointed as chair of the committee. The chief executive officer of the Ohio state university health system; chief medical officer of the medical center; the director of medical affairs of the James; the medical director of credentialing for the James; the chief of the medical staff of the university hospitals; the chief of the medical staff of the James; the associate dean of graduate medical education; the chief quality and patient safety officer; the chief nurse executive for the OSU health system; and the chief nursing officer for the James shall serve as ex-officio, voting members. Such other members as appointed by the chair of the university Wexner medical center board, in consultation with the chair of the quality and professional affairs committee.

(C) Review and recommendation. The chief medical officer of the medical center and the chief of the medical staff of university hospitals shall present and make recommendations to the quality and professional affairs committee only with respect to those actions involving the university hospitals. The director of medical affairs of the James, the medical director of credentialing for the James and chief of the medical staff of the James shall present and make recommendations to the quality and professional affairs committee only with respect to those actions involving the James.

(D) Voting. With respect to items coming before the quality and professional affairs committee as detailed in paragraph (A) of this rule, at least two voting, non-public members of the university Wexner medical center board must be present. Any action taken by this committee pursuant to the responsibilities as defined in paragraphs (A)(1) to (A)(11) of rule 3335-97-03 of the Administrative Code shall be taken only by the voting, non-public, committee members and approved by a majority vote thereof. The chief quality and patient safety officer shall recuse themselves from voting on matters defined in paragraphs (A)(7) and (A)(10) of rule 3335-97-03(A)(7) and (A)(10) of the Administrative Code.

(E) Meetings. The committee shall meet at least bimonthly (six times per calendar year, typically in the even numbered months) or at the call of the chair of the committee and shall advise the university Wexner medical center board of its activities regularly. The committee shall act on behalf of the university Wexner medical center board in order to maintain the continuity of operations of the hospitals of the Ohio state university and the university hospitals and the James medical staffs; to review and to approve medical staff membership and to grant appropriate clinical privileges for practitioners in accordance with applicable laws, accreditation requirements, bylaws and rules established by the university board of trustees, university Wexner medical center board and university hospitals and the James medical staffs. Meetings shall be conducted in accordance with the state laws of Ohio and open meetings laws.

Effective: 4/28/2016
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 10/04/2013, 12/03/2013, 05/16/2014

3335-97-04 University Wexner medical center board special or ad-hoc committees.

The university Wexner medical center board may establish special or ad-hoc committee as needed upon the approval of the university board of trustees.

Effective: 10/4/2013
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08