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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 3335-43 | Medical Staff Members

 
 
 
Rule
Rule 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 rules 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.

Supplemental Information

Authorized By: RC 3335
Amplifies: RC 3335.08
Rule 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, community affiliate A, and community affiliate D 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.

(E) To govern medical staff and credentialed practitioners these bylaws are not intended to and shall not create any contractual rights between the Ohio state university Wexner medical center and any practitioner. Any and all contracts of affiliation, association or employment shall control contractual and financial relationships between the Ohio state university Wexner medical center and such practitioners.

Last updated December 29, 2023 at 8:42 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 7/1/1984
Rule 3335-43-03 | Patients.
 

(A) The continuous care and treatment of individual patients is the medical responsibility of the member of the attending, community affiliate A and community affiliate D 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 patients 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 patients right to participate in decisions about his or her care, treatment and services, and further respects the patients right to refuse care treatment and services, in accordance with law and regulation.

Last updated December 29, 2023 at 8:42 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 6/6/2011
Rule 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 Wexner 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 university 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. All members, except for physician scholar medical staff, shall 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 and licensed health care professionals with clinical privileges shall comply with provisions of state law and the regulations of the state medical board or other state licensing board if applicable. 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 Wexner 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, clinical privileges, 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 quality and professional affairs committee of the Ohio state university Wexner medical center board, or the Ohio state university Wexner 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 and licensed health care professionals 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 and licensed health care professionals shall agree to comply with bylaws, rules and regulations, and policies and procedures adopted by the medical staff administrative committee and the Wexner medical center board, including but not limited to policies on professionalism, behaviors that undermine a culture of safety. Annual education and training approved by the medical staff administrative committee or as required by the Wexner medical center to meet accreditation standards, federal regulations, or quality and safety goals is required for medical staff members with clinical privileges in addition to conflict of interest disclosure. Medical staff members and licensed health care professionals with clinical privileges must also comply with the university integrity program requirements including but not limited to billing, self referral, ethical conduct and annual education. Medical staff members and licensed health care professionals with clinical privileges must immediately disclose to the chief medical officer and the department chairperson the occurrence of any of the following events: a licensure action in any state, any malpractice claims filed in any state or an arrest by law enforcement.

(3) All members of the medical staff and credentialed providers must maintain continuous uninterrupted enrollment with all governmental health care programs.

(a) It shall be the duty of all medical staff members and credentialed providers to promptly inform the chief medical officer and the corporate credentialing office of any investigation, action taken, or the initiation of any process which could lead to an action taken by any governmental programs.

(b) Exclusion of any medical staff member or credentialed provider 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. Medical staff members may submit a request to resign their medical staff membership to the chief medical officer in lieu of automatic termination. The resignation in lieu of automatic termination shall be discussed at the next credentialing committee and medical staff administrative committee in order to provide recommendations to the quality and professional affairs committee of the Wexner medical center board. A final determination should be decided by the quality and professional affairs committee at its next regular meeting.

(c) If the medical staff members or credentialed provider's participation in all governmental programs is fully reinstated, the affected medical staff member or credentialed provider shall be eligible to apply for membership and clinical privileges at that time.

(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 specialty/subspecialty 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.

(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) Waiver requests for the threshold eligibility requirements listed in paragraphs (A)(3) to (A)(5) of this rule may be requested and considered 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 qualifications 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 quality and professional affairs committee of the Ohio state university medical center and the Wexner medical center board regarding whether to grant or deny the request for a waiver and the basis for its recommendation.

(d) The Ohio state university Wexner medical center boards 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.

(e) Waiver requests for the threshold eligibility requirement listed in paragraph (A)(3) of this rule may only be considered for applicants who have voluntarily opted out of governmental health care programs. Applicants who have been excluded or suspended shall be ineligible to request a waiver.

(f) Waivers to requirements prescribed by regulatory, accrediting, or other external agencies will not be granted.

(7) 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 (G)(3) of rule 3335-43-07 of the Administrative Code.

(8) No applicant shall be entitled to medical staff membership and or clinical privileges merely by the virtue of fulfilling the listed 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 Wexner 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 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 D 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 thirty-six 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 university 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 university 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 appointees 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 university 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 Wexner 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 applicants credentials or releasing information to other institutions for the purpose of evaluating the applicants credentials in compliance with university 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 university Wexner medical center board members and members of the Ohio state university board of trustees concerning the applicants 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 applicants 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 Wexner medical center board, the applicant will provide documentation the applicants 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 Wexner medical center board.

(e) Verification by primary source documentation of:

(i) Current and previous state licensure;

(ii) Faculty appointment (not required for community affiliate B, community affiliate C, community affiliate D or contracted 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 B, community affiliate C and community affiliate D categories) or applicant qualifies for a waiver pursuant to paragraph (A)(6) 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 a criminal background investigation that meets the requirements of the Wexner medical center.

(j) Completion of drug testing for substances required for individuals applying for clinical privileges and in accordance with Wexner medical center approved testing protocols.

(k) Verification of completion of annual educational requirements approved by the medical staff administrative committee and maintained in the chief medical officers 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 quality and professional affairs committee, and the Wexner 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 quality and professional affairs committee through the expedited credentialing process or Wexner 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 university Wexner 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 departments 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 quality and professional affairs committee of the Wexner medical center board, and thereafter to the Wexner medical center board. When the Ohio state university Wexner 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 Wexner medical center board by the chief medical officer, who shall make a separate recommendation to the Wexner medical center board.

When the Ohio state university Wexner 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 members 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 departments 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 members 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 thirty-six 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) DEA registration when required for clinical privileges;

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

(iv) 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 3335-43-06 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 members 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 officers 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 members 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 Wexner 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 members 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 quality and professional affairs committee of the Wexner medical center board, and thereafter to the Wexner medical center board. When the Ohio state university Wexner 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 or credentialed provider 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 members or credentialed provider's current appointment. A member of the medical staff or credentialed provider 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 or credentialed provider shall be placed on immediate medical leave of absence until such time the member or credentialed provider 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 or credentialed provider shall not exercise his or her clinical privileges, and medical staff responsibilities and prerogatives shall be inactive.

(2) The member or credentialed provider 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 quality and professional affairs committee of the Wexner 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 members or credentialed provider's treating physician or the committee for practitioner health that might have a bearing on the medical staff members or credentialed provider'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 or credentialed provider 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 or credentialed providers 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 of clinical privileges, and in such event, the member or credentialed provider shall not be entitled to a hearing or appeal.

Last updated December 29, 2023 at 8:42 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 8/5/1996, 1/20/2009, 8/6/2010
Rule 3335-43-05 | Peer review and corrective action.
 

(A) Informal peer review.

(1) 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.

(2) 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.

(3) The practitioner evaluation committee chair or his or her designee may obtain information or opinions from medical staff members or credentialed providers as well as external peer review consultants pursuant to criteria outlined in university bylaws. The information or opinions from the informal peer review may be presented to the practitioner evaluation committee or another designated peer review committee.

(4) 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.

(5) 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:

(a) The matter warrants no further action;

(b) 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 members file. If documentation is included in the members 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

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

(6) 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 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 university 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. The formal peer review committee may recommend a reduction, suspension or revocation of the medical staff members 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. The written findings and recommendations for action are expected to be submitted within ninety days, unless an extension is deemed necessary by the committee.

(6) Upon receipt of the written report and recommendation from the formal peer review committee, the chief of the clinical department shall 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 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 and termination.

(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 members 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 notice of such suspension, the medical staff member or credentialed provider shall be deemed to no longer comply with medical staff requirements under rule 3335-43-04 of the Administrative Code and automatically relinquish 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 members appointment and privileges shall immediately and automatically terminate, unless resignation in lieu of automatic terminations is permitted to paragraph (A)(3) of rule 3335-43-04 of the Administrative Code.

(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 members appointment and privileges shall be immediately and automatically terminated.

(6) Whenever a medical staff members 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 university 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.

Supplemental Information

Authorized By: RC 3335
Amplifies: RC 3335.08
Prior Effective Dates: 3/13/1978, 1/31/1994, 11/23/2009
Rule 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 the staff member shall be entitled to an adjudicatory hearing.

(2) A medical staff member shall not be entitled to a hearing under the following circumstances:

(a) Denial by the Wexner medical center board to grant a waiver of board certification for a medical staff member.

(b) Termination of a medical staff member because of exclusion from participation in any government reimbursement program.

(c) Voluntary withdrawal of a medical staff application.

(d) Failure to submit a reappointment application.

(e) A leave of absence extending beyond current appointment or failure to request reinstatement of clinical privileges following a leave of absence.

(f) Actions or recommendations resulting from an informal peer review.

(g) Termination of community affiliate B and community affiliate C medical staff appointments upon approval by the Wexner medical center board.

(3) 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 members 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 witnesss 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 members 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 members 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 members 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 members 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.

Last updated December 29, 2023 at 8:42 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 4/29/2015, 11/12/2020
Rule 3335-43-08 | Organization of the medical staff.
 

(A) Each member of the attending, community affiliate A, community affiliate B, community affiliate C, community affiliate D, 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.

(1) Anesthesiology.

(2) Dermatology.

(3) Emergency medicine.

(4) Family and community medicine.

(5) Internal medicine.

(6) Neurological surgery.

(7) Neurology.

(8) Obstetrics and gynecology.

(9) Ophthalmology and visual science.

(10) Orthopaedics.

(11) Otolaryngology - head and neck surgery.

(12) Pathology.

(13) Pediatrics.

(14) Physical medicine and rehabilitation.

(15) Plastic and reconstructive surgery.

(16) Psychiatry and behavioral health.

(17) Radiation oncology.

(18) Radiology.

(19) Surgery.

(20) Urology.

(21) Dentistry.

(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.

(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 centers 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 hospitals 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 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.

Last updated December 29, 2023 at 8:43 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 12/4/1998, 6/23/2003, 11/23/2009
Rule 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 or its committees 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.

(5) 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.

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

(7) 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 health system and the Wexner medical center board.

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

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

(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.

(4) Assist the chief of staff with duties outlined in paragraphs (A)(1) to (A)(9) of this rule.

(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) 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 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 May 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.

Last updated December 29, 2023 at 8:43 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 11/21/2005, 8/6/2010, 9/18/2016
Rule 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 members 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 patients initial visit, there must be a notation documenting an examination for any changes in the patients condition since the history and physical was completed. The updated examination must be completed and documented in the patients 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 members 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 directors 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.

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 12/4/2009, 9/16/2012
Rule 3335-43-12 | Meetings and dues.
 

(A) Meetings

The medical staff of the Ohio state university hospitals shall conduct scheduled meetings at least annually. 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 and/or electronic 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.

Last updated December 29, 2023 at 8:43 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 11/12/2020
Rule 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 quality and professional affairs committee of the Wexner 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 Wexner 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 medical staff 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 quality and professional affairs committee of the Wexner 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 quality and professional affairs committee of the Wexner 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 quality and professional affairs committee of the Wexner medical center board by submitting their communication in writing to the chief of staff, who shall then communicate on their behalf to the quality and professional affairs committee of the Wexner 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 quality and professional affairs committee of the Wexner 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 medical staff bylaws.

Proposed amendments to the 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 secure ballot in a manner determined by the medical staff administrative committee. All attending medical staff members shall receive at least fourteen 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 medical staff 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 Wexner 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 quality and professional affairs committee of the Wexner medical center board an amendment to any rule, regulation, or policy by submitting a petition signed by twenty-five per cent 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 the bylaws, rules, regulations, and policies that are, in the committees 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 Wexner medical center board but must be approved by the vice president of health services. Neither the organized medical staff nor the Wexner medical center board may unilaterally amend the medical staff bylaws or rules and regulations.

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

Last updated December 29, 2023 at 8:43 AM

Supplemental Information

Authorized By: 3335
Amplifies: 3335.08
Prior Effective Dates: 4/27/2015
Rule 3335-43-14 | Rules of construction.
 

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

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

Supplemental Information

Authorized By: RC 3335
Amplifies: RC 3335.08
Prior Effective Dates: 6/14/2011