Ohio Admin. Code 3335-111-10

Current through all regulations passed and filed through December 23, 2024

Section 3335-111-10 - Administration of the medical staff of the CHRI

Medical staff committees.

(A) Appointments: Appointments to all medical staff committees except the medical staff administrative committee (MSAC) and the nominating committee will be made jointly by the chief of staff, chief of staff-elect, and the director of medical affairs with medical staff administrative committee ratification. Unless otherwise provided by the bylaws, all appointments to medical staff committees are for two years and may be renewed. The chairperson shall control the committee agenda, attendance of staff and guests and conduct the proceedings. A simple majority of appointed voting members shall constitute a quorum. All committee members appointed or elected to serve on a medical staff committee are expected to participate fully in the activities of those committees. The chief of staff, director of medical affairs and the chief executive officer of the CHRI may serve on any medical staff committee as an ex-officio member without vote.

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

(C) Medical staff administrative committee:

(1) Composition:

(a) Voting membership includes: chief of staff, chief of staff-elect, immediate past chief of staff, clinical department chief or division director of medical oncology, radiation oncology, anatomic pathology and molecular pathology; department chairperson or division director of hematology, gynecologic oncology, otolaryngology/head and neck, hospital medicine, human genetics, infectious diseases, surgical oncology, thoracic surgery, neurological oncology, orthopaedic oncology/sarcoma pulmonary, critical care, sleep medicine, and urology; medical director of James emergency services; clinical department chiefs of anesthesia, dermatology, physical medicine and rehabilitation, plastic surgery, psychiatry, and radiology; CHRI medical director of quality, CHRI medical director of credentialing, CHRI chief executive officer, CHRI director of medical affairs, director of the division of palliative medicine, chairperson of the cancer subcommittee, CCC director for clinical research, CCC director for cancer control, and medical director of the James surgical services. Up to two additional at-large member(s) may be appointed to the MSAC at the recommendation of the chief executive officer of the CHRI, subject to the approval of the medical staff administrative committee and subject to review and renewal on a yearly basis. If a division director is a member by leadership position, he or she will also fulfill the role of division director appointment. The director of medical affairs shall be the chairperson and the chief of staff shall be the vice-chairperson.

(b) Ex-officio non-voting membership includes: the CHRI executive director, the CHRI chief nursing officer, CHRI executive director of patient services, the medical director of university hospital and/or the chief medical officer of the medical center, the dean of the Ohio state university college of medicine, and the executive vice president for health sciences.

(c) Any member of the committee who anticipates absence from a meeting of the committee may appoint a temporary substitute as a representative at the meeting. The temporary substitute will have all the rights of the absent member.

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

(e) Any members may be removed from the medical staff administrative committee at the recommendation of the dean of the college of medicine, the director of medical affairs or the executive vice president for health sciences and subject to the review and approval of the medical staff administrative committee. A replacement will be appointed as outlined in this paragraph to maintain the medical staff administrative committee's composition as stated in this paragraph.

(2) Duties:

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

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

(c) To receive and act upon commission and committee reports. To delegate appropriate staff business to committees while retaining the right of executive responsibility and authority over all medical staff committees. This shall include but is not limited to review of and action upon medical staff appointments and reappointments whenever timely action is necessary.

(d) To approve and implement policies of the medical staff.

(e) To recommend action to the chief executive officer on matters of medico-administrative nature.

(f) To fulfill the medical staff's accountability to the Wexner medical center board for medical care rendered to patients in the CHRI, and for professional conduct and activities of the medical staff, including recommendations concerning

(i) Medical staff structure;

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

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

(iv) Participation in the CHRI's performance improvement, quality and patient safety activities; and

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

(g) To ensure the medical staff is kept abreast of the accreditation process and informed of the accreditation status of the CHRI.

(h) To review and act on medical staff appointments and reappointments.

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

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

(k) To create committees (for which membership is subsequently appointed pursuant to rule 3335-111-10 of the Administrative Code) to meet the needs of the medical staff and comply with the requirements of accrediting agencies.

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

(m) To oversee functions related to performance improvement of professional services provided by individuals with clinical privileges.

(n) To perform other functions as are appropriate.

(3) Executive session:

Upon recommendation of the credentialing committee, the medical staff administrative committee may vote to hold a portion of a regular, special or emergency medicine in executive session with participation limited to voting members of the medical staff administrative committee. Other individuals may be invited to attend any or all portions of an executive session as deemed necessary by the committee chair.

(4) Meetings:

The committee shall meet monthly and keep detailed minutes, which shall be distributed to each committee member before or at the next meeting of the committee.

(5) Voting:

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

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

(1) Composition:

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

The chief medical officer of the medical center shall appoint the credentialing committee of the hospitals of the Ohio state university. The director of medical affairs and medical director of credentialing shall make recommendation to the chief medical officer for representation on the credentialing committee of the hospitals of the Ohio state university.

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

(2) Duties:

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

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

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

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

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

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

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

(h) To review requests made for clinical privileges by other licensed allied health professionals as set forth in this chapter.

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

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

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

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

(3) Licensed health care professionals subcommittee:

(a) This subcommittee shall consist of other licensed health care professionals who have been appointed in accordance with paragraph (A) of rule 3335-111-10 of the Administrative Code. This subcommittee shall be chaired by a director of nursing.

(b) Duties:

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

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

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

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

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

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

(E) Medical staff bylaws committee:

(1) Composition.

The committee shall be composed of at least four members of the attending or associate attending staff pursuant to paragraph (A) of rule 3335-111-10 of the Administrative Code. The chairperson shall always be the chief of staff-elect.

(2) Duties.

To review and recommend amendments to the medical staff administrative committee as necessary to maintain bylaws that reflect the structure and functions of the medical staff but not less than every two years. This committee will recommend changes to the medical staff administrative committee.

(F) Committee for practitioner health.

(1) Composition:

The committee shall consist of medical staff members appointed in accordance with paragraph (A) of rule 3335-111-10 of the Administrative Code.

(2) Duties:

(a) To consider issues of licensed practitioner health or impairment whenever a self-referral or referral is requested by an affected member or another member or committee of the medical staff, CHRI hospital staff, or any other individual.

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

(c) To consult regularly with the chief of staff, medical director of credentialing and director of medical affairs of the CHRI.

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

(e) It will be the responsibility of the chairperson of the committee to assure that all proceedings and records, including the identify of the person referring the case, are handled and maintained in the strictest of confidence in accordance with the laws of the state of Ohio.

(f) To educate CHRI hospital and the medical staff about illness and impairment recognition issues, including at risk criteria specific to licensed practitioners.

(G) Cancer subcommittee:

(1) Composition:

Required to be included as members of the cancer subcommittee are physician representatives from surgery, medical oncology, radiology, radiation oncology, anesthesia, plastic surgery, urology, otolaryngology/head and neck, hematology, gynecologic oncology, thoracic surgery, orthopaedic oncology, neurological oncology, emergency medicine, palliative medicine and pathology, the cancer liaison physician and nonphysician representatives from the cancer registry, administration, nursing, social services, and quality assurance. Other disciplines should be included as appropriate for the institution. The chairperson is appointed at the recommendation of the chief executive officer of the CHRI and the director of medical affairs, subject to the approval of the medical staff administrative committee and subject to review and renewal on a yearly basis.

(2) Duties:

(a) Develop and evaluate the annual goals and objectives for the clinical, educational, and programmatic activities related to cancer.

(b) Promote a coordinated, multidisciplinary approach to patient management.

(c) Ensure that educational and consultative cancer conferences cover all major site and related issues.

(d) Ensure that an active supportive care system is in place for patients, families, and staff.

(e) Monitor quality management and improvement through completion of quality management studies that focus on quality, access to care, and outcomes.

(f) Promote clinical research.

(g) Supervise the cancer registry and ensure accurate and timely abstracting, staging, and follow-up reporting.

(h) Perform quality control of registry data.

(i) Encourage data usage and regular reporting.

(j) Ensure content of the annual report meets requirements.

(k) Publishes the annual report by November first of the following year.

(l) Upholds medical ethical standards.

(m) Serve as cancer committee for commission on cancer program of the american college of surgeons.

(3) Meetings:

(a) The subcommittee shall meet in collaboration with the medical staff administrative committee as a policy-advisory and administrative body with documentation of activities and specialties in attendance.

(b) Any member anticipating an absence from the meeting should designate a representative to attend in their place.

(H) Ethics committee.

(1) Composition.

The committee is a joint committee and shall consist of members of the medical staff, nursing, hospital administration, and other persons representing both the CHRI and UH who, by reason of training, vocation, or interest, may make a contribution. Appointments will be made as provided by in this chapter.

The chairperson shall be a physician who is a clinically active member of the medical staff of UH or the CHRI.

(2) Duties

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

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

(c) To provide a support mechanism for primary decision makers at the CHRI.

(d) To provide educational resources on ethics to all

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

(I) Practitioner evaluation committee.

(1) Composition.

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

(2) Duties:

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

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

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

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

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

(J) Professionalism consultation committee.

(1) Composition.

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

(2) Duties.

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

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

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

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

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

Ohio Admin. Code 3335-111-10

Effective: 10/7/2024
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 10/18/1993, 05/26/1995, 03/20/1998, 02/18/2000, 09/28/2000, 08/19/2002, 10/04/2002, 03/08/2004, 11/28/2005, 09/11/2006, 03/06/2009, 11/24/2009, 08/06/2010, 03/15/2011, 03/25/2011, 08/03/2011, 09/20/2012, 07/31/2013, 04/27/2015, 06/23/2016, 09/18/2016, 11/12/2020, 12/29/2023