84-13 Operating room committee

(A)  The operating room committee shall have representation from clinical departments using the operating room, the medical director of the operating room, nursing, director of the operating room, the operating room coordinator, and hospital administration. The committee is appointed by the medical director in consultation with the executive director of university hospitals. The committee shall meet at least quarterly and carry out the following duties:

  1. Insure that surgical privileges have been delineated for each member of the medical staff who uses the operating rooms.
  2. Develop written policies and procedures concerning the scope and provision of care in the surgical suite in cooperation with the departments and services concerned.
  3. Consider problems in operating room functions brought to its attention by any of its members.
  4. Monitor medical staff compliance with operating room policies established for patient safety, infection control, and smooth functioning of the operating rooms.
  5. Develop and make recommendations to the medical staff administrative committee regarding conduct of medical staff in the operating rooms.
  6. Maintain written records of actions taken, and results of those actions, and make these available to each committee member, the vice president for health sciences, the medical director, the executive director, and the associate executive directors.
  7. The operating room committee shall be a hospital committee and be appointed in accordance with policies and procedures of the Ohio state Wexner medical center board.

(B)  Each member of the medical staff shall conform to the policies established by the operating room committee, including the following:

A member of the attending surgical staff shall be present in person during surgical procedures and a member of the attending anesthesiology staff shall be present in person during anesthetization, shall be familiar with the progress of the procedure, and be immediately available at all times during the procedure.

(Board approval dates: 9/6/2002, 5/14/2010, 4/6/2016)