Chapter 3335-101 Medical staff

3335-101-01  General.

The university Wexner medical center board shall hold the medical staff organization of university hospitals and the medical staff organization of the James cancer hospital accountable to the university Wexner medical center board for establishing and maintaining standards of medical care for their respective facilities. As provided in rule 3335-101-04 of the Administrative Code, revisions to medical staff bylaws are subject to review and approval by the university Wexner medical center board before they are submitted to the Ohio state university board of trustees for adoption.

(Board approval dates: 4/3/2009, 10/29/2010, 2/01/2013)

 

3335-101-02  Medical staff.

For purposes of this chapter, the words "medical staff" shall include all physicians, psychologists, podiatrists, and dentists who are authorized to attend patients in any medical care facility or program administered by the university Wexner medical center, and may include such other health care professionals as the medical staff bylaws designate.

(Board approval dates: 4/3/2009, 2/01/2013, 8/28/2015)

 

3335-101-03  Medical staff organization.

The organization of the medical staffs of the university Wexner medical center shall discharge those duties and responsibilities assigned to them by the university Wexner medical center board and is subject to the approval and authorization of the university Wexner medical center board. Those duties and responsibilities include the following purposes:

(A)  To monitor the quality of medical care and make recommendations to the university Wexner medical center board to ensure that all patients - admitted to or treated at any of the facilities, departments, or services of university hospitals or the James cancer hospital - receive high quality medical care.

(B)  To recommend, through the appropriate medical staff administrative committee, to the quality and professional affairs committee of the university Wexner medical center board the appointment or reappointment of an applicant to the medical staff of university hospitals or the James cancer hospital, the clinical privileges such applicant shall enjoy in the facilities of or associated with university hospitals or the James cancer hospital, and appropriate professional review action that may be necessary in connection with any member of the medical staff.

(C)  To represent the medical staffs of university hospitals and the James cancer hospital and to provide the means whereby issues concerning the medical staffs and university hospitals and the James cancer hospital are discussed within the medical staff organization and among representatives of the medical staff, the university Wexner medical center board, and the medical center administration.

(D)  To establish and enforce medical staff bylaws, rules and regulations governing actions of members of the medical staffs and practitioners granted clinical privileges.

(Board approval dates: 4/3/2009; 10/29/2010; 2/1/2013, 8/28/2015)

 

3335-101-04  Medical staff bylaws.

The medical staff organization shall recommend to the quality and professional affairs committee and the university Wexner medical center board amendments to medical staff bylaws, rules, and regulations that set forth by the medical staff organization and the governance process for maintaining such bylaws, rules, and regulations to accomplish the purposes set forth in rule 3335-101-03 of the Administrative Code. When such medical staff bylaws, rules, and regulations are adopted by the university Wexner medical center board and the Ohio state university board of trustees, they shall become effective and be part of the medical staff bylaws, rules, and regulations of the medical center and the hospital and other facilities to which they apply. The medical staff organizations shall also be responsible for reviewing these bylaws, rules, and regulations periodically and recommending appropriate revisions to the quality and professional affairs committee and university Wexner medical center board.

(Board approval dates: 4/3/2009; 10/29/2010; 2/01/2013, 8/28/2015)

 

3335-101-05  Appointment to the medical staff and assignment of clinical privileges.

Upon recommendation of the medical staff of university hospitals or the James cancer hospital and in accordance with the medical staff bylaws, the university Wexner medical center board may appoint physicians, dentists, psychologists, and podiatrists meeting the qualifications prescribed in the medical staff bylaws, to membership on the medical staff of the university hospitals and the James cancer hospital and shall grant clinical privileges to such practitioners. Appointment to the medical staff carries with it full responsibility for the treatment of patients of the university Wexner medical center subject to such limitations as may be imposed by the university Wexner medical center board or the medical staff bylaws, rules, and regulations of the medical staff. Appointment and reappointment to the medical staff shall be for a period not to exceed two years and shall be renewable in accordance with the reappointment procedure set forth in the medical staff bylaws. The chief medical officer of the medical center and the director of medical affairs for the James cancer hospital are delegated the responsibility by the university Wexner medical center board to grant temporary clinical privileges. The granting of temporary privileges shall be limited to situations which fulfill an important patient care need, and shall not be granted for a period of more than one hundred twenty days.

(Board approval dates: 4/3/2009; 10/29/2010; 2/01/2013, 8/28/2015)

 

3335-101-06  Medical staff administrative committees.

(A)  Purpose. The medical staff administrative committee for the university hospitals medical staff and the medical staff administrative committee for the James cancer hospital each shall establish and maintain means of accountability to the university Wexner medical center board, in accordance with their respective medical staff bylaws. Each medical staff administrative committee shall concern itself primarily with the quality of medical care within the facilities of, or associated with, the university Wexner medical center. Each medical staff administrative committee shall receive and act upon all medical staff committee reports and make recommendations regarding medical staff status and clinical privileges to the university Wexner medical center board, through the board’s quality and professional affairs committee. Other specific duties of the medical staff administrative committee are identified in the medical staff bylaws.

(B)  Composition. The composition of the medical staff administrative committee of the university hospitals medical staff shall be determined in accordance with the university hospitals medical staff bylaws and the chief medical officer of the medical center shall serve as chair of the university hospitals medical staff administrative committee. The composition of the medical staff administrative committee of the James cancer hospital medical staff shall be determined in accordance with the James cancer hospital medical staff bylaws and the James cancer hospital director of medical affairs shall serve as chair of the James cancer hospital medical staff administrative committee. Any members may be removed from the medical staff administrative committee in accordance with the medical staff bylaws. Replacement or additional members may be appointed to the medical staff administrative committees in accordance with the medical staff bylaws and subject to review/renewal on a yearly basis to maintain the medical staff administrative committee’s constituency.

(C)  Meetings. Each medical staff administrative committee shall meet monthly. Minutes of the meetings shall be available to all members of the university Wexner medical center board and the quality and professional affairs committee of the university Wexner medical center board, the executive vice president for health sciences, the dean of the college of medicine, the dean of the college of dentistry, and the deans of other professional colleges whose faculty have appointments on the medical and dental staffs.

(Board approval dates: 4/3/2009; 10/29/2010; 2/01/2013, 8/28/2015)

 

3335-101-07  Hospitals clinical departments.

(A)  Appointment of the chief of each clinical department of each hospital as defined in Chapter 3335-104 of the Administrative Code is subject to approval by the university Wexner medical center board on the recommendation of the dean of the applicable professional college and the executive vice president for health sciences. All such appointments shall be periodically reviewed by the university Wexner medical center board. Any vacancy in the position of chief of a clinical department may be filled on an interim basis by the dean of the appropriate professional college, after consultation with the university Wexner medical center board. (In standard practice, the chief of a clinical department will be the chair of the corresponding academic department.)

(B)  The university Wexner medical center board may delegate, through approval of the medical staff bylaws or by appropriate board resolution, to the chiefs of the clinical departments responsibility for maintaining the quality of medical care in their services, and for recommending an applicant's appointment or reappointment to the appropriate medical staff and privileges for such an applicant.

(C)  The executive vice president of health sciences shall recommend a candidate for the appointment of the chief medical officer of the medical center to the university Wexner medical center board and the Ohio state university board of trustees. The Ohio state university board of trustees shall appoint the chief medical officer of the medical center. The chief medical officer of the medical center shall report to the vice president for health services, the executive vice president for health sciences and to the university Wexner medical center board. In matters relating to medical care in the university hospitals, members of the clinical departments of the university hospitals are accountable to the clinical chiefs, and medical directors who are accountable to the chief medical officer of the medical center.

(D)  The chief medical officer is the senior medical officer for the medical center with the responsibility and authority for all health and medical care delivered at the medical center. The chief medical officer is responsible for overall quality improvement and clinical leadership throughout the medical center, physician alignment, patient safety and medical staff development. The chief medical officer is a key member of the senior management team and is expected to participate in all strategic, operational and policy decisions as a senior corporate officer of the medical center. The chief medical officer is accountable for developing and managing systems and forums that foster the transfer of knowledge, information and process improvement methodologies to administrative and clinical leadership and staff. The chief medical officer has the authority and responsibility of the organization of clinical service to optimize high quality care.

(E)  The executive vice president for health sciences shall appoint a medical director for each of the university hospitals, university hospitals east, Harding hospital, and Ross heart hospital. The medical director of each hospital shall report to the chief executive officer or executive director of the respective hospital, to the chief medical officer of the medical center, and to the university Wexner medical center board. In matters relating to medical care in the hospitals, members of the clinical departments of the hospitals are accountable to the clinical chiefs, who are accountable to the medical directors.

(F)  The executive vice president for health sciences shall appoint a director of medical affairs for the James cancer hospital who shall be the chief medical officer of the James cancer hospital. The director of medical affairs shall report to the chief executive officer of the James cancer hospital and to the university Wexner medical center board. In matters relating to medical care in the James cancer hospital, members of the clinical departments of the hospitals are accountable to the clinical chiefs, who are accountable to the director of medical affairs.

(G)  The chief medical officer of the medical center, the director of medical affairs of the James cancer hospital and the medical directors of each hospital shall each be a physician and shall maintain an appointment as an attending staff member of his or her respective medical staff. The chief medical officer of the medical center, medical directors of each hospital and director of medical affairs shall have authority as conferred by the executive vice president for health sciences shall appoint a director of medical affairs for the James cancer hospital who shall be the chief medical officer of the James cancer hospital. The director of medical affairs shall report to the chief executive officer of the James cancer hospital and to the university Wexner medical center board. In matters relating to medical care in the James cancer hospital, members of the clinical departments of the hospitals are accountable to the clinical chiefs, who are accountable to the director of medical affairs executive vice president for health sciences and the university Wexner medical center board; including the responsibility for clinical research and education programs and services, supervision of patient and clinical activity; and responsibility for the clinical organization of his or her respective hospital. The chief medical officer of the medical center and director of medical affairs shall direct and supervise the medical staff quality assurance, utilization review, and credentialing activity. The chief medical officer of the medical center, medical directors of each hospital and director of medical affairs shall establish priorities, jointly with the chief executive officer or executive director of his or her respective hospital, for capital medical equipment, clinical space, and the establishment of new clinical programs, or the revision of existing clinical programs.

(Board approval dates: 4/3/2009; 10/29/2010; 2/01/2013, 8/28/2015)