3335-43-08 Organization of the medical staff.

(A)  Each member of the attending medical, courtesy A and B medical, community affiliate medical, 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 and divisions.

(1)  Anesthesiology

(2)  Emergency medicine

(3)  Family medicine

Sports medicine

(4)  Internal medicine. The following divisions are designated:

Cardiovascular medicine

Dermatology

Endocrinology, diabetes and metabolism

Gastroenterology, hepatology and nutrition

General internal medicine and geriatrics

Hematology

Hospital medicine

Human genetics

Infectious diseases

Medical oncology

Nephrology

Pulmonary, allergy, critical care and sleep medicine

Rheumatology - immunology

(5)  Neurological surgery

(6)  Neurology

Cognitive neurology

Electrodiagnostics

Epilepsy

General neurology

Multiple sclerosis and neuroimmunology

Neuromuscular disease

Neurooncology

Sleep

Stroke

(7)  Obstetrics and gynecology. The following divisions are designated:

General obstetrics and gynecology

Maternal - fetal medicine

Female pelvic medicine and reconstructive surgery

Gynecologic oncology

Reproductive endocrinology and infertility

(8)  Ophthalmology

(9)  Orthopaedics. The following divisions are designated:

Hand

Orthopaedic oncology

Podiatry

Sports medicine

Trauma

(10)  Otorhinolaryngology

(11)  Pathology. The following divisions are designated:

Anatomic pathology

Clinical pathology

(12)  Pediatrics. The following divisions are designated:

Ambulatory pediatrics

Adolescent medicine

Allergy

Biochemical disorders

Cardiology

Clinical genetics

Dermatology

Endocrinology/metabolism

Gastroenterology

General pediatrics

Handicapped child

Hematology/oncology

Infectious diseases

Neonatology

Nephrology

Neurology

Nutrition

Pediatric education/research and evaluation

Pharmacology/toxicology

Psychology

Pulmonary

(13)  Physical medicine and rehabilitation. The following division is designated:

Pediatric physical medicine and rehabilitation

Rehabilitation psychology

(14)  Plastic surgery.

(15)  Psychiatry. The following divisions are designated:

General psychiatry

Child and adolescent psychiatry

Geriatric psychiatry

Health psychology

(16)  Radiation oncology.

Pediatric radiation oncology

(17)  Radiology. The following divisions are designated:

Diagnostic radiology

Nuclear medicine

(18)  Surgery. The following divisions are designated:

Cardiac surgery

Colon and rectal surgery

General and gastrointestinal surgery

Pediatric surgery

Surgical oncology

Thoracic surgery

Transplant

Trauma, critical care and burn

Vascular diseases and surgery

(19)  Urology.

(20)  Dentistry. The following divisions are designated:

General dentistry

Oral and maxillofacial surgery

(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. Clinical divisions may be added or deleted upon the recommendation of the chief of the clinical department with the concurrence of a majority of the medical staff administrative committee.

(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 center’s 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 hospital’s 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 independent 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.

(Board approval dates: 6/7/2002, 7/6/2002, 3/5/2003, 6/4/2004, 5/6/2005, 11/4/2005, 2/1/2006, 2/2/2007, 9/21/2007, 9/19/2008, 9/18/2009, 10/29/2009, 9/17/2010, 4/8/2011, 8/31/2012, 1/31/2014)