11 Committees.

In addition to the medical staff committees, the medical staff shall participate in the following hospital and monitoring functions: infection control, clinical quality management, safety, and disaster planning and in other leadership council for clinical quality, safety and service advisor policy groups.

Operating Room Committee

(A)  The operating room committee shall have representation from all clinical departments utilizing the operating room. Representation will include: medical director of the CHRI operating room, the section or division chief, or their designee, of: surgery, gynecologic oncology, urology, otolaryngology, radiation oncology, thoracic surgery, surgical oncology, neurological surgery, orthopedic surgery, anesthesia, and plastic surgery; epidemiology/infection control, the medical director of perioperative services for the Ohio state university, the CHRI medical director of quality, the director of perioperative services of the CHRI operating room, the manager of perioperative services, the director of admitting, the operating room coordinator, and the CHRI director of operations. The committee chair will be a CHRI surgeon selected by the nominating committee and shall serve a two-year term beginning on the first of July. The committee shall meet monthly and carry out the following duties:

(1)  Develop written policies and procedures concerning the scope and provision of care in the surgical suite in cooperation with the departments and services concerned, including allocation of operating room resources. Allocation of operating room time will be done by the director of medical affairs and approved by the operating room committee.

(2)  Monitor quality concerns and consider problems and improvements in operating room functions brought to its attention by any of its members.

(3)  Monitor medical staff compliance with operating room policies established for patient safety, infection control, access and throughput, and smooth functioning of the operating rooms.

(4)  Maintain written records of actions taken, and results of those actions, and make these available to each committee member, the vice president of health services, the director of medical affairs, and the executive director of the CHRI.

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

Pharmacy and Therapeutics Committee (P & T Committee)

The P & T committee shall be appointed in conformity with the medical staff bylaws and have representation from medical staff, nursing, pharmacy department, and the hospital administration. The majority of members shall be members of the medical staff. The committee shall meet at least quarterly and carry out the following duties:

(A)  Review the appropriateness, safety, and effectiveness of the prophylactic empiric and therapeutic use of drugs, including antibiotics, through the analysis of individual or aggregate patterns of drug practice.

(B)  Consider the welfare of patients as well as education, research and economic factors when analyzing the utilization of drugs and related products.

(C)  Advise on the use and control of experimental drugs.

(D)  Develop or approve policies and procedures relating to the selection, distribution, use, handling, and administration of drugs and diagnostic testing materials.

(E)  Review all significant untoward drug reactions.

(F)  Maintain the Formulary of Accepted Drugs with review of proposed additions and deletions and review of use of non-formulary drugs within the institution.

(G)  Maintain written reports of conclusions, recommendations, actions taken, and the results of actions taken, and report these at least quarterly to the medical staff administrative committee.

(H)  Create sub-committees, as follows: pharmacy and therapeutic and drug utilization executive sub-committee; formulatory sub-committee; antibiotic usage sub-committee; medication safety and policy sub-committee; and the therapeutic drug monitoring sub-committee.

(I)  Establish methods by which serum blood levels may be used to improve the therapeutic activity of drugs.

(J)  Establish programs to educate health care providers to the appropriate methods of monitoring the therapeutic effect in drugs via serum drug assays.

(K)  Provide guidance to the therapeutic drug monitoring service at the CHRI.

(L)  Recommend the development of policies and procedures to the pharmacy and therapeutic and drug utilization executive subcommittee.

Transfusion and Isoimmunization Committee

(A)  The transfusion and isoimmunization committee has representation from physicians of the clinical departments frequently using blood products, nursing, transfusion service, and hospital administration. The majority of members shall be members of the medical staff. The committee shall meet at least quarterly and carry out the following duties:

(1)  Evaluate the appropriateness of all transfusions, including the use of whole blood and blood components.

(2)  Evaluate all confirmed or suspected transfusion reactions.

(3)  Develop and recommend to the medical staff administrative committee policies and procedures relating to the distribution, use, handling, and administration of blood and blood components.

(4)  Review the adequacy of transfusion services to meet the needs of patients.

(5)  Review ordering practices for blood and blood products.

(6)  Provide a liaison between the clinical departments, nursing services, hospital administration, and the transfusion service.

(7)  Use clinically valid criteria for screening and more intensive evaluation of known or suspected problems in blood usage.

(8)  Keep written records of meetings, conclusions, recommendations, and actions taken, and the results of actions taken, and make these available to each committee member and to the medical staff administrative committee.

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

(1)  All pregnant patients admitted for delivery or abortion shall be tested for Rh antigen.

(2)  No medication may be added to blood or blood products.

Infection Control Committee

(A)  The committee members shall be appointed and shall also include representation from nursing, environmental services, and hospital administration. The chairperson will be a physician with experience and/or training in infectious diseases and carry out the following duties.

(1)  Oversee surveillance and institute any recommendations necessary for investigation, prevention, and containment of nosocomial and clinical infectious diseases of both patients and staff at all facilities operated by CHRI and subject to TJC standards.

(2)  The chairperson of the committee and the hospital epidemiologist, in consultation with the director of medical affairs of the CHRI, will take necessary actions to prevent and control emerging spread or outbreaks of infections; isolate communicable and infectious patients as indicated; and obtain all necessary cultures in emergent situations when the responsible medical staff member is unavailable.

Leadership Council for Clinical Quality, Safety and Service

The leadership council for clinical quality, safety and service shall consist of members appointed pursuant to the university hospital's medical staff bylaws, and shall include the senior vice president for health sciences, the dean of the college of medicine and the chairperson of the professional affairs committee of the Wexner medical center board as ex officio members without a vote, and the director of medical affairs and chief of staff as voting members. The chief quality officer shall be the chairperson of the leadership council for clinical quality, safety and service. The leadership council for clinical quality, safety and service shall authorize policy groups to be formed to accomplish necessary hospital and medical staff functions on behalf of the CHRI and university hospitals.

CHRI representatives on the leadership council for clinical quality, safety and service shall be appointed as provided in the CHRI bylaws.

(A)  Duties include:

(1)  To design and implement systems and initiatives to enhance clinical care and outcomes throughout the integrated health care delivery systems.

(2)  To serve as the oversight council for the clinical quality management and patient safety plan.

(3)  To establish goals and priorities for clinical quality, safety and service on an annual basis.

(B)  Clinical quality and patient safety committee.

(1)  Composition.

The members shall include physicians from various clinical areas and support services, the director of clinical quality management policy group, and representation from nursing and hospitals administration. The chairperson of the policy group will be a physician.

(2)  Duties.

(a)  Coordinate the quality management related activities of the clinical sections or departments, the medical information management department, utilization review, infection control, pharmacy and therapeutics and drug utilization committee, transfusion and immunization, and other medical staff and hospital committees.

(b)  Implement clinical improvement programs to achieve the goals of the CHRI quality management plan, as well as assure optimal compliance with accreditation standards and governmental regulations concerning performance improvement.

(c)  Review, analyze, and evaluate on a continuing basis the performance of the medical staff and other health care providers; and advise the clinical section or department clinical quality sub-committees in defining, monitoring, and evaluating quality indicators of patient care and services.

(d)  Serve as liaison between the CHRI and the Ohio peer review organizations through the chairperson of the policy group and the director of clinical quality.

(e)  Make recommendations to the medical staff administrative committee on the establishment of and the adherence to standards of care designed to improve the quality of patient care delivered in the CHRI.

(f)  Hear and determine issues concerning the quality of patient care rendered by members of the medical staff and hospitals staff, make appropriate recommendations and evaluate action plans when appropriate to the director of medical affairs, the chief of a clinical section or department, or hospitals administration.

(g)  Appoint ad-hoc interdisciplinary teams to address hospital-wide quality management plan.

(h)  Annually review and revise as necessary the hospital-wide clinical quality management plan.

(i)   Report and coordinate with the leadership council for clinical quality, safety and service all quality improvement initiatives.

(C)  Clinical resource utilization policy group.

(1)  Composition.

The members shall include physicians from various areas and support services, the director of clinical resource utilization policy group, and representation from nursing and hospitals administration. The chairperson of the policy group will be a physician.

(2)  Duties.

(a)  Promote the most efficient and effective use of hospital facilities and services by participating in the review process and continued stay reviews on all hospitalized patients.

(b)  Formulate and maintain a written resource management review plan for hospitals consistent with applicable governmental regulations and accreditation requirements.

(c)  Conduct resource management studies by clinical service or by disease entity as requested or in response to variation from benchmark data would indicate.

(d)  Report and recommend to the leadership council for clinical quality, safety and service changes in clinical practice patterns in compliance with applicable governmental regulations and accreditation requirements when the opportunity exists to improve the resource management.

(D)  Evidence-based practice policy group.

(1)  Composition.

The members shall include physicians from various areas and support services, the director of the practice guidelines policy group, and representation from nursing and hospitals administration. The chairperson of the policy group will be a physician.

(2)  Duties.

(a)  Oversee the planning, development, approval, implementation and periodic review of evidence-based medicine resources (i.e. clinical practice guidelines, quick reference guides, clinical pathways, and clinical algorithms) for use within the CHRI. Planning should be based on the prioritization criteria approved by the leadership council and review should focus on incorporating recent medical practice, literature or developments. Annual review should be done in cooperation with members of the medical staff with specialized knowledge in the field of medicine related to the guidelines.

(b)  To report regularly to the leadership council for clinical quality, safety and service for approval of all new and periodically reviewed evidence-based medicine resources for use within the CHRI.

(c)  Oversee the development, approval and periodic review of the clinical elements of computerized ordersets and clinical rules to be used within the information system of the CHRI. Computerized ordersets and clinical rules related to specific practice guidelines should be forwarded to the leadership council for clinical quality, safety and service for approval. All other computerized value enhancement for approval. All other computerized ordersets and clinical rules should be forwarded to the leadership council for clinical quality, safety and service for information.

(d)  To initiate and support research projects when appropriate in support of the objectives of the leadership council for clinical quality, safety and service.

(e)  Oversee ongoing education of the medical staff (including specifically limited staff) and other appropriate hospital staff on the fundamental concepts and value of evidence-based practice and outcomes measurement and its relation to quality improvement.

(f)  Regularly report a summary of all actions to the leadership council for clinical quality, safety and service.

(Board approval dates: 11/4/2005, 7/7/2006, 2/6/2009, 9/18/2009, 5/14/2010, 2/11/2011, 4/8/2011, 4/6/2016)