Current through all regulations passed and filed through September 16, 2024
(A)
Qualifications.
(1) Membership on the medical
staff of the Ohio state university hospitals is a privilege extended to doctors
of medicine, osteopathic medicine, dentistry, and to practitioners of
psychology and podiatry who consistently meet the qualifications, standards,
and requirements set forth in the bylaws, rules and regulations of the medical
staff, the Wexner medical center board and the board of trustees of the Ohio
state university. Membership on the medical staff is available on an equal
opportunity basis without regard to race, color, creed, religion, sexual
orientation, national origin, gender, age, handicap, or veteran/military
status. Doctors of medicine, osteopathic medicine, dentistry, and practitioners
of psychology and podiatry in faculty and administrative positions who desire
medical staff membership shall be subject to the same procedures as all other
applicants for the medical staff.
(2) All members of the medical staff of the
Ohio state university hospitals shall, except as specifically provided in
university bylaws, be members of the faculty of the Ohio state university
college of medicine, or in the case of dentists, of the Ohio state university
college of dentistry. All members, except for physician scholar medical staff,
shall be duly licensed or certified to practice in the state of Ohio. Members
of the limited staff shall possess a valid training certificate, or an
unrestricted license from the applicable state board based on the eligibility
criteria defined by that board. All members of the medical staff and limited
staff and licensed health care professionals with clinical privileges shall
comply with provisions of state law and the regulations of the state medical
board or other state licensing board if applicable. Only those physicians,
dentists, and practitioners of psychology and podiatry who can document their
education, training, experience, competence, adherence to the ethics of their
profession, dedication to educational and research-goals, and ability to work
with others with sufficient adequacy to assure the Wexner medical center board
and the board of trustees of the Ohio state university that any patient treated
by them at university hospitals will be given the high quality of medical care
provided at university hospitals, shall be qualified for membership on the
medical staff of the Ohio state university hospitals.
All applicants for membership, clinical privileges, and members
of the medical staff must provide basic health information to fully demonstrate
that the applicant or member has, and maintains, the ability to perform
requested clinical privileges. The chief medical officer of the medical center,
medical directors, the department chairperson, the credentialing committee, the
medical staff administrative committee, the quality and professional affairs
committee of the Ohio state university Wexner medical center board, or the Ohio
state university Wexner medical center board may initiate and request a
physical or mental health evaluation of an applicant or member. Such request
shall be in writing to the applicant. All members of the medical staff and
licensed health care professionals will comply with medical staff and the Ohio
state university policies regarding employee and medical staff health and
safety; uncompensated care; and will comply with appropriate administrative
directives and policies to avoid disrupting those operations of the Ohio state
university hospitals which adversely impact overall patient care or which
adversely impact the ability of the Ohio state university hospitals employees
or staff to effectively and efficiently fulfill their responsibilities. All
members of the medical staff and licensed health care professionals shall agree
to comply with bylaws, rules and regulations, and policies and procedures
adopted by the medical staff administrative committee and the Wexner medical
center board, including but not limited to policies on professionalism,
behaviors that undermine a culture of safety. Annual education and training
approved by the medical staff
administrative committee or as required by the Wexner medical center to meet
accreditation standards, federal regulations, or quality and safety goals is
required for medical staff members with clinical privileges in addition to
conflict of interest disclosure. Medical staff members and licensed
health care professionals with clinical privileges must also comply with the
university integrity program requirements including but not limited to billing,
self referral, ethical conduct and annual education. Medical staff members and
licensed health care professionals with clinical privileges must immediately
disclose to the chief medical officer and the department chairperson the
occurrence of any of the following events: a licensure action in any state, any
malpractice claims filed in any state or an arrest by law enforcement.
(3) All members of the medical
staff and credentialed providers must maintain continuous uninterrupted
enrollment with all governmental health care programs.
(a) It shall be the duty of all medical staff
members and credentialed providers to promptly inform the chief medical officer
and the corporate credentialing office of any investigation, action taken, or
the initiation of any process which could lead to an action taken by any
governmental programs.
(b)
Exclusion of any medical staff member or credentialed provider from
participation in any federal or state government program or suspension from
participation, in whole or part, in any federal or state government
reimbursement program, shall result in immediate lapse of membership on the
medical staff of the Ohio state university hospitals and the immediate lapse of
clinical privileges at the Ohio state university hospitals as of the effective
date of the exclusion or suspension. Medical staff members may submit a request
to resign their medical staff membership to the chief medical officer in lieu
of automatic termination. The resignation in lieu of automatic termination
shall be discussed at the next credentialing committee and medical staff
administrative committee in order to provide recommendations to the quality and
professional affairs committee of the Wexner medical center board. A final
determination should be decided by the quality and professional affairs
committee at its next regular meeting.
(c) If the medical staff member's or
credentialed provider's participation in all governmental programs is fully
reinstated, the affected medical staff member or credentialed provider shall be
eligible to apply for membership and clinical privileges at that
time.
(4) An applicant
for membership shall at the time of appointment or reappointment, be and remain
board certified in his or her primary are of practice at the Ohio state
university hospitals. This board certification must be approved by at least one
of the American board of medical specialties, or other applicable certifying
boards, including certifying boards if applicable for doctors of osteopathy,
podiatry, psychology, and dentistry. All applicants must be and remain
certified within the specific areas for which they have requested clinical
privileges. Applicants who are not board certified at the time of application
but who have completed their residency or fellowship training within the last
five years will be eligible for medical staff appointment. However, in order to
remain eligible, those applicants must achieve board certification in their
primary area of practice within five years from the date of completion of their
residency or fellowship training. Applicants must maintain board certification
and, to the extent required by the applicable specialty/subspecialty board,
satisfy recertification requirements. Recertification will be assessed at
reappointment. Failure to meet or maintain board certification shall result in
immediate termination of membership on the medical staff of the Ohio state
university hospitals.
(5) All applicants must demonstrate recent
clinical activity in their primary area of practice during the last two years
to satisfy minimum threshold criteria for privileges within their clinical
departments.
(6)
Waiver requests for the threshold eligibility
requirements listed in paragraphs (A)(3) to (A)(5) of this rule may be
requested and considered as follows:
(a)
A request for a waiver will only be considered if the
applicant provides information sufficient to satisfy his or her burden of
demonstrating that his or her qualifications are equivalent to or exceed the
criterion in question and that there are exceptional circumstances that warrant
a waiver. The clinical department chief must endorse the request for waiver in
writing to the credentialing committee.
(b)
The credentialing
committee may consider supporting documentation submitted by the prospective
applicant, any relevant information from third parties, input from the relevant
department chiefs, and the best interests of the hospital and the communities
it serves. The credentialing committee will forward its recommendation,
including the basis for such, to the medical staff administrative
committee.
(c)
The medical staff administrative committee will review
the recommendation of the credentialing committee and make a recommendation to
the quality and professional affairs committee of the Ohio state university
medical center and the Wexner medical center board regarding whether to grant
or deny the request for a waiver and the basis for its
recommendation.
(d)
The Ohio state university Wexner medical center board's
determination regarding whether to grant a waiver is final. A determination not
to grant a waiver is not a "denial" of appointment or clinical privileges and
does not give rise to a right to a hearing. The prospective applicant who
requested the waiver in a particular case is not intended to set a precedent
for any other applicant. A determination to grant a waiver does not mean that
an appointment will be granted. Waivers of threshold eligibility criteria will
not be granted routinely. No applicant is entitled to a waiver or to a hearing
if a waiver is not granted.
(e)
Waiver requests
for the threshold eligibility requirement listed in paragraph (A)(3) of this
rule may only be considered for applicants who have voluntarily opted out of
governmental health care programs. Applicants who have been excluded or
suspended shall be ineligible to request a waiver.
(f)
Waivers to
requirements prescribed by regulatory, accrediting, or other external agencies
will not be granted.
(7) Any medical staff
member whose membership has been terminated pursuant to paragraph (A)(3) or
(A)(4) of this rule shall not be entitled to request a hearing and appeal in
accordance with rule
3335-43-06 of the Administrative
Code. Any licensed health care professional whose clinical privileges have been
terminated pursuant to paragraph (A)(4) of this rule may not request an appeal
in accordance with paragraph (G)(3) of rule
3335-43-07 of the Administrative
Code.
(8) No applicant shall
be entitled to medical staff membership and or clinical privileges merely by
the virtue of fulfilling the listed qualifications or holding a previous
appointment to the medical staff.
(B) Application for membership.
Initial application for medical staff membership for all
categories of the medical staff shall be made by the applicant to the chief of
the clinical department on forms prescribed by the medical staff administrative
committee stating the qualifications and references of the applicant and giving
an account of the applicant's current licensure, relevant professional training
and experience, current competence and ability to perform the clinical
privileges requested. All applications for appointment must specify the
clinical privileges requested. Applications may be made only if the applicant
meets the qualifications outlined in paragraph (A) of this rule. The
application shall include written statements of the applicant to abide by the
bylaws, rules and regulations and policies and procedures of the medical staff,
the Wexner medical center board, and the board of trustees of the Ohio state
university. The applicant shall produce a government-issued photo
identification to verify his/her identity pursuant to hospital/medical staff
policy. The applicant shall agree that membership on the medical staff requires
participation in the peer review process of evaluating credentials, medical
staff membership and clinical privileges, and that a condition for membership
requires mutual covenants between all members of the medical staff to release
one another from civil liability in this review process as long as the peer
review was taken in the reasonable belief that it was in furtherment of quality
health care based upon a reasonable review and appropriate procedural due
process. In order to optimize the clinical organization resource
utilization and planning of the Ohio state university hospitals, the chief of
the clinical department may require that the community affiliate
D medical staff member identify categories of
diagnosis, extent of anticipated patient activity, and service areas to be
utilized and may prepare a statement of participation for the applicant, which
shall be made a part of the application for appointment. A separate record
shall be maintained for each applicant requesting appointment to the medical
staff.
(C) Terms of
appointment. Initial appointment to the medical staff shall be for a period not
to exceed thirty-six months. During the first six months of the
initial appointment, except for medical staff appointments without clinical
privileges, appointees shall be subject to focused professional practice
evaluation (FPPE) in order to evaluate the privilege-specific competence of the
practitioner who does not have documented evidence of competently performing
the requested privilege at the organization pursuant to university bylaws. FPPE
requires the evaluation by of the chief of the clinical department with
oversight by the credentials committee and the medical staff administrative
committee. Following the six-month FPPE period, the chief of the clinical
department may:
(1) recommend the initial
appointee to transition to ongoing professional practice evaluation (OPPE),
which is described later in university bylaws to the medical staff
administrative committee;
(2) extend
the FPPE period, which is not considered an adverse action, for an additional
six months not to exceed a total of twelve months for purposes of further
monitoring and evaluation; or
(3)
terminate the initial appointee's medical staff membership and clinical
privileges. In the event that the medical staff administrative committee
recommends that an adverse action be taken against an initial appointee, the
initial appointee shall be entitled to the provisions of due process as
outlined in university bylaws.
(D) Ethics and ethical relationship. The code
of ethics as adopted, or as may be amended, by the American medical
association, the American dental association, the American psychological
association, American osteopathic association and the American podiatric
medical association shall govern the professional ethical conduct of the
respective members of the medical staff.
(E) Procedure for appointment.
(1) The written and signed application for
membership on the medical staff shall be presented to the applicable chief of
the clinical department. The applicant shall include in the application a
signed statement indicating the following:
(a)
If the applicant should be accepted to membership on the medical staff, the
applicant agrees to be governed by the bylaws, rules and regulations of the
medical staff, the Wexner medical center board and the board of trustees of the
Ohio state university.
(b) The
applicant consents to be interviewed in regard to the application.
(c) The applicant authorizes the Ohio state
university hospitals to consult with members of the medical staffs of other
hospitals with which the applicant has been or has attempted to be associated,
and with others who may have information bearing on the applicant's competence,
character and ethical qualifications.
(d) The applicant consents to the Ohio state
university hospitals' inspection of all records and documents that may be
material to the evaluation of the applicant's professional qualifications and
competence to carry out the clinical and educational privileges for which the
applicant is seeking as well as the applicant's professional ethical
qualifications for medical staff membership.
(e) The applicant releases from any
liability:
(i) All representatives of
university hospitals for acts performed in connection with evaluating the
applicant's credentials or releasing information to other institutions for the
purpose of evaluating the applicant's credentials in compliance with university
bylaws performed in good faith; and
(ii) All third parties who provide
information, including otherwise privileged and confidential information, to
members of the medical staff, the Ohio state university hospitals staff, Ohio
state university Wexner medical center board members and members of the Ohio
state university board of trustees concerning the applicant's credentials
performed in good faith.
(f) The applicant has an affirmative duty to
disclose any prior termination, voluntary or involuntary, current loss,
restriction, denial, or the voluntary or involuntary relinquishment of any of
the following: professional licensure, board certification, DEA registration,
membership in any professional organization or medical staff membership or
privileges at any other hospital or health care facility.
(g) The applicant further agrees to disclose
to the chief medical officer of the Ohio state university hospitals the
initiation of any process which could lead to such loss or restriction of the
applicant's professional licensure, board certification, DEA registration,
membership in any professional organization or medical staff membership or
privileges at any other hospital or health care facility.
(h) The applicant agrees that acceptance of
membership on the medical staff of the Ohio state university hospitals
authorizes the Ohio state university hospitals to conduct any appropriate
health assessment including but not limited to drug or alcohol screens on a
practitioner at any time during the normal pursuit of medical staff duties,
based upon reasonable cause as determined by the chief of the practitioner's
clinical department or the chief medical officer of the Ohio state university
hospitals or their authorized designees.
(2) The purpose of the health assessment
shall be to ensure that the member of the medical staff is able to fully
perform and discharge the clinical, educational, administrative and research
responsibilities which the member is permitted to exercise by reason of medical
staff membership. If, at the time of the initial request for a health
assessment, and at any time a medical staff member refuses to participate as
needed in a health assessment, including but not limited to a drug or alcohol
screening, this shall result in automatic lapse of membership, privileges, and
prerogatives until remedied by compliance with the requested health assessment.
Upon request of the medical staff administrative committee or Wexner medical
center board, the applicant will provide documentation the applicant's physical
and mental status with sufficient adequacy to demonstrate that any patient
treated by the applicant will receive care of a generally professionally
recognized level of quality and efficiency. The conditions of this paragraph
shall be deemed continuing and may be applicable to issues of continued good
standing as a member of the medical staff.
(3) An application for membership on the
medical staff shall be considered complete when all the information requested
on the application form is provided, the application is signed by the applicant
and the information is verified. A completed application must contain:
(a) Peer recommendation from at least three
individuals with "first hand" knowledge about the applicant's clinical and
professional skills.
(b) Evidence
of required immunizations.
(c)
Evidence of current professional medical malpractice liability coverage
required for the exercise of clinical privileges.
(d) Satisfaction of ECFMG requirements, if
applicable. If an individual receives a conceded eminence certificate or a
clinical research faculty certificate from the state medical board of Ohio, the
requirement for ECFMG certification may be waived at the discretion of the
Wexner medical center board.
(e)
Verification by primary source documentation of:
(i) Current and previous state
licensure;
(ii) Faculty appointment
(not required for community affiliate B, community
affiliate C, community affiliate D or contracted category);
(iii) DEA registration when required for
exercise of clinical privileges;
(iv) Graduation from an accredited medical or
professional school;
(v) Successful
completion or record of post graduate medical or professional education;
and
(vi) Board certification active
candidacy for board certification (may not be required for community affiliate
B, community affiliate C and community affiliate
Dcategories) or
applicant qualifies for a waiver pursuant to paragraph (A)(6) of rule
3335-43-04 of the Administrative
Code.
(f) Information
from the national practitioner data bank.
(g) Verification that the applicant has not
been excluded from any federally funded health care program.
(h) Complete disclosure by applicant of all
past and current claims, suits, and settlements, if any.
(i) Completion of a criminal
background investigation that meets the requirements of the Wexner medical
center.
(j) Completion of
drug
testing for substances required for individuals
applying for clinical privileges and in accordance with Wexner medical center
approved testing protocols.
(k) Verification of completion of annual
educational requirements approved by the medical staff administrative committee
and maintained in the chief medical officer's office.
(l) Demonstration of recent active clinical
practice during the last two years required for exercise of clinical
privileges.
(m) Attestation of
current Ohio automated Rx reporting system ("OARRS") account for all applicants
who have a DEA registration.
(4) The chief of the applicable clinical
department shall be responsible for investigating and verifying the character,
qualifications, and professional standing of the applicant by making inquiry of
the primary source of such information and shall within thirty days of receipt
of the complete application, submit a report of those findings along with a
recommendation on membership and clinical privileges to the chief medical
officer of the Ohio state university hospitals.
(5) The chief medical officer shall receive
all initial signed and verified applications from the chief of the clinical
department and shall make an initial determination as to whether the
application is complete. The credentials committee, the medical staff
administrative committee, the quality and professional affairs committee, and
the Wexner medical center board have the right to render an application
incomplete, and therefore not able to be processed, if the need arises for
additional or clarifying information.
The chief medical officer shall forward all complete
applications to the credentials committee. The applicant shall have the burden
of producing information for an adequate evaluation of applicant's
qualifications for membership and for the clinical privileges requested. If the
applicant fails to complete the prescribed forms or fails to provide the
information requested within sixty days of receipt of the signed application,
processing of the application shall cease and the application shall be deemed
to have been voluntarily withdrawn which action is not subject to hearing or
appeal pursuant to rule
3335-43-06 of the Administrative
Code.
If the chief of the applicable clinical department does not
submit a report and recommendation on a timely basis, the completed application
shall be forwarded to the chief medical officer for presentation to the
credentials committee on the same basis as other applicants.
(6) Completed applications shall be acted
upon as follows:
(a) By the credentials
committee within thirty days after receipt of a completed application from the
chief medical officer.
(b) By the
medical staff administrative committee within thirty days after receipt of a
completed application and the report and recommendation of the credentials
committee.
(c) By the quality and
professional affairs committee through the expedited credentialing process or
Wexner medical center board within sixty days after receipt of a completed
application and the report and recommendation of the medical staff
administrative committee.
All applications shall be acted upon by the Ohio state
university Wexner medical center board within one hundred twenty days of
receipt of a completed application. These time periods are deemed guidelines
only and do not create any right to have an application processed within these
precise periods. These periods may be stayed or altered pending receipt and
verification of further information requested from the applicant, or if the
application is deemed incomplete at any time. If the procedural rights
specified in rule
3335-43-06 of the Administrative
Code are activated, the time requirements provided therein govern the continued
processing of the application.
(7) The credentials committee shall review
the application, evaluate and verify the supporting documentation, references,
licensure, the chief of the clinical department's report and recommendation,
and other relevant information. The credentials committee shall examine the
character, professional competence, professional conduct, qualifications and
ethical standing of the applicant and shall determine, through information
contained in personal references and from other sources available to the
credentials committee, including an appraisal from the chief of the clinical
department in which clinical privileges are sought, whether the applicant has
established and meets all of the necessary qualifications for the category of
medical staff membership and clinical privileges requested. The credentials
committee shall, within thirty days from receipt of a complete application,
make a recommendation to the chief medical officer that the application be
accepted, rejected, or modified. The chief medical officer shall forward the
recommendation of the credentials committee to the medical staff administrative
committee. The credentials committee or the chief medical officer may recommend
to the medical staff administrative committee that certain applications for
appointment be reviewed in executive session. The recommendation of the medical
staff administrative committee regarding an appointment decision shall be made
within thirty days of receipt of the credentials committee recommendation and
shall be communicated by the chief medical officer, along with the
recommendation of the chief medical officer to the quality and professional
affairs committee of the Wexner medical center board, and thereafter to the
Wexner medical center board. When the Ohio state university Wexner medical
center board has acted, the chairperson of the board shall instruct the chief
medical officer to transmit the final decision to the chief of the clinical
department and applicant and, if appropriate, to the director of the applicable
clinical division.
(8) At any time
the medical staff administrative committee first recommends non-appointment of
an initial applicant for medical staff membership or recommends denial of any
clinical privileges requested by the applicant, the medical staff
administrative committee shall require the chief medical officer to notify the
applicant by certified return receipt mail that the applicant may request an
evidentiary hearing as provided in paragraph (D) of rule
3335-43-06 of the Administrative
Code. The applicant shall be notified of the requirement to request a hearing
as provided by paragraph (B) of rule
3335-43-06 of the Administrative
Code. If a hearing is properly requested, the applicant shall be subject to the
rights and responsibilities of rule
3335-43-06 of the Administrative
Code. If an applicant fails to properly request a hearing, the medical staff
administrative committee shall accept, reject, or modify the application for
appointment to membership and clinical privileges.
The final recommendation of the medical staff administrative
committee shall be directly communicated to the Wexner medical center board by
the chief medical officer, who shall make a separate recommendation to the
Wexner medical center board.
When the Ohio state university Wexner medical center board has
acted, the chairperson of the board shall instruct the chief medical officer to
transmit the final decision to the chief of the clinical department and
applicant and, if appropriate, to the director of the applicable clinical
division. The chairperson of the board shall also notify the dean of the
college of medicine and the chief executive officer of the Ohio state
university hospitals of the decision of the board.
(F) Procedure for reappointment
(1) At least ninety days prior to the end of
the medical staff member's appointment period, the chief of the clinical
department shall provide each medical staff member with an application for
reappointment to the medical staff on forms prescribed by the medical staff
administrative committee. The reappointment application shall include all
information necessary to update and evaluate the qualifications of the medical
staff member. The chief of the clinical department shall review the information
available on each medical staff member, and the chief of the clinical
department shall make recommendations regarding reappointment to the medical
staff and for granting clinical privileges for the ensuing appointment period.
The chief of the clinical department's recommendation shall be transmitted in
writing along with the signed and completed reappointment forms to the chief
medical officer at least forty-five days prior to the end of the medical staff
member's appointment period.
The terms of paragraphs (A), (B), (C),
(D), (E)(1), and (E)(2) of this rule shall apply to all applicants for
reappointment. Reappointment to the medical staff shall be done on a regular
basis for a period not to exceed thirty-six months. Only completed
applications for reappointment shall be considered by the credentials
committee. An application for reappointment is complete when all the
information requested on the reappointment application form is provided, the
reappointment form is signed by the applicant, and the information is verified,
and no need for additional or clarifying Information is identified. A completed
reappointment application form must contain:
(a) Evidence of required immunizations if
applicable since last appointment.
(b) Evidence of current professional medical
malpractice liability insurance required for the exercise of clinical
privileges.
(c) Verification of
primary source documentation of:
(i) State
licensure;
(ii)
DEA registration when required for clinical privileges;
(iii)
Successful completion or record of additional post graduate medical or
professional education; and
(iv) Board
certification, re-certification, or continued active candidacy for
certification (may not be required for community affiliate category) or
applicant qualifies for a waiver pursuant to paragraph (A)(4) of rule
3335-43-06 of the Administrative Code.
(d) Information from the national
practitioner data bank.
(e)
Verification that the applicant has not been excluded from any federally funded
health care program.
(f) Specific
requests for any changes in clinical privileges sought at reappointment with
supporting documentation as required by credentialing guidelines.
(g) Specific requests for any changes in
medical staff category.
(h) A
summary of the member's clinical activity during the previous appointment
period.
(i) Patterns of care as
demonstrated through quality assurance records.
(j) Verification of completion of annual
educational requirements approved by the medical staff administrative committee
and maintained in the chief medical officer's office.
(k) Complete disclosure by medical staff
members of claims, suits, and settlements, if any.
(l) Continuing medical education and
applicable continuing professional education activities. Documentation of
category one CME that at least in part relates to the individual medical staff
member's specialty or sub-specialty area and are consistent with the licensing
requirements of the applicable Ohio state licensing board shall be
required.
(m) Attestation of
current OARRS account for all applicants who have a DEA registration.
(2) The member for reappointment
shall be required to submit any reasonable evidence of current ability to
perform the clinical privileges requested. The chief of the clinical department
shall review and evaluate the reappointment application and the supporting
documentation. The chief of the clinical department shall evaluate all matters
relevant to recommendation, including the member's professional competence;
clinical judgment; clinical or technical skills; ethical conduct; participation
in medical staff affairs; compliance with the bylaws, rules and regulations of
the medical staff, the Wexner medical center board, and the board of trustees
of the Ohio state university; cooperation with the Ohio state university
hospitals' personnel and the use of the Ohio state university hospitals'
facilities for patients; relations with other physicians, other health
professionals or other staff, and maintenance of a professional attitude toward
patients; and the responsibility to the Ohio state university hospitals and the
public.
(3) The chief medical
officer shall forward the reappointment forms and the recommendations of the
chief of the clinical department to the credentials committee. The credentials
committee shall review the request for reappointment in the same manner, and
with the same authority as an original application for medical staff
membership. The credentials committee shall review all aspects of the
reappointment application including source verification of the member's quality
assurance record for continuing membership qualifications and for clinical
privileges. The credentials committee shall review each member's
performance-based profile to ensure that the same level of quality of care is
delivered by all medical staff members with similar delineated clinical
privileges across all clinical departments and across all categories of medical
staff membership.
The credentials committee shall forward its recommendations to
the chief medical officer at least thirty days prior to the end of the period
of appointment. The chief medical officer shall transmit the completed
reappointment application and the recommendation of the credentials committee
to the medical staff administrative committee.
Failure of the member to submit a reappointment application
shall be deemed a voluntary resignation from the medical staff and shall result
in automatic expiration of membership and all clinical privileges at the end of
the medical staff member's current appointment period, which action shall not
be subject to a hearing or appeal pursuant to rule
3335-43-06 of the Administrative
Code. A request for reappointment subsequently received from a member who has
been automatically expired shall be processed as a new appointment.
Failure of the chief of the clinical department to act timely
on an application for reappointment shall be the same as provided in paragraph
(E)(5) of this rule.
(4)
The medical staff administrative committee shall review each request for
reappointment in the same manner and with the same authority as an original
application for medical staff membership. The medical staff administrative
committee shall accept, reject, or modify the request for reappointment in the
same manner and with the same authority as an original application for medical
staff membership. The recommendation of the medical staff administrative
committee regarding reappointment of a member shall be communicated by the
chief medical officer, along with the recommendation of the chief medical
officer, to the quality and professional affairs committee of the Wexner
medical center board, and thereafter to the Wexner medical center board. When
the Ohio state university Wexner medical center board has acted, the
chairperson of the board shall instruct the chief medical officer to transmit
the final decision to the chief of the clinical department and applicant and,
if appropriate, to the director of the applicable clinical division.
(5) When the decision of the medical staff
administrative committee results in a decision of non-reappointment or
reduction, suspension or revocation of clinical privileges, the medical staff
administrative committee shall instruct the chief medical officer to give
written notice to the affected member of the decision, the stated reason for
the decision, and the member's right to a hearing pursuant to paragraphs (A)
and (B) of rule
3335-43-06 of the Administrative
Code. This notification and an opportunity to exhaust the appeal process shall
occur prior to an adverse decision unless the provisions outlined in paragraph
(D) of rule 3335-43-05 of the Administrative Code apply. The notice by the
chief medical officer shall be sent certified return receipt mail to the
affected member's last known address as determined by the Ohio state university
records.
(6) If the affected member
of the medical staff does not make a written request for a hearing to the chief
medical officer within thirty-one days after receipt of the adverse decision,
it shall be deemed a waiver of the right to any hearing or appeal as provided
in rule 3335-43-06 of the Administrative
Code to which the staff member might otherwise have been entitled on the
matter
(7) If a timely, written
request for hearing is made, the procedures set forth in rule
3335-43-06 of the Administrative
Code shall apply.
(G)
Resumption of clinical activities following leave of absence.
(1) A member of the medical staff or
credentialed provider shall request a leave of absence in writing for good
cause shown such as medical reasons, educational and research reasons or
military service to the chief of clinical service and the chief medical
officer. Such leave of absence shall be granted at the discretion of the chief
of the clinical service and the chief medical officer provided, however, such
leave shall not extend beyond the term of the member's or credentialed
provider's current appointment. A member of the medical staff or credentialed
provider who is experiencing health problems that may impair his or her ability
to care for patients has the duty to disclose such impairment to his or her
chief of clinical department and the chief medical officer and the member or
credentialed provider shall be placed on immediate medical leave of absence
until such time the member or credentialed provider can demonstrate to the
satisfaction of the chief medical officer that the impairment has been
sufficiently resolved and can request for reinstatement of clinical activities.
During any leave of absence, the member or credentialed provider shall not
exercise his or her clinical privileges, and medical staff responsibilities and
prerogatives shall be inactive.
(2)
The member or credentialed provider must submit a written request for the
reinstatement of clinical privileges to the chief of the clinical service. The
chief of the clinical service shall forward his recommendation to the
credentialing committee which, after review and consideration of all relevant
information, shall forward its recommendation to the medical staff
administrative committee and quality and professional affairs committee of the
Wexner medical center board. The credentials committee, the chief medical
officer, the chief of the clinical service or the medical staff administrative
committee shall have the authority to require any documentation, including
advice and consultation from the member's or credentialed provider's treating
physician or the committee for practitioner health that might have a bearing on
the medical staff member's or credentialed provider's ability to carry out the
clinical and educational responsibilities for which the medical staff is
seeking privileges. Upon return from a leave of absence for medical reasons the
medical staff member or credentialed provider must demonstrate his or her
ability to exercise his or her clinical privileges upon return to clinical
activity.
(3) All members of the
medical staff or credentialed providers who take a leave of absence for medical
or non-medical reasons must be in good standing on the medical staff upon
resumption of clinical activities. No member shall be granted leave of absence
in excess or his or her current appointment and the usual procedures for
appointment and reappointment, including deadlines for submission of
application as set forth in this rule, will apply irrespective of the nature of
the leave. Absence extending beyond his or her current term or failure to
request reinstatement of clinical privileges shall be deemed a voluntary
resignation from the medical staff and of clinical privileges, and in such
event, the member or credentialed provider shall not be entitled to a hearing
or appeal.
