Current through all regulations passed and filed through September 16, 2024
(A)
Right to hearing and to an appeal.
(1) When a
member of the medical staff who has exhausted all remedies under paragraphs (E)
and (F) of rule
3335-43-04 of the Administrative
Code on appointment or reappointments; or under rule
3335-43-05 of the Administrative
Code for corrective action; or who has been summarily suspended under paragraph
(D) of rule
3335-43-05 of the Administrative
Code the staff member shall be entitled to an adjudicatory hearing.
(2) A medical staff member shall not be
entitled to a hearing under the following circumstances:
(a) Denial by the Wexner medical center board
to grant a waiver of board certification for a medical staff member.
(b) Termination of a medical staff member
because of exclusion from participation in any government reimbursement
program.
(c) Voluntary withdrawal
of a medical staff application.
(d)
Failure to submit a reappointment application.
(e) A leave of absence extending beyond
current appointment or failure to request reinstatement of clinical privileges
following a leave of absence.
(f)
Actions or recommendations resulting from an informal peer review.
(g) Termination of community
affiliate B and community affiliate C
medical staff appointments upon approval by the Wexner medical center
board.
(3) All hearings
and appeals shall be in accordance with the procedural safeguards set forth in
this rule to assure that the affected medical staff member is accorded all
rights to which the member is entitled.
(B) Request for hearing.
(1) The request for a hearing shall be
submitted in writing by the affected medical staff member to the chief medical
officer within thirty days of notification by the chief medical officer of the
intended action. The chief medical officer shall forward the request to the
medical staff administrative committee along with instructions to convene a
hearing.
(2) The failure of a
medical staff member to request a hearing, to which the member is entitled by
these bylaws within the time and in the manner herein provided, shall be deemed
a waiver of the right to any review by the medical staff administrative
committee. The chief medical officer shall then implement the decision and that
action shall become and remain effective against the medical staff member in
the same manner as a final decision of the Ohio state university Wexner medical
center board as provided for in paragraph (F) of rule
3335-43-05 of the Administrative
Code. The chief medical officer shall promptly inform the affected medical
staff member that the proposed decision, which had entitled the medical staff
member to a hearing, has now become final.
(C) Notice of hearing.
(1) After receipt of a timely request for
hearing by the chief medical officer from a medical staff member entitled to
such hearing, the medical staff administrative committee shall be notified of
the request for hearing by the chief medical officer and shall at the next
scheduled meeting take the following action:
(a) Instruct the chief medical officer and
chief of staff to jointly appoint within seven days a hearing committee,
consisting of five members of the medical staff who are not members of the
medical staff administrative committee, are not direct competitors, do not have
a conflict of interest, and who have not previously participated in the formal
peer review of the matter under consideration.
(b) Instruct the hearing committee to
schedule and arrange for a hearing which hearing shall be conducted not less
than thirty days nor more than sixty days from the date of the receipt of the
request for hearing by the chief medical officer; provided, however, that a
hearing for a medical staff member who is under suspension, which is then in
effect, shall be held as soon as arrangements may be reasonably made.
(2) The medical staff member shall
be given at least ten days prior notice of the scheduled hearing, provided that
this notice may be waived in writing by the medical staff member. Notice shall
be by certified return receipt mail to the staff member at the staff member's
last known address as reflected by university records. The notice of hearing
shall state in concise language the acts or omissions with which the medical
staff member is charged; a list of representative medical records or documents
being used; names of potential witnesses to be called; and any other reason or
evidence that may be considered by the hearing committee during the
hearing.
(D) Conduct of
hearing.
(1) The hearing committee shall
select a chairperson from the committee to preside over the hearing. The
chairperson may require a representative for the individual and for the medical
staff administrative committee (or the Wexner medical center board) to
participate in a pre-hearing conference. At the pre-hearing conference, the
chairperson shall resolve all procedural questions, including any objections to
exhibits or witnesses, the role of legal counsel, and determine the time to be
allotted to each witness's testimony and cross-examination.
The hearing committee shall have benefit of Ohio state
university legal counsel. The hearing committee may grant continuances,
recesses, and the chairperson may excuse a member of the hearing committee from
attendance temporarily for good cause, provided that there shall be at no time
less than four members of the hearing committee present unless the affected
staff member waives this requirement.
All members of the hearing committee must be present to
deliberate and vote. No member may vote by proxy. The person who has taken
action from which the affected staff member has requested the hearing shall not
participate in the deliberation or voting of the hearing committee. The hearing
shall be a de novo hearing, although evidence of the prior recommendations and
decisions may be presented.
(2) An accurate record of the hearing shall
be kept. The mechanism for taking the record shall be by the use of a
professional stenographer. This record shall be available to the affected
member of the medical staff upon request at the member's expense.
(3) The personal presence of the medical
staff member for whom the hearing has been scheduled shall be required. A
medical staff member who fails without good cause to appear and proceed at such
hearing shall be deemed to have waived all rights to appear and to have a
hearing before the medical staff administrative committee in the same manner as
provided in paragraph (B) of this rule, and to have accepted the adverse
recommendation or decision involved and the same shall therein become and
remain in effect as provided in paragraph (B) of this rule. The medical staff
administrative committee may, in its own discretion, order the hearing
committee to proceed with the hearing without the medical staff member and
impose a sanction which is greater or lesser than that originally
imposed.
(4) The hearing need not
be conducted strictly according to the rules of law related to the examination
of witnesses or presentation of evidence. Any relevant matters upon which
responsible persons customarily rely in the conduct of serious affairs shall be
considered, regardless of the existence of any common law or statutory rule
which might make evidence inadmissible over objection in civil or criminal
action. The member of the medical staff for whom the hearing is being held
shall, prior to, or during the hearing, be entitled to submit memoranda
concerning any issues of procedure or of fact and such memoranda shall become a
part of the hearing record.
(5) The
affected medical staff member shall have the following rights: to be
represented by an attorney at law and to call and examine witnesses; to
introduce evidence; to cross-examine any witnesses on any matter relevant to
the issue of the hearing; and to challenge any witness and to rebut any
evidence. If the medical staff member does not testify in his or her own
behalf, the staff member may be called and examined as if under
cross-examination.
(6) The hearing
committee shall request the person who has taken the action from which the
affected staff member has requested the hearing to present evidence to the
hearing committee in support of the adverse recommendation. The hearing
committee may proceed to hear evidence and testimony from either party in
whatever order the hearing committee deems appropriate. The hearing committee
may call its own witnesses, may recall any parties witnesses, and may question
witnesses as it deems appropriate. All parties shall be responsible to secure
the attendance of their own witnesses. All witnesses and evidence received by
the hearing committee shall be open to challenge and cross-examination by the
parties. Witnesses shall not be placed under oath. At the close of the evidence
the hearing committee may request each party to make summary statements, either
oral or written. The hearing committee may request legal representation from
the Ohio state university.
(7) The
hearing committee may, without special notice, recess the hearing and reconvene
the same for the convenience of the participants or for the purpose of
obtaining new or additional evidence or consultation. The hearing committee
shall make its best effort to expeditiously determine the issues presented. The
hearing committee may elect to limit its proceedings when sufficient material
has been received. The parties may be required by the hearing committee to
provide evidence in oral or written form. Upon conclusion of the presentation
of oral and written evidence, the hearing shall be closed. The committee may
thereupon, at a time convenient to itself, conduct its deliberations outside
the presence of the medical staff member for whom the hearing was
convened.
(8) Within sixty days
after its appointment, the hearing committee shall forward its written report
and recommendation together with the transcript of the hearing and all other
documentation provided by the parties to the medical staff administrative
committee. The affected medical staff member shall be notified of the
recommendation of the hearing committee including a statement of the basis for
the recommendation. The medical staff administrative committee shall accept,
reject, or modify the recommendation of the hearing committee. The medical
staff administrative committee may conduct further hearings as it deems
necessary or may remand the matter back to the hearing committee for further
action as directed. The medical staff administrative committee may impose a
greater or lesser sanction than that recommended by the hearing
committee.
(9) The medical staff
administrative committee shall submit a written report, including its
recommendation to the chairperson of the Wexner medical center board within
fourteen days of the final vote by the medical staff administrative committee.
An adverse action which must be reported to the state medical board or the
federal government, including the national practitioner data bank, shall
entitle an affected medical staff member to the procedures of this rule. The
affected member of the medical staff shall be notified of the decision of the
medical staff administrative committee by the chief medical officer.
(10) The decision and record of the medical
staff administrative committee shall be transmitted to the quality and
professional affairs committee of the Wexner medical center board, which shall,
subject to the affected member's right to appeal and implementation of
paragraph (E) of this rule, consider the matter at its next scheduled meeting,
or at a special meeting to be held no less than thirty days following receipt
of the transmittal. The quality and professional affairs committee may accept,
reject, or modify the decision of the medical staff administrative committee.
The quality and professional affairs committee may remand that matter back to
the medical staff administrative committee for further action as
directed.
(11) The recommendation
of the quality and professional affairs committee shall be promptly considered
by the Wexner medical center board, at its next scheduled meeting. The Wexner
medical center board may accept, reject, or modify the recommendation of the
quality and professional affairs committee. The Wexner medical center board may
remand the matter back to the medical staff administrative committee for
further action as directed.
(12) A
copy of the Wexner medical center board decision shall be sent certified return
receipt mail to the affected medical staff member at the member's last known
address as determined by university records.
(E) Appeal process.
(1) Within thirty days after receipt of a
notice by an affected medical staff member of the decision of the medical staff
administrative committee, the member may, by written notice to the chairperson
of the Ohio state university Wexner medical center board, request an appeal.
The appeal shall only be held on the record before the medical staff
administrative committee.
(2) If an
appeal is not requested within thirty days, the affected medical staff member
shall be deemed to have:
(a) Waived the
member's right to appeal, and
(b)
Accepted the adverse decision.
(3) The appeal shall be conducted by the
quality and professional affairs committee of the Wexner medical center
board.
(4) The affected medical
staff member shall have access to the reports and records, including
transcripts, if any, of the hearing committee and of the medical staff
administrative committee and all other material, favorable or unfavorable, that
has been considered by the medical staff administrative committee. The staff
member shall then submit a written statement indicating those factual and
procedural matters with which the member disagrees, specifying the reasons for
such disagreement. This written statement may cover any matters raised at any
step in the procedure to which the appeal is related, and legal counsel may
assist in its preparation. Such written statement shall be submitted to the
quality and professional affairs committee no later than seven days following
the date of the affected member's notice of appeal.
(5) New or additional matters not raised
during the hearing or in the medical staff administrative committee hearings
shall only be considered on appeal at the sole discretion of the quality and
professional affairs committee.
(6)
Within fourteen days following submission of the written statement by the
affected medical staff member, the quality and professional affairs committee
shall recommend to the Ohio state university Wexner medical center board that
the adverse decision be affirmed, modified or rejected, or to refer the matter
back to the medical staff administrative committee for further review and
recommendation. Such referral to the medical staff administrative committee may
include a request for further investigation.
(7) Any final decision by the Wexner medical
center board shall be communicated by the chief medical officer and by
certified return receipt mail to the affected medical staff member at that
member's last known address as determined by university records. The chief
medical officer shall also notify in writing the executive vice president for
health sciences, the dean of the college of medicine, the chief executive
officer of the Ohio state university hospitals and the vice president for
health services, chief of staff, the chief of the clinical department, and the
person(s) who initiated the request for formal peer review. The chief medical
officer shall take immediate steps to implement the final decision.