Ohio Administrative Code
Title 3335 - Ohio State University
Chapter 3335-43 - Medical Staff Members
Section 3335-43-07 - Categories of the medical staff
Universal Citation: OH Admin Code 3335-43-07
Current through all regulations passed and filed through September 16, 2024
The medical staff of the Ohio state university hospitals shall be divided into nine categories: attending; community affiliate A; community affiliate B; community affiliate C; community affiliate D; consulting; contracted; physician scholar and limited staff. Medical staff members who do not wish to obtain any clinical privileges shall be exempt from the requirements of medical malpractice liability insurance, DEA registration, demonstration of recent active clinical practice during the last two years and specific annual education requirements but are otherwise subject to the provisions of university bylaws.
(A) Attending .
(1) Qualifications: The attending medical
staff shall consist of those faculty members of the colleges of medicine and
dentistry to whom clinical teaching responsibilities are assigned in the Ohio
state university hospitals and who satisfy the requirements and qualifications
for membership set forth in rule
3335-43-04 of the Administrative
Code. The assignment of teaching responsibility is the prerogative of the chief
of the clinical department or the chief's designee.
(2) Prerogatives.
An attending medical staff member may:
(a) Admit patients consistent with their
clinical privileges and the balanced teaching and patient care responsibilities
of the Ohio state university hospitals. When, in the judgment of the chief of
the clinical department, a balanced teaching program is jeopardized, following
consultation with the dean of the college of medicine and the Ohio state
university hospitals' chief executive officer, and with the concurrence of a
majority of the medical staff administrative committee, the chief of the
clinical department may restrict an attending medical staff member's ability to
admit patients. Imposition of such restrictions shall not entitle the attending
medical staff member to a hearing or appeal pursuant to rule
3335-43-06 of the Administrative
Code.
(b) Be free to exercise such
clinical privileges as are granted pursuant to university bylaws.
(c) Vote on all matters presented at general
and special meetings of the medical staff and of the department and committees
of which he or she is a member unless otherwise provided by resolution of the
medical staff, clinical department, or committee and approved by the medical
staff administrative committee.
(d)
Hold office in the medical staff organization and in the clinical department
and committees of which he or she is a member, unless otherwise provided by
resolution of the medical staff, clinical department, or committee and approved
by the medical staff administrative committee.
(3) Responsibilities:
Each member of the attending medical staff with clinical privileges shall:
(a) Meet the basic
responsibilities set forth in rules
3335-43-02 and
3335-43-03 of the Administrative
Code.
(b) Retain responsibility
within the member's area of professional competence for the continuous care and
supervision of each patient in the Ohio state university hospitals for whom the
member is providing care, or arrange a suitable alternative for such care and
supervision.
(c) Actively
participate in such quality evaluation and monitoring activities as required by
the medical staff, and discharge such medical staff functions as may be
required from time to time.
(d)
Satisfy the requirements set forth in rule
3335-43-11 of the Administrative
Code for attendance at staff and departmental meetings and meetings of those
committees of which he or she is a member and for payment of membership
dues.
(e) Supervise members of the
limited staff in the provision of patient care in accordance with accreditation
standards and policies and procedures of approved clinical training programs.
It is the responsibility of the attending physician to authorize each member of
the limited staff to perform only those services which the limited staff member
is competent to perform under supervision.
(f) Supervise other licensed healthcare
professionals as necessary in accordance with accreditation standards and state
law. It is the responsibility of the attending physician to authorize each
licensed healthcare professional to perform only those services which the
licensed healthcare professional is privileged to perform.
(g) Take call as assigned by the chief of the
clinical department.
(B) Community affiliate A .
(1) Qualifications: The
community
affiliate A medical staff shall consist of physicians and other licensed healthcare
professional who do not
meet the
criteria for attending medical staff appointment. This category includes
community physicians and physicians employed by an
affiliate entity who have clinical activity required for
membership and actively participate in teaching programs.
(2) Prerogatives:
The community affiliate A medical staff may:
(a) Exercise such clinical privileges as are
granted pursuant to these bylaws.
(b) Admit, consistent with their clinical
privileges, patients who complement the clinical teaching program.
(c) Attend meetings as a member of the
medical staff and the clinical department of which he or she is a member and
any medical staff or the Ohio state university hospitals education programs.
The community affiliate A medical staff member may vote
on medical staff policies, bylaws, rules
and regulations and for elected officials of the medical staff. Members
of the community affiliate A medical staff may
by appointed to serve on
medical staff committees as
provided by university bylaws.
(3) Responsibilities: Each member of the
community
affiliate A medical staff with clinical privileges shall be required to
have a faculty appointment and discharge the
basic responsibilities specified in paragraph (B)(3) of this rule.
(C) Community affiliate B .
(1) Qualifications: The
community
affiliate B medical staff shall consist of those
doctors of medicine, osteopathic medicine, dentists and
practitioners of podiatry or psychology who are employed by an affiliate
entity, do not have patient activity at university hospitals but who are
enrolled under institutional managed care contracts or other contractual
arrangements and who work at facilities not owned by the Wexner medical center.
Community affiliate B medical staff members shall not be required to obtain
appointment to the faculty of the Ohio state university and will not possess
clinical privileges. Community affiliate B medical staff shall not be eligible
to hold office or required to pay medical staff dues and shall not be eligible
to vote on medical staff policies, rules and regulations, or bylaws.
(D) Community affiliate C.
(1)
Qualifications:
The community affiliate C medical staff shall consist of those physicians and
other licensed healthcare professionals who do not qualify for attending
medical staff appointment and shall not possess clinical privileges. This
category is comprised of referring physicians who desire to be associated with
the Ohio state university hospitals to refer and follow patients. Community
affiliate C medical staff members shall not be eligible to vote on medical
staff policies, rules and regulations, or bylaws, shall not be eligible to hold
office and are not required to pay medical staff dues.
(2)
Prerogatives:
Community affiliate C medical staff members may:
(a)
Have access to the Ohio state university hospitals and
shall be given notice of all medical staff activities and
meetings.
(b)
Attend meetings as a member of the medical staff and
the clinical departments of which he or she is a member and any medical staff
of the Ohio state university hospitals education programs.
(c)
The grant of
community affiliate C medical staff appointment to physicians is a courtesy
only and may be terminated by the Wexner medical center board upon
recommendation of the medical staff administrative committee without the right
to a hearing or appeal.
(E) Community affiliate D.
This is a closed medical staff category that was created as a one-time grandfathering category for medical staff members of the Ohio state university hospitals east prior to July 1, 2007.
(1)
Qualifications: Community affiliate medical staff shall
consist of those doctors of medicine, osteopathic medicine, dentists and
practitioners of podiatry or psychology who:
(a)
Do not qualify
for an attending medical staff appointment;
(b)
Are community
affiliate members seeking reappointment; and
(c)
Satisfy the
requirements and qualifications set forth in rule
3335-43-04 of the Administrative
Code and are already appointed to the community affiliate medical staff
pursuant to university bylaws.
(2)
A community
affiliate medical staff member shall meet and maintain the same standards for
quality patient care applicable to all members of the medical staff. Community
affiliate medical staff members shall be subject to university bylaws and the
rules and regulations of the medical staff except as provided in this
paragraph. The community affiliate medical staff member shall not be required
to obtain appointment to the faculty of the Ohio state university. The
community affiliate medical staff member shall not be subject to the
requirement for board certification within the community affiliate medical
staff member's respective area of practice if that requirement was waived when
he or she became a member of the Ohio state university east medical staff.
Teaching and research accomplishments shall not be required in determining the
qualifications of applicants to this category of the medical
staff.
(3)
To optimize the clinical organization, resource
utilization, and planning of the hospitals, the chief of the clinical
department may require that the applicant for community affiliate medical staff
membership to 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 will be made a part of the application
for appointment.
(4)
Prerogatives:
A community affiliate medical staff member may:
(a)
Admit patients consistent with the limitations of bed
and service allocations established by the medical directors and approved by
the medical staff administrative committee, and the Wexner medical center
board. If, in the judgment of the medical directors, a balanced teaching
program is jeopardized, following consultation with the chief of the clinical
department, and with the concurrence of a majority of the medical staff
administrative committee, the medical director may restrict admissions of
members of the community affiliate medical staff. Patients admitted under the
care of the community affiliate medical staff will not be required to
participate in the educational mission of the Ohio state university hospitals.
Ordinarily, no coverage by the limited medical staff will be afforded, with the
exception of emergency medical services.
(b)
Exercise the
clinical privileges granted, have access to all medical records, and be
entitled to utilize the facilities of the Ohio state university hospitals
incidental to the clinical privileges granted pursuant to university
bylaws.
(c)
Attend teaching and educational conferences approved by
the Ohio state university, attend medical staff social functions, and
participate as providers in the Ohio state university or the Ohio state
university hospitals affiliated health plans.
(5)
Responsibilities:
Each member of the community affiliate D medical staff shall:
(a)
Participate in the management of and represent the
interests of the clinical department for which he or she is granted clinical
privileges.
The community affiliate medical staff member shall comply with all provisions of university bylaws and rules and regulations of the medical staff, unless expressly exempted under this rule.
(b)
The community affiliate medical staff member shall
comply with all the Ohio state university hospitals' policies and accreditation
standards, and shall be subject to the same quality evaluation, monitoring, and
resource management requirements as other members of the medical
staff.
(c)
Be responsible within the member's area of professional
competence for the continuous care and supervision of each patient in the Ohio
state university hospitals for whom the member is providing care, or arrange a
suitable alternative for such care and supervision.
(d)
Not be eligible
to vote on medical staff policies, rules and regulations, or bylaws or to hold
office. Members of the community affiliate medical staff may serve on
non-elected medical staff committees as provided by university
bylaws.
(e)
Be subject to payment of medical staff dues or
assessments as approved by the medical staff.
(F) Consulting .
(1) Qualifications. The consulting medical
staff shall consist of those faculty members of the colleges of medicine and
dentistry who:
(a) Satisfy the requirements
and qualifications for membership set forth in rule
3335-43-04 of the Administrative
Code.
(b) Are consultants of
recognized professional ability and expertise who provide a service not readily
available from the attending medical staff. These practitioners provide
services at the Ohio state university hospitals only at the request of
attending or community affiliate A members of the medical
staff.
(c) Demonstrate
participation on the active medical staff at another accredited hospital
requiring performance improvement/quality assessment activities similar to
those of the Ohio state university hospitals. The practitioner shall also hold
at such other hospital the same privileges, without restriction, that he/she is
requesting at the Ohio state university hospitals. An exception to this
qualification may be made by the Wexner medical center board provided the
practitioner is otherwise qualified by education, training and experience to
provide the requested service.
(2) Prerogatives:
Consulting medical staff members may:
(a) Exercise the clinical privileges granted
for consultation purposes on an occasional basis when requested by an attending
or community affiliate A medical staff member.
(b) Have access to all medical records and be
entitled to utilize the facilities of the Ohio state university hospitals
incidental to the clinical privileges granted pursuant to university
bylaws.
(c) Not admit patients to
the Ohio state university hospitals.
(d) Not vote on medical staff policies, rules
and regulations, or bylaws, and may not hold office.
(e) Must actively participate in such quality
evaluation and monitoring activities as required by the medical staff and as
outlined in the medical staff policy entitled "Consulting medical staff member
policy."
(f) Attend medical staff
meetings, but shall not be entitled to vote at such meetings or hold
office.
(g) Attend department
meetings, but shall not be entitled to vote at such meetings or serve as chief
of a clinical department.
(h) Serve
as a non-voting member of a medical staff committee; provided, however, that
he/she may not serve as a committee chair or as a member of the medical staff
administrative committee.
(3) Responsibilities.
Each member of the consulting medical staff shall:
(a) Meet the basic responsibilities set forth
in rules
3335-43-02 and
3335-43-03 of the Administrative
Code.
(b) Be exempt from all
medical staff dues.
(G) Contracted.
(1)
Qualifications:
contraced medical staff shall consist of those members who meet the
requirements for medical staff membership and are providing services to Wexner
medical center patients exclusively through a contract with the Wexner medical
center. Contracted medical staff members shall meet and maintain the same
standards for quality patient care applicable to all members of the medical
staff and shall be subject to these bylaws and the rules and regulations of the
medical staff except as provided in this paragraph.
Contracted medical staff shall not be required to obtain appointment to the faculty of the Ohio state university. Contracted medical staff shall not be eligible to vote on medical staff policies, rules and regulations, or bylaws, shall not be eligible to hold office or required to pay medical staff dues.
(2)
Prerogatives:
Contracted medical staff may:
Exercise such clinical
privileges as are granted pursuant to university bylaws.
(3)
Any
contracted medical staff member whose membership has been terminated due to
loss of contract and/or clinical privileges shall not be entitled to request a
hearing and appeal in accordance with rule
3335-43-06 of the Administrative
Code.
(H) Physician scholar.
(1)
Qualifications:
The physician scholar medical staff shall be composed of those faculty members
of the colleges of medicine and dentistry who are recognized for outstanding
reputation, notable scientific and professional contributions, and high
professional stature. This medical staff category includes but is not limited
to emeritus faculty members. Nominations may be made to the chair of the
credentialing committee who shall present the candidate to the medical staff
administrative committee for approval.
(2)
Prerogatives:
Members of the physician scholar medical staff shall have access to the Ohio
state university hospitals and shall be given notice of all medical staff
activities and meetings. Members of the physician scholar medical staff shall
enjoy all rights of an attending medical staff member except physician scholar
members shall not possess clinical privileges.
(3)
Physician scholar
medical staff must have either a full license or an emeritus registration by
the state medical board of Ohio.
(I) Limited staff.
Limited staff are not considered full members of the medical staff, do not have delineated clinical privileges and do not have the right to vote in general medical staff elections. Except where expressly stated, members of the limited staff are bound by the terms of university bylaws, the rules and regulations of the medical staff, and the limited staff agreement.
(1)
Qualifications:
(a)
The limited staff
shall consist of doctors of medicine, osteopathic medicine, dentists and
practitioners of podiatry or psychology who are accepted in good standing by a
program director into a post-doctoral graduate medical education program and
appointed to the limited staff in accordance with university
bylaws.
(b)
The limited staff shall maintain compliance with the
requirements of state law, including regulations adopted by the Ohio state
university medical board, or the limited staff member's respective licensing
board.
(c)
Members of the limited staff shall possess a valid
training certificate or an unrestricted Ohio license from the applicable state
board based on eligibility criteria defined by that state board. All members of
the limited staff shall be required to successfully obtain an Ohio training
certificate prior to beginning training within a program.
(2)
Responsibilities:
Each member of the limited staff shall:
(a)
Be responsible to respond to all questions and to
complete all forms as may be required by the credentials
committee.
(b)
Participate fully in the teaching programs,
conferences, and seminars of the clinical department in which he or she is
appointed in accordance with accreditation standards and policies and
procedures of the graduate medical education committee and approved clinical
training programs.
(c)
Participate in the care of all patients assigned to the
limited staff member under the appropriate supervision of a designated member
of the attending or community affiliate A medical staff in accordance with
accreditation standards and policies and procedures of the clinical training
programs. The clinical activities of the limited staff shall be determined by
the program director appropriate for the level of education and training.
Limited staff shall be permitted to perform only those services that they are
authorized to perform by the member of the attending or community affiliate A
medical staff based on the competence of the limited staff to perform such
services. The limited staff may admit or discharge patients only when acting on
behalf of the attending or community affiliate A medical staff. The limited
staff member shall follow all rules and regulations of the service to which the
limited staff member is assigned, as well as the general rules of the Ohio
state university hospitals pertaining to limited staff. Specifically, a limited
staff member shall consult with the attending or community affiliate A member
of the medical staff responsible for the care of the patient before the limited
staff member undertakes a procedure or treatment that carries a significant,
material-risk to the patient unless the consultation would cause a delay that
would jeopardize the life or health of the patient.
(d)
Serve as a member
of various medical staff committees in accordance with established committee
composition as described in university bylaws and/or the rules and regulations
of the medical staff. The limited staff member shall not be eligible to vote or
hold elected office in the medical staff organization but may vote on
committees to which the limited staff member is assigned.
(e)
Be expected to
make regular satisfactory professional progress including anticipated
certification by the respective specialty or sub-specialty program of
post-doctoral training in which the limited staff member is enrolled.
Evaluation of professional growth and appropriate humanistic qualities shall be
made on a regular schedule by the clinical departmental chief, program
director, teaching faculty or evaluation committee in accordance with
accreditation standards and policies and procedures of the approved training
programs.
(f)
Appeal by a member of the limited staff of probation,
lack of promotion, suspension or termination for failure to meet expectations
for professional growth or failure to display appropriate humanistic qualities
or failure to successfully complete any other competency as required by the
accreditation standards of an approved training program will be conducted and
limited in accordance with written guidelines established by the respective
department or training program and approved by the program director and the
Ohio state university hospitals graduate medical education committee as
delineated in the limited staff agreement and by the graduate medical education
policies. Alleged misconduct by a member of the limited staff, for reasons
other than failure to meet expectations of professional growth as outlined in
this paragraph, shall be handled in accordance with rules
3335-43-05 and
3335-43-06 of the Administrative
Code.
(3)
Failure to meet reasonable expectations.
Termination of employment from the limited staff member's residency or fellowship training program shall result in automatic termination of the limited staff member's appointment pursuant to university bylaws.
(4)
Temporary
appointments.
(a)
Limited staff members who are Ohio state university
faculty may be granted an early commencement or an extension of appointment
upon the recommendation of the chief of the clinical department, with prior
concurrence of the associate dean for graduate medical education, when it is
necessary for the limited staff member to begin his or her training program
prior to or extend his or her training program beyond a regular appointment
period. These appointments shall not exceed sixty days.
(b)
Temporary
appointments may be granted upon the recommendation of the chief of the
clinical department, with prior concurrence of the medical directors, for
limited staff members who are not Ohio state university faculty but who,
pursuant to education affiliate agreements approved by the university, need to
satisfy approved graduate medical education clinical rotation requirements.
These appointments shall not exceed a total of one hundred twenty days in any
given post-graduate year. In such cases, the mandatory requirement for a
faculty appointment may be waived. All other requirements for limited staff
member appointment must be satisfied.
(5)
Supervision.
Limited staff members shall be under the supervision of an attending or community affiliate A medical staff member. Limited staff members shall have no privileges as such but shall be able to care for patients under the supervision and responsibility of their attending or community affiliate A medical staff member. The care they extend will be governed by university bylaws and the general rules and regulations of each clinical department. The practice of care shall be limited by the scope of privileges of their attending or community affiliate A medical staff member. Any concerns or problems that arise in the limited staff member's performance should be directed to the attending or community affiliate A medical staff member or the director of the training program.
(a)
Limited staff
members may write admission, discharge and other orders for the care of
patients under the supervision of the attending or community affiliate A
medical staff member.
(b)
All records of limited staff member cases must document
involvement of the attending or community affiliate A medical staff member in
the supervision of the patient's care to include co-signature of the admission
order, history and physical, operative report, and discharge
summary.
(J) Temporary medical staff appointment.
(1)
External peer review. When peer review activities are
being conducted by someone other than a current member of the medical staff,
the chief medical officer may admit a practitioner to the medical staff for a
limited period of time. Such membership is solely for the purpose of conducting
peer review in a particular evaluation and this temporary membership
automatically expires upon the member's completion of duties in connection with
such peer review Such appointment does not include clinical privileges and is
for a limited purpose.
(2)
Proctoring. Temporary privileges may be extended to
visiting medical faculty for special clinical or educational activities as
provided by the Ohio state medical or dental board. When medical staff members
require proctoring for the purposes of gaining experience to become
credentialed to perform a procedure, a visiting physician may apply for
temporary privileges per the prescribed medical staff proctoring
policy.
(K) Clinical privileges.
(1) Delineation of clinical
privileges:
(a) Every person practicing at the
Ohio state university hospitals by virtue of medical staff membership, faculty
appointment, contract or under authority granted in university bylaws shall, in
connection with such practice, be entitled to exercise only those clinical
privileges specifically applied for and granted to the staff member or other
licensed health care professional by the Ohio state university Wexner medical
center board after recommendation from the medical staff administrative
committee.
Each clinical department shall develop specific clinical criteria and standards for the evaluation of clinical privileges with emphasis on invasive or therapeutic procedures or treatment which present significant risk to the patient or for which specific professional training or experience is required. Such criteria and standards are subject to the approval of the medical staff administrative committee and the Wexner medical center board.
(b) Requests for the
exercise and delineation of clinical privileges must be made as part of each
application for appointment or reappointment to the medical staff on the forms
prescribed by the medical staff administrative committee. Every person in an
administrative position who desires clinical privileges shall be subject to the
same procedure as all other applicants. Requests for clinical privileges must
be submitted to the chief of the clinical department in which the clinical
privileges will be exercised. Clinical privileges requested other than during
appointment or reappointment to the medical staff shall be submitted to the
chief of the clinical department and such request must include documentation of
relevant training or experience supportive of the request.
(c) The chief of the clinical department
shall review each applicant's request for clinical privileges and shall make a
recommendation regarding clinical privileges to the chief medical officer.
Requests for clinical privileges shall be evaluated based upon the applicant's
education, training, experience, demonstrated competence, references, and other
relevant information, including the direct observation and review of records of
the applicant's performance by the clinical department in which the clinical
privileges are exercised. Whenever possible the review should be of primary
source information. The applicant shall have the burden of establishing the
applicant's qualifications and competency in clinical privileges requested and
shall have the burden of production of adequate information for the proper
evaluation of qualifications.
(d)
The applicant's request for clinical privileges and the recommendation of the
chief of the clinical department shall be forwarded to the credentials
committee and shall be processed in the same manner as applications for
appointment and reappointment pursuant to rule
3335-43-04 of the Administrative
Code.
(e) Medical staff members who
are granted new or initial privileges are subject to FPPE, which is a six-month
period of focused monitoring and evaluation of practitioners' professional
performance. Following FPPE medical staff members with clinical privileges are
subject to ongoing professional practice evaluation (OPPE), which information
is factored into the decision to maintain existing privileges, to revise
existing privileges, or to revoke an existing privilege prior to or at the time
of renewal. FPPE and OPPE are fully detailed in medical staff policies that
were approved by the medical staff administrative committee and the Wexner
medical center board.
(f) Upon
resignation, termination or expiration of the medical staff member's faculty
appointment or employment with the university for any reason, such medical
staff appointment and clinical privileges of the medical staff member shall
automatically expire.
(g) Medical
staff members authorize the Ohio state university hospitals and clinics to
share credentialing, quality and peer review information pertaining to the
medical staff member's clinical competence and/or professional conduct. Such
information may be shared at initial appointment and/or reappointment and at
any time during the medical staff member's medical staff appointment to the
medical staff of the Ohio state university hospitals.
(h) Medical staff members authorize the Ohio
state university hospitals to release information, in good faith and without
malice, to managed care organizations, regulating agencies, accreditation
bodies and other health care entities for the purposes of evaluating the
medical staff member's qualifications pursuant to a request for appointment,
clinical privileges, participation or other credentialing or quality
matters.
(2) Temporary
privileges:
(a) Temporary privileges may be
extended to a doctor of medicine, osteopathic medicine, dental surgery,
psychologist, podiatry or to a licensed health care professional upon
completion of an application prescribed by the medical staff administrative
committee, upon recommendation of the chief of the clinical department. All
temporary privileges are granted by the chief executive officer or authorized
designee. The temporary privileges granted shall be consistent with the
applicant's training and experience and with clinical department guidelines.
Prior to granting temporary privileges, primary source verification of
licensure and current competence shall be required. Temporary privileges shall
be limited to situations which fulfill an important patient-care need, and
shall be granted for a period not to exceed one hundred twenty days.
(b) Temporary privileges may be extended to
visiting medical faculty or for special activity as provided by the Ohio state
medical or dental board.
(c)
Temporary privileges granted for locum tenens may be exercised for a maximum of
ninety days, consecutive or not, any time during the thirty-six
month period following the date they are granted.
(d) Practitioners granted temporary
privileges will be restricted to the specific delineations for which the
temporary privileges are granted. The practitioner will be under the
supervision of the chair of the clinical department while exercising any
temporary privileges granted.
(e)
Special privileges. Upon receipt of a written request for specific temporary
privileges and the approval of the clinical department chief and the chief
medical officer, an appropriately licensed practitioner of documented
competence, who is not an applicant for medical staff membership, may be
granted special privileges for the care of one or more specific patients. Such
privileges shall be exercised in accordance with the conditions specified in
university bylaws.
(f)
Practitioners exercising temporary privileges shall abide by medical staff
bylaws, rules and regulations, and hospital and medical staff
policies.
(g) The temporary and
special privileges must be in conformity with accrediting bodies' standards and
the rules and regulations of the professional boards of Ohio.
(3) Expedited privileges.
If the Wexner medical center board is not scheduled to convene in a timeframe that permits the timely consideration of the recommendation of a complete application by the medical staff administrative committee, applicants may be granted expedited privileges by the quality and professional affairs committee of the Wexner medical center board. Certain restrictions apply to the appointment and granting of clinical privileges via the expedited process. These include but are not limited to: an involuntary termination of medical staff membership at another hospital, involuntary termination of medical staff membership at another hospital, involuntary limitation, or reduction, denial or loss of clinical privileges, a history of professional liability actions resulting in a final judgment against the applicant or a challenge by a state licensing board.
(4)
Podiatric privileges:
(a) Practitioners of
podiatry may admit patients to the Ohio state university hospitals if such
patients are being admitted solely to receive care that a podiatrist may
provide without medical assistance, pursuant to the scope of the professional
license of the podiatrist. Practitioners of podiatry must, in all other
circumstances, co-admit patients with a member of the medical staff who is a
doctor of medicine or osteopathic medicine. A member of the medical staff who
is a doctor of medicine or osteopathy shall be responsible for any medical
problems that the patient has while an inpatient of the Ohio state university
hospitals.
(b) A member of the
medical staff who is a doctor of medicine or osteopathy:
(i) Shall be responsible for any medical
problems that the patient has while an inpatient of the Ohio state university
hospitals; and
(ii) Shall confirm
the findings, conclusions and assessment of risk prior to high-risk diagnosis
or therapeutic interventions defined by the medical staff.
(c) Practitioners of podiatry shall be
responsible for the podiatric care of the patient including the podiatric
history and physical examination and all appropriate elements of the patient's
record.
(d) The podiatrist shall be
responsible to the chief of the department of orthopaedics.
(5) Psychology privileges.
(a) Psychologists shall be granted clinical
privileges based upon their training, experience and demonstrated competence
and judgment consistent with their license to practice. Psychologists shall not
prescribe drugs, or perform surgical procedures, or in any other way practice
outside the area of their approved clinical privileges or expertise, unless
otherwise authorized by law.
(b)
Psychologists may not admit patients to the Ohio state university hospitals,
but may diagnose and treat a patient's psychological illness as part of the
patient's comprehensive care while hospitalized. All patients admitted for
psychological care shall receive the same medical appraisal as all other
hospitalized patients. A member of the medical staff who is a doctor of
medicine or osteopathic medicine shall admit the patient and shall be
responsible for the history and physical and any medical care that may be
required during the hospitalization, and shall determine the appropriateness of
any psychological therapy based on the total health status of the patient.
Psychologists may provide consultation within their area of expertise on the
care of patients within the Ohio state university hospitals.
In outpatient settings, psychologists shall diagnose and treat their patients' psychological illness. Psychologists shall ensure that their patients receive referral for appropriate medical care.
(c) Psychologists shall be responsible to the
chief of the clinical department in which they are appointed.
(6) Dental privileges.
(a) Practitioners of dentistry, who have not
been granted clinical privileges as oral and maxillofacial surgeons, may admit
patients to the Ohio state university hospitals if such patients are being
admitted solely to receive care which a dentist may provide without medical
assistance, pursuant to the scope of the professional license of the dentist.
Practitioners of dentistry must, in all other circumstances co-admit patients
with a member of the medical staff who is a doctor of medicine or osteopathic
medicine. A member of the medical staff who is a doctor of medicine or
osteopathy shall be responsible for any medical problems that the patient has
while an inpatient of the Ohio state university hospitals.
(b) A member of the medical staff who is a
doctor of medicine or osteopathy:
(i) Shall be
responsible for any medical problems that the patient has while an inpatient of
the Ohio state university hospitals; and
(ii) Shall confirm the findings, conclusions
and assessment of risk prior to high-risk diagnosis or therapeutic
interventions defined by the medical staff.
(c) Practitioners of dentistry shall be
responsible for the dental care of the patient including the dental history and
physical examination and all appropriate elements of the patient's
record.
(7) Oral and
maxillofacial surgical privileges.
All patients admitted to the Ohio state university hospitals for oral and maxillofacial surgical care shall receive the same medical appraisal as all other hospitalized patients. Qualified oral and maxillofacial surgeons shall admit patients, shall be responsible for the plan of care for the patients, shall perform the medical history and physical examination, if they have such privileges, in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedure(s), and shall be responsible for the medical care that may be required at the time of admission or that may arise during hospitalization.
(8) Other licensed health care professionals.
(a) Clinical privileges may be exercised by
licensed health care professionals who are duly licensed in the state of Ohio,
and who are either:
(i) Members of the faculty
of the Ohio state university, or
(ii) Employees of the Ohio state university
whose employment involves the exercise of clinical privileges, or
(iii) Employees or members of the medical
staff.
(b) A licensed
health care professional as used herein, shall not be eligible for medical
staff membership but shall be eligible to exercise those clinical privileges
granted pursuant to these bylaws and in accordance with applicable Ohio state
law. If granted such privileges under this rule and in accordance with
applicable Ohio state law, other licensed health care professionals may perform
all or part of the medical history and physical examination of a patient.
Licensed health care professionals with privileges are subject to FPPE and
OPPE.
(c) Licensed health care
professionals shall apply and re-apply for clinical privileges on forms
prescribed by the medical staff administrative committee and shall be processed
in the same manner as provided in rule
3335-43-04 of the Administrative
Code subject to the provisions of paragraph (G)(8) of this rule.
(d) Licensed health care professionals are
not members of the medical staff, but may write admitting orders for patients
of the Ohio state university hospitals when granted such privileges under this
rule and in accordance with applicable Ohio state law. If such privileges are
granted, the patient will be admitted under the medical supervision of the
responsible medical staff member. Licensed health care professionals shall not
be eligible to hold office, vote on medical staff affairs, or serve on standing
committees of the medical staff unless specifically authorized by the medical
staff administrative committee.
(e)
Each licensed health care professional shall be individually assigned to a
clinical department and shall be sponsored by one or more members of the
medical staff. The licensed health care professional's clinical privileges are
contingent upon the sponsoring medical staff member's privileges. In the event
that the sponsoring medical staff member loses privileges or resigns, the
licensed health care professionals whom he or she has sponsored shall be placed
on administrative hold until another sponsoring medical staff member is
assigned. The new sponsoring medical staff member must be assigned in less than
thirty days.
(f) Licensed health
care professionals must comply with all limitations and restrictions imposed by
their respective licenses, certifications, or legal credentials as required by
Ohio law, and may only exercise those clinical privileges granted in accordance
with provisions relating to their respective professions.
(g) Only applicants who can document the
following shall be qualified for clinical privileges as a licensed health care
professional:
(i) Current license,
certification, or other legal credential required by Ohio law.
(ii) Certificate of authority, standard care
agreement, or utilization plan.
(iii) Education, training, professional
background and experience, and professional competence.
(iv) Patient care quality indicators
definition for initial appointment. This data will be in a format determined by
the licensed health care professional subcommittee and the quality management
department.
(v) Adherence to the
ethics of the profession for which an individual holds a license,
certification, or other legal credential required by Ohio law.
(vi) Evidence of required
immunization.
(vii) Evidence of
good personal and professional reputation as established by peer
recommendations.
(viii)
Satisfactory physical and mental health to perform requested clinical
privileges.
(ix) Ability to work
with members of the medical staff and the Ohio state university hospitals
employees.
(h) The
applicant shall have the burden to produce documentation with sufficient
adequacy to assure the medical staff and the Ohio state university hospitals
that any patient cared for by the licensed health care professional seeking
clinical privileges shall be given quality care, and that the efficient
operation of the Ohio state university hospitals will not be disrupted by the
applicant's care of patients in the Ohio state university hospitals.
(i) By applying for clinical privileges as a
licensed health care professional, the applicant agrees to the following terms
and conditions:
(i) The applicant has read the
bylaws and rules and regulations of the medical staff of the Ohio state
university hospitals and agrees to abide by all applicable terms of such bylaws
and any applicable rules and regulations, including any subsequent amendments
thereto, and any applicable Ohio state university hospitals policies that the
Ohio state university hospitals may from time to time put into
effect.
(ii) The applicant releases
from liability all individuals and organizations who provide information to the
Ohio state university hospitals regarding the applicant and all members of the
medical staff, the Ohio state university hospitals staff, the Ohio state
university Wexner medical center board and the Ohio state university board of
trustees for all acts in connection with investigating and evaluating the
applicant.
(iii) The applicant
shall not deceive a patient as to the identity of any practitioner providing
treatment or service in the Ohio state university hospitals.
(iv) The applicant shall not make any
statement or take any action that might cause a patient to believe that the
licensed health care professional is a member of the medical staff.
(v) The applicant shall not perform any
patient care in the Ohio state university hospitals that is not permitted under
the applicant's license, certification, or other legal credential required
under Ohio law.
(vi) The applicant
shall obtain and continue to maintain professional liability insurance in such
amounts required by the medical staff.
(j) Licensed health care professionals shall
be subject to quality review and corrective action as outlined in this
paragraph for violation of university bylaws, their certificate of authority,
standard of care agreement, utilization plan, or the provisions of their
licensure, including professional ethics. Review may be requested by any member
of the medical staff, a chief of the clinical department, or by the chief
quality officer or his or her designee. All requests shall be in writing and
shall be submitted to the chief quality officer. The chief quality officer
shall appoint a three-person committee to review and make recommendations
concerning appropriate action. The committee shall consist of at least one
licensed health care professional and one medical staff member. The committee
shall make a written recommendation to the chief quality officer, who may
accept, reject, or modify the recommendation. The chief quality officer
forwards his or her recommendation to the chief medical officer for final
determination.
(k) Appeal process.
(i) A licensed health care professional may
submit a notice of appeal to the chairperson of the quality and professional
affairs committee within thirty days of receipt of written notice of any
adverse corrective action pursuant to university bylaws.
(ii) If an appeal is not so requested within
the thirty-day period, the licensed health care professional shall be deemed to
have waived the right to appeal and to have conclusively accepted the decision
of the chief medical officer.
(iii)
The appellate review shall be conducted by the chief of staff, the chair of the
licensed health care professionals subcommittee and one medical staff member
from the same discipline as the licensed health care professional under review.
The licensed health care professional under review shall have the opportunity
to present any additional information deemed relevant to the review and appeal
of the decision.
(iv) The affected
licensed health care professional 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 chief quality officer. The
licensed health care professional shall 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 review committee no later than seven days following the
date of the licensed health care professional's notice of appeal.
(v) New or additional matters shall only be
considered on appeal at the sole discretion of the quality and professional
affairs committee.
(vi) Within
thirty days following submission of the written statement by the licensed
health care professional, the chief of staff shall make a final recommendation
to the chair of the quality and professional affairs committee of the Wexner
medical center board. The quality and professional affairs committee of the
Wexner medical center board shall determine whether the adverse decision will
stand or be modified and 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 review committee for further
review and recommendation. Such referral to the review committee may include a
request for further investigation.
(vii) Any final decision by the Wexner
medical center board shall be communicated by the chief quality officer and by
certified return receipt mail to the last known address of the licensed health
care professional as determined by university records. The chief quality
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
and the chief of the applicable clinical department or departments. The chief
medical officer shall take immediate steps to implement the final
decision.
(9)
Emergency privileges.
In case of an emergency, any member of the medical staff to the degree permitted by the member's license or certification and regardless of department or medical staff status shall be permitted to do everything possible to save the life of a patient using every facility of the Ohio state university hospitals necessary, including the calling for any consultation necessary or desirable. After the emergency situation resolves, the patient shall be assigned to an appropriate member of the medical staff. For the purposes of this paragraph, an "emergency" is defined as a condition which would result in serious permanent harm to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger.
(10) Disaster
privileges.
Disaster privileges may be granted in order to provide voluntary services during a local, state, or national disaster in accordance with hospital/medical staff policy and only when the following two conditions are present: the emergency management plan has been activated and the hospital is unable to meet immediate patient needs. Such privileges may be granted by the chief medical officer or his or her designee to fully licensed or certified, qualified individuals who at the time of the disaster are not members of the medical staff. These privileges will be limited in scope and will terminate once the disaster situation subsides or at the discretion of the chief medical officer.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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