Ohio Administrative Code
Title 3364 - University of Toledo
Chapter 3364-1 - Board of Trustees In General; Medical Center and Clinical Operations
Section 3364-1-12.1 - Powers and duties

The university board of trustees retains ultimate authority and fiduciary responsibility for UTH, including determination of the mission, vision, and strategic objectives for UTH, as well as the establishment of fiscal, personnel, and patient care policies.

Under the ultimate authority of the university board of trustees and consistent with Ohio law, the university board of trustees authorizes and designates the UTH board to act as the governing body on behalf of the university for quality and patient care matters, including, but not limited to, licensing, accreditation, compliance, quality of medical services, and related purposes for any and all of the hospitals and clinics of the university. This shall include, but is not limited to, approval of clinical privileging forms; medical and dental staff appointments; clinical privileges; medical staff operations, including the approval, adoption, and amendment of medical staff bylaws and rules and regulations; and the conducting of peer review and professional review actions for medical staff and credentialed providers within university board of trustees-defined parameters. Except as provided in this rule, a committee of the UTH board will review medical staff membership, credentialing, privileges, and renewal of privileges, and recommend action on such matters to the UTH board for approval. In the months where no regularly scheduled UTH board meeting is held, such committee of the UTH board is delegated the responsibility to act on behalf of the UTH board in regard to medical staff membership, credentialing, privileging and renewal of privileges of medical staff of UTMC. Medical staff membership, credentialing, privileging, and renewal of privileges will be done in accordance with the policies and procedures of the UTH board, the UTMC medical staff bylaws, the standards of the joint commission or other accrediting body, as applicable, the centers for medicare and medicaid services conditions of participation, and state of Ohio or other regulatory obligations on these matters. The committee will make a full report of its activities at the next regularly scheduled UTH board meeting. For the avoidance of doubt, in the absence of a seated committee of the UTH board, the university board of trustees or a committee of the university board of trustees will review and recommend action on medical staff membership, credentialing, privileges, and renewal of privileges of medical staff of UTMC.