Current through all regulations passed and filed through September 16, 2024
(A) Policy statement
The university of Toledo ("UT") will create and maintain a
standard of care committee ("committee") as part of its litigation management
process that will review standard of care issues that allegedly resulted in
claims. In order to improve patient safety and reduce future risk exposures to
UT and the university of Toledo physicians, limited liability company ("UTP"),
the committee will communicate any standard of care or patient safety concerns
to the medical staff peer review committee.
(B) Purpose of policy
The committee supports legal defense by evaluating the care
provided in litigation claims and determining if there were any standard of
care issues. The committee improves patient safety and reduces future risk by
referring any standard of care or patient safety concerns to the medical staff
peer review committee.
(C)
Committee functions
(1) Case reviews will be
done by the office of legal affairs on all lawsuits filed against UT, UTP,
affiliated practitioners who participate in the university insurance program,
residents, students or employees of UT. One hundred eighty-day letters and
potential claims will be reviewed as appropriate in accordance with rule
3364-10-16 of the Administrative
Code (professional liability claims reporting and management policy).
(2) The committee will discuss each case
presented to determine whether:
(a) The
standard of care was met;
(b) The
standard of care was met, but there are concerns; or
(c) The standard of care was not
met.
(3) The committee
will assess responsibility of any standard of care issues and allocate the
portion of responsibility amongst the parties.
(4) The office of legal affairs-health
science campus ("HSC") will direct the committee's determination to the proper
channels, including the claims management committee.
(5) All issues with regard to a finding that
the standard of care was not met will be provided to the medical staff peer
review committee. Action will be taken as appropriate by the medical staff peer
review committee to educate and improve patient safety and quality of
care.
(D) Committee
membership
Members of the standard of care committee will be:
Executive vice
president for clinical affairs (chair);
UTP president;
UTP vice
president;
UTMC chief executive
officer;
Chief of staff;
Vice chief of
staff;
Chief
medical officer;
A minimum of six
hospital medical staff members representative of the clinical services offered
by UTMC (appointed by the committee chair);
Chief administrative
officer for quality and patient safety;
Chief nursing
officer;
(11) Deputy general
counsel*;
(12) Risk management*.
* Non-voting members
(E) Meetings
The committee will meet monthly or as often as necessary.
Attendance of five attending physicians constitutes a quorum.
The UTP president will serve as committee chair in the absence
of the executive vice president for clinical affairs.
(F) Protected information
The committee performs quality assurance activities and is an
integral part of university's peer review and quality assurance process. Those
sections of the Revised Code pertaining to immunity and confidentiality of peer
review and quality assurance committees apply to the committee. The committee
also supports legal counsel in litigation preparation, defense, and resolution
decisions. The activities of this committee, including any information, data,
reports, or records are part of peer review records as well as attorney-client
privileged/work product, and are protected from disclosure.
(G) Definitions
(1) Claims mean any of the following against
any person or entity insured by the university insurance program:
(a) Lawsuits - summons and complaints served,
regardless of which court the action was filed.
(b) One-hundred eighty-day letters (Ohio) or
notices of intent (Michigan) that give notice of consideration of suing or
requests from an attorney or patient for medical records where the request form
indicates that the party is considering filing a lawsuit.
(c) Any written demands for compensation by
patient, family or legal representative.
(2) Potential claim means any procedure or
treatment which may have contributed to:
(a)
An event that has resulted in an unanticipated death or major permanent loss of
function, not related to the natural course of the patient's illness or
underlying condition, including but not limited to unexpected deaths or
unexpected outcomes of a serious nature:
(i)
Unanticipated neurological, sensory or systemic deficits: including but not
limited to brain damage, spinal cord injury, paralysis or nerve injury, organ
failure or sepsis;
(ii) Severe
burns, including but not limited to thermal, chemical, radiological or
electrical, resulting in extensive hospitalization and/or skin
grafting;
(iii) Severe internal
injuries, lacerations, infectious processes, foreign body retentions, or
sensory or reproductive organ injuries; or
(iv) Substantial disabilities, including
fractures, amputations or disfigurements.
(b) Any outcome that is classified as a
sentinel event (per policy 3364-100-50-38 of the UT medical center (sentinel
events/adverse events)) and requires a root cause analysis to be
performed.
