Ohio Admin. Code 3335-43-07 - Categories of the medical staff

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. Community affiliate B medical staff shall not be assigned to a clinical department under rule 3335-43-08 of the Administrative Code.

(2) Appointment and reappointment: For purposes of processing applications for appointment and reappointment of community affiliate B medical staff, the duties of the chief of the clinical department set forth in rule 3335-43-04 of the Administrative Code shall be assigned by the chief medical officer to be performed by the chief physician of the affiliate entity or authorized designee. To perform these duties on behalf of community affiliate B medical staff, the chief physician or authorized designee must be an active member of the medical staff under these bylaws and will also serve as a voting member on the medical staff administrative committee.

(3) Termination of medical staff membership: The medical staff membership of a community B affiliate physician shall automatically terminate upon loss of employment with the affiliate entity. This automatic termination shall not entitle the community B affiliate physician to any of the hearing processes set forth in rule 3335-43-06 of the Administrative Code.

(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 univeristy 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 historical 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 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 prescrived 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.

Notes

Ohio Admin. Code 3335-43-07

Effective: 10/7/2024
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 07/01/1984, 11/29/1987, 02/02/1992, 01/31/1994, 05/26/1995, 03/20/1998, 06/15/1998, 02/18/2000, 02/04/2002, 08/19/2002, 10/04/2002, 07/01/2003, 02/01/2005, 06/20/2005, 11/21/2005, 03/26/2007, 02/27/2008, 01/20/2009, 11/23/2009, 08/06/2010, 06/14/2011, 09/16/2012, 07/31/2013, 04/29/2015, 06/23/2016, 11/12/2020, 03/08/2022, 04/09/2024