Ohio Admin. Code 3335-43-08 - Organization of the medical staff

(A) Each member of the attending, community affiliate A, community affiliate B, community affiliate C, community affiliate D, limited, and physician scholar medical staff shall be assigned to a clinical department and division, if applicable, upon the recommendation of the applicable chief of the clinical department.

(B) Names of clinical departments.

(1) Anesthesiology.

(2) Dermatology.

(3) Emergency medicine.

(4) Family and community medicine.

(5) Internal medicine.

(6) Neurological surgery.

(7) Neurology.

(8) Obstetrics and gynecology.

(9) Ophthalmology and visual science.

(10) Orthopaedics.

(11) Otolaryngology - head and neck surgery.

(12) Pathology.

(13) Pediatrics.

(14) Physical medicine and rehabilitation.

(15) Plastic and reconstructive surgery.

(16) Psychiatry and behavioral health.

(17) Radiation oncology.

(18) Radiology.

(19) Surgery.

(20) Urology.

(21) Dentistry.

(C) The directors of the divisions in the Ohio state university hospitals shall be appointed by the chiefs of the clinical departments in the Ohio state university hospitals in which the divisions are included.

(D) Qualifications and responsibilities of the chief of the clinical department.

The academic department chairperson shall ordinarily serve also as the chief of the clinical department. Each chief of the clinical department shall be qualified by education and experience appropriate to the discharge of the responsibilities of the position. Each chief of the clinical department must be board certified by an appropriate specialty board or must establish comparable competence. The chief of the clinical department must be a medical staff member at the Ohio state university hospitals. Such qualifications shall be judged by the respective dean of the college of medicine or dentistry. Qualifications for chief of the clinical department generally shall include: recognized clinical competence, sound judgment and well-developed administrative skills.

(1) Procedure for appointment and reappointment of the chief of the clinical department.

Appointment or reappointment of chief of the clinical department shall be made by the dean of the respective college of medicine or dentistry in consultation with elected representatives of the medical staff and the chief medical officer.

(2) Term of appointment of the chief of the clinical department.

The term of appointment of the chief of the clinical department shall be concurrent with the chief's academic appointment but shall be no longer than four years. Prior to the end of said four-year term, a review shall be conducted by the dean of the college of medicine and such review shall serve as the basis for the recommendation for reappointment pursuant to paragraph (D)(1) of this rule.

(3) Duties of the chief of the clinical department.

Each chief of the clinical department is responsible for the following:

(a) Clinically related activities of the department;

(b) Administratively related activities of the department, unless otherwise provided by the hospital;

(c) Continuing surveillance of the professional performance of all practitioners in the department who have delineated clinical privileges;

(d) Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department;

(e) Recommending clinical privileges for each practitioner of the department based on relevant training and experience, current appraised competence, health status that does not present a risk to patients, and evidence of satisfactory performance with existing privileges;

(f) Assessing and recommending to the relevant hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the hospital;

(g) The integration of the department or service into the primary functions of the hospital, developing services that complement the medical center's mission and plan for clinical program development;

(h) The coordination and integration of interdepartment and intradepartmental services;

(i) The development and implementation of policies and procedures that guide and support the provision of care, treatment, and services. This includes the development, implementation, enforcement and updating of departmental policies and procedures that are consistent with the hospital's mission. The clinical department chief shall make such policies and procedures available to the medical staff;

(j) The recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services, including ensuring that call coverage provides for continuous high quality and safe care;

(k) The determination of the qualifications and competence of department or service personnel who are not licensed practitioners and who provide patient care, treatment, and services;

(l) The continuous assessment and improvement of the quality of care, treatment, and services;

(m) The maintenance of quality control programs, as appropriate;

(n) The orientation and continuing education of all persons in the department or service;

(o) Recommending space and other resources needed by the department or service; and

(p) Hold regular clinical department meetings and ensure open lines of communication are maintained in the clinical department. The agenda for the meetings shall include, but not be limited to, a discussion of the clinical activities of the department and communication of the decisions of the medical staff administrative committee. Minutes of departmental meetings, including a record of attendance, shall be electronically available and/or distributed to all medical staff members in the clinical department, and such minutes shall be kept in the clinical department.

Notes

Ohio Admin. Code 3335-43-08

Effective: 10/7/2024
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 05/21/1983, 04/27/1986, 08/18/1986, 08/10/1987, 05/25/1991, 02/02/1992, 01/31/1994, 05/26/1995, 03/20/1998, 06/15/1998, 12/04/1998, 02/04/2002, 08/19/2002, 10/04/2002, 06/23/2003, 02/01/2005, 06/20/2005, 11/21/2005, 04/24/2006, 03/26/2007, 11/30/2007, 01/20/2009, 11/23/2009, 12/03/2009, 03/15/2011, 06/14/2011, 09/16/2012, 02/21/2014, 12/29/2023