Ohio Admin. Code 3335-97-03 - Quality and professional affairs committee
(A) Responsibilities. The quality and
professional affairs committee shall be responsible for the following specific
duties:
(1) Reviewing and evaluating the
patient safety and quality improvement programs of the university Wexner
medical center, including, but not limited to, the hospitals, clinics,
ambulatory care facilities, and physician office facilities;
(2) Overseeing all patient care activity in
all facilities that are a part of the university Wexner medical center,
including, but not limited to, the hospitals, clinics, ambulatory care
facilities, and physicians' office facilities;
(3) Monitoring quality assurance performance
in accordance with the standards set by the university Wexner medical
center;
(4) Monitoring the
achievement of accreditation and licensure requirements;
(5) Reviewing and recommending to the
university Wexner medical center board changes to the medical staff bylaws and
medical staff rules and regulations;
(6) Reviewing and approving clinical
privilege forms;
(7) Reviewing and
approving membership and granting appropriate clinical privileges for the
credentialing of practitioners recommended for membership and clinical
privileges by the university hospitals medical staff administrative committee
and the James medical staff administrative committee;
(8) Reviewing and approving membership and
granting appropriate clinical privileges for the expedited credentialing of
such practitioners that are eligible by satisfying minimum approved criteria as
determined by the university Wexner medical center board and are recommended
for membership and clinical privileges by the university hospitals medical
staff administrative committee and the James medical staff administrative
committee;
(9) Reviewing and
approving reinstatement of clinical privileges for a practitioner after a leave
of absence from clinical practice;
(10) Conducting peer review activities and
recommending professional review actions to the university Wexner medical
center board;
(11) Reviewing and
resolving any petitions by the medical staffs for amendments to any rule,
regulation or policy presented by the chief of staff on behalf of the medical
staff pursuant to the medical staff bylaws and communicating such resolutions
to the university hospitals medical staff administrative committee and the
James medical staff administrative committee for further dissemination to the
medical staffs; and
(12) Such other
responsibilities as assigned by the chair of the university Wexner medical
center board.
(B)
Composition. The committee shall consist of: no fewer than four voting members
of the university Wexner medical center board, appointed annually by the chair
of the university Wexner medical center board, one of whom shall be appointed
as chair of the committee. The executive vice president and
chancellor for health affairs
chief executive officer; the chief executive officer
of the Ohio state university health system; the
chief clinical officer of the medical center; the chief administrative officer
of the Ohio state university health system, the director of medical affairs of
the James; the medical director of credentialing for the James; the chief of
the medical staff of the university hospitals; the chief of the medical staff
of the James; the associate dean of graduate medical education; the chief
quality and patient safety officer; the chief nurse
executive
nursing officer for
the Ohio state university
health system
hospital; and the chief nursing officer for the James
shall serve as ex-officio, voting members. Such other members as appointed by
the chair of the university Wexner medical center board, in consultation with
the chair of the quality and professional affairs committee.
(C) Review and recommendation. The chief
clinical officer of the medical center and the chief of staff for the medical
staff of university hospitals shall present and make recommendations to the
quality and professional affairs committee only with respect to those actions
involving the university hospitals. The director of medical affairs of the
James, the medical director of credentialing for the James and chief of staff
for the medical staff of the James shall present and make recommendations to
the quality and professional affairs committee only with respect to those
actions involving the James.
(D)
Voting. With respect to items coming before the quality and professional
affairs committee as detailed in paragraph (A) of this rule, at least two
voting, non-public members of the university Wexner medical center board must
be present. Any action taken by this committee pursuant to the responsibilities
as defined in paragraphs (A)(1) to (A)(11) of rule
3335-97-03 of the Administrative
Code shall be taken only by the voting, non-public, committee members and
approved by a majority vote thereof. The chief quality and patient safety
officer shall recuse themselves from voting on matters defined in paragraphs
(A)(7) and (A)(10) of rule
3335-97-03 of the Administrative
Code.
(E) Meetings. The committee
shall meet at least quarterly (four times per calendar year) or at the call of
the chair of the committee and shall advise the university Wexner medical
center board of its activities regularly. The committee shall act on behalf of
the university Wexner medical center board in order to maintain the continuity
of operations of the hospitals of the Ohio state university and the university
hospitals and the James medical staffs; to review and to approve medical staff
membership and to grant appropriate clinical privileges for practitioners in
accordance with applicable laws, accreditation requirements, bylaws and rules
established by the university board of trustees, university Wexner medical
center board and university hospitals and the James medical staffs. Meetings
shall be conducted in accordance with the state laws of Ohio and open meetings
laws.
Notes
Promulgated Under: 111.15
Statutory Authority: 3335
Rule Amplifies: 3335.08
Prior Effective Dates: 10/04/2013, 12/03/2013, 05/16/2014, 04/28/2016, 11/11/2020
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