Ohio Admin. Code 3335-111-04 - Membership
(A)
Qualifications.
(7)(8) Resignation,
termination or non-reappointment to the faculty of the Ohio state university
shall result in immediate termination of membership on the medical staff of the
CHRI for attending, associate attending and clinical attending staff
members.
(8)(9) Any staff member
whose membership has been terminated pursuant to paragraph (A)(4),
or (A)(5)
or (A)(7) of this rule shall not be
entitled to request a hearing and appeal in accordance with rule
3335-111-06 of the
Administrative Code. Any allied health professional whose clinical privileges
have been terminated pursuant to paragraph (A)(4) of this rule may not request
an appeal in accordance with paragraph (J)(8)(i) of rule
3335-111-07 of the
Administrative Code.
(9)(10) No applicant shall
be entitled to medical staff membership and or clinical privileges merely by
the virtue of fulfilling the above qualifications or holding a previous
appointment to the medical staff.
(1) Membership on the medical
staff of the CHRI is a privilege extended to doctors of medicine, osteopathic
medicine, dentistry, and to practitioners of psychology and podiatry who
consistently meet the qualifications, standards, and requirements set forth in
the bylaws, rules and regulations of the medical staff, and the board of
trustees of the Ohio state university. Membership on the medical staff is
available on an equal opportunity basis without regard to race, color, creed,
religion, sexual orientation, national origin, gender, age, handicap, genetic
information or veteran/military status. Doctors of medicine, osteopathic
medicine, dentistry, and practitioners of psychology and podiatry in faculty
and administrative positions who desire medical staff membership shall be
subject to the same policies and procedures as all other applicants for the
medical staff.
(2) All members of
the medical staff of the CHRI, except physician scholar medical staff, shall be
members of the faculty of the Ohio state university college of medicine, or in
the case of dentists, of the Ohio state university college of dentistry, and
shall be duly licensed or certified to practice in the state of Ohio. Members
of the limited staff shall possess a valid training certificate, or an
unrestricted license from the applicable state board based on the eligibility
criteria defined by that board. All members of the medical staff and limited
staff and licensed health care professionals with clinical priviledges shall
comply with provisions of state law and the regulations of the respective state
medical board or other state licensing board if applicable. Only those
physicians, dentists, and practitioners of psychology and podiatry who can
document their education, training, experience, competence, adherence to the
ethics of their profession, dedication to educational and research goals and
ability to work with others with sufficient adequacy to assure the Wexner
medical center board and the board of trustees of the Ohio state university
that any patient treated by them at the CHRI will be given high quality medical
care provided at CHRI, shall be qualified for eligibility for membership on the
medical staff of the CHRI. CHRI medical staff members shall also hold
appointments to the medical staff of the Ohio state university hospitals for
consulting purposes. Loss of such appointment shall result in immediate
termination of membership on the CHRI medical staff and immediate termination
of clinical privileges as of the effective date of the Ohio state university
hospitals appointment termination. This consequence does not apply to an
individual's suspension for completion of medical records. If the medical staff
member regains an appointment to the Ohio state university hospitals medical
staff, the affected medical staff member shall be eligible to apply for CHRI
medical staff membership at that time. All applicants for membership, clinical
privileges, and members of the medical staff must provide basic health
information to fully demonstrate that the applicant or member has, and
maintains, the ability to perform requested clinical privileges. The director
of medical affairs of the CHRI, the medical director of credentialing, the
department chairperson, the credentialing committee, the medical staff
administrative committee, the quality and professional affairs committee of the
Ohio state university Wexner medical center board, or the Ohio state university
Wexner medical center board may initiate and request a physical or mental
health evaluation of an applicant or member. Such request shall be in writing
to the applicant.
(3) All members
of the medical staff and licensed health care professionals will comply with
medical staff and the CHRI policies regarding employee and medical staff health
and safety, provision of uncompensated care, and will comply with appropriate
administrative directives and policies which, if not followed, could adversely
impact overall patient care or may adversely impact the ability of the CHRI
employees or staff to effectively and efficiently fulfill their
responsibilities. All members of the medical staff and licensed health care
professionals shall agree to comply with bylaws, rules and regulations, and
policies and procedures adopted by the medical staff administrative committee
and the Wexner medical center board, including but not limited to policies on
professionalism, behaviors that undermine a culture of safety, annual
. Annual
education and training (list approved by the medical
staff administrative committee and maintained in the chief medical officer's
office), conflict of interest, HIPAA compliance and access and communication
guidelines
approved by the medical staff
administrative committee or as required by the CHRI to meet accreditation
standards, fedural regulations, or quality and safety goals is required for
medical staff members with clinical privileges in addition to conflict of
interest disclosure . Medical staff members and licensed health care
professionals with clinical priviledges
must also comply with the university integrity program requirements including
but not limited to billing, self referral, ethical conduct and annual
education. Medical staff members and licensed health care professionals with
clinical privileges must immediately disclose to the chief medical officer and
the department chairperson the occurrence of any of the following events: a
licensure action in any state, any malpractice claims filed in any state or an
arrest by law enforcement.
(4) All
members of the medical staff and credentialed providers must maintain
continuous uninterrupted enrollment with all governmental healthcare programs.
This includes any federal and state government programs.
(a) It shall be the duty of all medical staff
members and credentialed providers to promptly inform the chief medical officer
and the corporate credentialing office of any investigation, action taken, or
the initiation of any process which could lead to an action taken by any
governmental program.
(b) Exclusion
of any medical staff member or credentialed provider from participation in any
federal or state government program or suspension from participation, in whole
or in part, in any federal or state government reimbursement program, shall
result in immediate lapse of membership on the medical staff of the CHRI and
the immediate lapse of clinical privileges at the CHRI as of the effective date
of the exclusion or suspension. Medical staff members may submit a request to
resign their medical staff membership to the chief medical officer in lieu of
automatic termination. The resignation in lieu of automatic termination shall
be discussed at the next credentialing committee and medical staff
administrative committee in order to provide recommendations to the quality and
professional affairs committee of the Wexner medical center board. A final
determination should be decided by the quality and professional affairs
committee at its next regular meeting.
(c) If the medical staff member's or
credentialed provider's participation in all governmental programs is fully
reinstated, the affected medical staff member or credentialed provider shall be
eligible to apply for membership and clinical privileges at that
time.
(5) Board
certification.
An applicant for membership shall at the time of appointment or
reappointment, be board certified in his or her specialty. This board
certification must be approved by the American board of medical specialties, or
other applicable certifying boards for doctors of osteopathy, podiatry,
psychology, and dentistry. All applicants must be certified within the specific
areas for which they have requested clinical privileges. Applicants who are not
board certified at the time of application but who have completed their
residency or fellowship training within the last five years will be eligible
for medical staff appointment. However, in order to remain eligible, those
applicants must achieve board certification in their primary area of practice
within five years from the date of completion of their residency or fellowship
training. Applicants must maintain board certification and, to the extent
required by the applicable specialty/subspecialty board, satisfy
recertification requirement. Recertification will be assessed at reappointment.
Failure to meet or maintain board certification shall result in termination of
membership on the medical staff of the CHRI. Waiver
of these eligibility criteria is as follows:
(a) A request for a waiver will only
be considered if the applicant provides information sufficient to satisfy his
or her burden to demonstrate that his or her qualifications are equivalent to
or exceed the criterion in question and that there are exceptional
circumstances that warrant a waiver. The clinical department chief must endorse
the request for waiver in writing to the credentialing
committee.
(b) The credentialing committee may
consider supporting documentation submitted by the prospective applicant, any
relevant information from third parties, input from the relevant clinical
department chiefs, and the best interests of the hospital and the communities
it serves. The credentialing committee will forward its recommendation,
including the basis for such, to the medical staff administrative
committee.
(c) The medical staff
administrative committee will review the recommendation
of the credentialing committee and make a
recommendation to the Wexner medical center board regarding whether to grant or
deny the request for a waiver and the basis for its
recommendation.
(d) The Wexner medical center board
determination regarding whether to grant a waiver is final. A determination not
to grant a waiver is not a denial of appointment or clinical privileges and
does not give rise to a right to a hearing. The prospective applicant who
requested the waiver is not entitled to a hearing. A determination to grant a
waiver in a particular case is not intended to set a precedent for any other
applicant. A determination to grant a waiver does not mean that an appointment
will be granted. Waivers of threshold eligibility criteria will not be granted
routinely. No applicant is entitled to a waiver or to a hearing if a waiver is
not granted.
(6)
All applicants must demonstrate recent clinical activity in their primary area
of practice during the last two years to satisfy minimum threshold criteria for
privileges within their clinical departments.
(7)
Waiver requests
for the threshold eligibility requirements listed in paragraphs (A)(4) to
(A)(6) of this rule may be requested and considered as follows:
(a)
A request for a
waiver will only be considered if the applicant provides information sufficient
to satisfy his or her burden to demonstrate that his or her qualifications are
equivalent to or exceed the criterion in question and that there are
exceptional circumstances that warrant a waiver. The clinical department chief
must endorse the request for waiver in writing to the credentialing
committee.
(b)
The credentialing committee may consider supporting
documentation submitted by the prospective applicant, any relevant information
from third parties, input from the relevant clinical department chiefs, and the
best interests of the hospital and the communities it serves. The credentialing
committee will forward its recommendation, including the basis for such, to the
medical staff administrative committee.
(c)
The medical staff
administrative committee will review the recommendation of the credentialing
committee and make a recommendation to the Wexner medical center board
regarding whether to grant or deny the request for a waiver and the basis for
its recommendation.
(d)
The Wexner medical center board determination regarding
whether to grant a waiver is final. A determination not to grant a waiver is
not a denial of appointment or clinical privileges and does not give rise to a
right to a hearing. The prospective applicant who requested the waiver is not
entitled to a hearing. A determination to grant a waiver in a particular case
is not intended to set a precedent for any other applicant. A determination to
grant a waiver does not mean that an appointment will be
granted.
(e)
Waivers of threshold eligibility criteria will not be
granted routinely. No applicant is entitled to a waiver or to a hearing if a
waiver is not granted.
(f)
Waivers to requirements prescribed by regulatory,
accrediting, or other external agencies will not be granted.
(B) Application for membership.
Initial application for all categories of medical staff membership shall be made by the applicant to the clinical department chief or designee on forms prescribed by the medical staff administrative committee, stating the qualifications and references of the applicant and giving an account of the applicant's current licensure, relevant professional training and experience, current competence and ability to perform the clinical privileges requested. All applications for appointment must specify the clinical privileges requested. Applications may be made only if the qualifications are fulfilled as outlined in paragraph (A) of this rule. See paragraph (E)(1) of rule 3335-111-07 of the Administrative Code for exceptions to signature requirements. The application shall include written statements by the applicant that commit the applicant to abide by the bylaws, rules and regulations and policies and procedures of the medical staff, the Wexner medical center board, and the board of trustees of the Ohio state university. The applicant shall produce a government issued photo identification to verify his/her identity pursuant to hospital/medical staff policy. The applicant for medical staff membership shall agree that membership requires participation in and cooperation with the peer review processes of evaluating credentials, medical staff membership and clinical privileges, and that a condition for membership requires mutual covenants between all members of the medical staff to release one another from civil liability in these review processes as long as the peer review is not conducted in bad faith, with malice, or without reasonable effort to ascertain the accuracy of information being disclosed or relied upon. A separate record shall be maintained for each applicant requesting appointment to the medical staff.
(C) Terms of
appointment.
Initial appointment to the medical staff, except for the
honorary category, shall be for a period not to exceed
twenty-four
The provisional appointee identifies the primary hospital. Following the six month FPPE period, the clinical department chief may:
(1) recommend the initial appointee to
transition to ongoing professional practice evaluation (OPPE), which is
described later in university bylaws to the medical staff administrative
committee;
(2) extend the FPPE
period, which is not considered an adverse action, for an additional six months
not to exceed a total of twelve months for purposes of further monitoring and
evaluation; or
(3) terminate the
initial appointee's medical staff membership and clinical privileges. In the
event that the medical staff administrative committee recommends that an
adverse action be taken against an initial appointee, the initial appointee
shall be entitled to the provisions of due process as outlined in university
bylaws.
(D) Professional
ethics.
The code of ethics as adopted, or as may be amended, by the American medical association, the American dental association, the American osteopathic association, the American psychological association, the American college of surgeons, or the American podiatric medical association shall usually govern the professional ethical conduct of the respective members of the medical staff.
(E)
Procedure for appointment.
(1) The completed
and signed application for membership of all categories of the medical staff as
defined in rule
3335-111-07 of the
Administrative Code, shall be presented to the clinical department chief or
designee. The applicant shall include in the application a signed statement
indicating the following:
(a) If the applicant
should be appointed to a category of the CHRI medical staff, the applicant
agrees to be governed by the bylaws, rules and regulations of the medical
staff, the Wexner medical center board, and the board of the trustees of the
Ohio state university.
(b) The
applicant consents to be interviewed in regard to the application.
(c) The applicant authorizes the CHRI to
consult with members of the medical staffs of other hospitals with which the
applicant has been or has attempted to be associated, and with others who may
have information bearing on the applicant's competence, character and ethical
qualifications.
(d) The applicant
consents to the CHRI's inspection of all records and documents that may be
material to the evaluation of the applicant's professional qualifications and
competence to carry out the clinical and educational privileges which the
applicant is seeking as well as the applicant's professional and ethical
qualifications for medical staff membership.
(e) The applicant releases from any
liability:
(i) All representatives of the CHRI
for acts performed in connections with evaluating the applicant's credentials
or releasing information to other institutions for the purpose of evaluating
the applicant's credentials in compliance with university bylaws performed in
good faith and without malice; and
(ii) All third parties who provide
information, including otherwise privileged and confidential information, to
members of the medical staff, the CHRI staff, the Wexner medical center board
members, and members of the Ohio state university board of trustees concerning
the applicant's credentials performed in good faith and without
malice.
(f) The
applicant has an affirmative duty to disclose any prior termination, voluntary
or involuntary, current loss, restriction, denial, or the voluntary or
involuntary relinquishment of any of the following: professional licensure,
board certification, DEA registration, membership in any professional
organization or medical staff membership or privileges at any other hospital or
health care facility.
(g) The
applicant further agrees to disclose to the director of medical affairs or the
medical director of credentialing the initiation of any process which could
lead to such loss or restriction of the applicant's professional licensure,
board certification, DEA registration, membership in any professional
organization or medical staff membership or privileges at any other hospital or
health care facility.
(h) The
applicant agrees that acceptance of an appointment to any category of the CHRI
medical staff authorizes the CHRI to conduct any appropriate health assessment
including, but not limited to, drug or alcohol screens on a practitioner before
granting of privileges and at any time during the normal pursuit of medical
staff duties, based upon reasonable cause as determined by the chief of the
practitioner's clinical department or the director of medical affairs of the
CHRI or their authorized designees.
(2) The purpose of the health assessment
shall be to ensure that the applicant or appointee to the CHRI medical staff is
able to fully perform and discharge the clinical, educational, administrative
and research responsibilities which the applicant or appointee would or is
permitted to exercise by reason of medical staff appointment. If, at the time
of the initial request for a health assessment, and at any time an appointee
refuses to participate as needed in a health assessment, including, but not
limited to, a drug or alcohol screening, this shall result in automatic lapse
of membership, privileges, and prerogatives until remedied by compliance with
the requested health assessment. Upon request of the medical staff
administrative committee or the Wexner medical center board, the applicant or
appointee will provide documentation of their physical/mental status with
sufficient adequacy to demonstrate that any patient treated by the applicant or
appointee will receive efficient and quality care at a professionally
recognized level of quality and efficiency. The conditions of this paragraph
shall be deemed continuing and may be applicable to issues of continued good
standing as an appointee to the medical staff.
(3) An application for membership on the
medical staff shall be considered complete when all the information requested
on the application form is provided, the applicant signs the application and
the information is verified. A completed application must contain:
(j)(f) Information from
the national practitioner data bank and other JCAHO approved sources;
(k)(g)
Verification that the applicant has not been excluded from any federally funded
health care program; and
(l)(h) Complete disclosure
by the applicant of all past and current claims, suits, verdicts, and
settlements, if any.
(m)(i) Completion of
a criminal history
check by the Ohio state university medical center security
department
background investigation that meets
the requirements of the Wexner medical center .
(n)(j) Completion of the
Ohio state university medical center drug testing.
(o)(k) Verification of
completion of annual educational requirements
approved by the medical staff administrative committee and maintained in the
chief medical officer's office
specific
competencies required for clinical privileges, as approved by the medical staff
administrative committee and maintained in the provider's credentials files.
All other required annual online learning must be completed within sixty days
of employment .
(p)(l) Demonstration of
recent active clinical practice during the last two years required for exercise
of clinical privileges.
(q)(m) Attestation of
current Ohio automated Rx reporting system ("OARRS") account for all applicants
who have a DEA registration.
(a) Peer recommendations from at least three
individuals with first hand knowledge about the applicant's clinical and
professional skills within the last year;
(b) Evidence of required
immunizations;
(c) Evidence of
current professional medical malpractice liability coverage required for the
exercise of clinical privileges;
(d) Satisfaction of ECFMG requirements, if
applicable;. If an individual receives a conceded eminence certificate or a
clinical research faculty certificate from the state medical board of Ohio, the
requirement for ECFMG certification may be waived at the discretion of the
Wexner medical center board.
(e)
Verification by primary source documentation of:
(f)(iii) DEA
registrations, when required for the exercise of requested clinical
privileges;
(g)(iv) Graduation from an
accredited professional school, when applicable;
(h)(v) Successful
completion or record of post professional graduate medical education;
(i)(vi)
Board certification or, active candidacy for board certification or applicant
qualifies for a waiver pursuant to paragraph (A)(5) of this rule.
(i) Current and previous state licensure,
and
(ii) Faculty appointment, when
applicable.
(4) The clinical department chief shall be
responsible for investigating and verifying the character, qualifications and
professional standing of the applicants by making inquiry of the primary source
of such information and shall within thirty days of receipt of the completed
application, submit a report of those findings along with a recommendation on
medical staff membership and clinical privileges to the applicant's respective
CHRI department chairperson and/or division director. Licensed allied health
professional applicants will have their clinical department chief's report
submitted to the subcommittee of the credentials committee charged with review
of applications for associates to the medical staff.
(5) The department chairperson and/or
division director shall receive all initial signed and verified applications
from the appropriate clinical department chief and shall make a recommendation
to the medical director of credentialing on each application. The medical
director of credentialing shall make an initial determination as to whether the
application is complete. The credentials committee, the medical staff
administrative committee, the quality and professional affairs committee, and
the Wexner medical center board have the right to render an application
incomplete, and therefore not able to be processed, if the need arises for
additional or clarifying information. The medical director of credentialing
shall forward all completed applications to the credentials
committee.
(6) The applicants shall
have the burden of producing information for an adequate evaluation of his/her
qualifications for membership and for the clinical privileges requested. If the
applicant fails to complete the prescribed forms or fails to provide the
information requested within sixty days of receipt of the signed application,
processing of the application shall cease and the application shall be deemed
to have been voluntarily withdrawn, action which is not subject to hearing or
appeal pursuant to rule
3335-111-06 of the
Administrative Code.
(7) If the
clinical department chief does not submit a report and recommendation on a
timely basis, the completed application shall be forwarded to the medical
director of credentialing for presentation to the credentials committee on the
same basis as other applicants.
(8)
Completed applications shall be acted upon as follows:
(a) By the credentials committee within
thirty days after receipt of a completed application from the medical director
of credentialing;
(b) By the
medical staff administrative committee within thirty days after receipt of a
completed application and the report of the recommendation of the credentials
committee;
(c) By the quality and
professional affairs committee of the Wexner medical center board;
(d) By the Wexner medical center board within
one hundred twenty days after receipt of a completed application and the report
and recommendation of the medical staff administrative committee; and
(e) By the Wexner medical center board, or a
subcommittee of the Wexner medical center board if eligible for expedited
credentialing, within one hundred twenty days after receipt of a completed
application and the report and recommendation of the medical staff
administrative committee.
(9) These time periods are deemed guidelines
only and do not periods. These periods may be stayed or altered pending receipt
and verification of further information requested from the applicant, or if the
application is deemed incomplete at any time. If the procedural rights create
any right to have an application processed within these precise specified in
rule 3335-111-06 of the
Administrative Code are activated, the time requirements provided therein
govern the continued processing of the application.
(10) The credentials committee shall review
the application, evaluate and verify the supporting documentation, references,
licensure, the clinical department chief's report and recommendation, and other
relevant information. The credentials committee shall examine the character,
professional competence, professional conduct, qualifications, and ethical
standing of the applicant and shall determine, through information contained in
the personal references and from other sources available, whether the applicant
established and met all of the necessary qualifications for the category of the
medical staff and clinical privileges requested.
(11) The credentials committee shall, within
thirty days from receipt of a completed application, make a recommendation to
the medical director of credentialing that the application be accepted,
rejected or modified. The medical director of credentialing shall forward the
recommendation of the credentials committee to the medical staff administrative
committee. The credentials committee or the medical director of credentialing
may recommend to the medical staff administrative committee that certain
applications for appointment be reviewed in executive session.
(12) The recommendation of the medical staff
administrative committee regarding an appointment decision shall be made within
thirty days of receipt of the credentials committee recommendation and shall be
communicated by the medical director of credentialing, along with the
recommendation of the director of medical affairs, to the quality and
professional affairs committee of the Wexner medical center board, and
thereafter to the Wexner medical center board. When the Wexner medical center
board has acted, the chair of the Wexner medical center board shall instruct
the director of medical affairs to transmit the final decision to the clinical
department chief, the applicant, and the respective department chairperson
and/or division director.
(13) At
any time, the medical staff administrative committee first recommends
non-appointment of an initial applicant for any category of the medical staff
or recommends denial of any clinical privileges requested by the applicant, the
medical staff administrative committee shall require the medical director of
credentialing to notify the applicant by certified return receipt mail that
applicant may request an evidentiary hearing as provided in paragraph (D) of
rule 3335-111-06 of the
Administrative Code. The applicant shall be notified of the requirement to
request a hearing as provided by paragraph (B) of rule
3335-111-06 of the
Administrative Code. If a hearing is properly requested, the applicant shall be
subject to the rights and responsibilities of rule
3335-111-06 of the
Administrative Code. If an applicant fails to properly request a hearing, the
medical staff administrative committee shall accept, reject, or modify the
application for appointment to membership and clinical privileges.
(14) The director of medical affairs, who may
make a separate recommendation to the Wexner medical center board, shall
directly communicate the final recommendation of the medical staff
administrative committee to the Wexner medical center board. When the Wexner
medical center board has acted, the director of medical affairs will transmit
the final decision to the clinical department chief, the applicant, the
respective department chairperson and/or division director, and the Ohio state
university board of trustees.
(F) Procedure for reappointment.
(1) Reappointment for all categories of the
medical staff shall be for a period not to exceed twenty-four
thirty-six
months. An appointment or grant of privileges for a period of less than
twenty-four
thirty
six months shall not be deemed an adverse action. At least ninety days
prior to the end of the medical staff member' or licensed allied health
professional's appointment period, the clinical department chief shall provide
each individual with an application for reappointment to the medical staff on
forms prescribed by the medical staff administrative committee.
(2) The reappointment application shall
include all information necessary to update and evaluate the qualification of
the applicant. The clinical department chief shall review the information
available on each applicant for reappointment and shall make recommendations
regarding reappointment to the medical staff and for granting of privileges for
the ensuing appointment period. The clinical department chief's recommendation
shall be transmitted in writing along with the signed and completed
reappointment forms to the appropriate department chairperson and/or division
director at least forty-five days prior to the end of the individual's
appointment. The terms of paragraphs (A), (B), (C), (D), (E)(1), and (E)(2) of
this rule shall apply to all applicants for reappointment. Only completed
applications for reappointment shall be considered by the credentials
committee.
(3) An application for
reappointment is complete when all the information requested on the
reappointment application is provided, the reappointment form is signed by the
applicant, and the information is verified, and no need for additional or
clarifying information is identified. A completed reappointment application
must contain:
(a) Evidence of current
professional medical malpractice liability insurance required for the exercise
of clinical privileges;
(b)
Verification by primary source documentation of state licensure;
(c) DEA registration when required for
clinical privileges as requested;
(d) Successful completion or record of any
additional post graduate medical or professional education not submitted since
initial or last appointment;
(e)
Board certification, recertification, or continued active candidacy for
certification or applicant qualifies for a waiver pursuant to paragraph (A)(5)
of this rule.
(f) Information from
the national practitioner data bank;
(g) Verification that the applicant has not
been excluded from any federally funded health care program;
(h) Specific requests for any changes in
clinical privileges sought at reappointment with supporting documentation as
required by credentialing guidelines;
(i) Specific requests for any changes in
medical staff category;
(j) A
summary of the member's clinical activity during the previous appointment
period;
(k) Verification of
completion of any annual education requirements approved by the medical staff
administrative committee and maintained in the chief medical officer's
office;
(l) Complete disclosure by
individuals of claims, suits, verdicts and settlements, if any since last
appointment; and
(m) Continuing
medical education and applicable continuing professional education activities:
documentation of category one CME that, at least in part, relates to the
individual medical staff member's specialty or subspecialty area and is
consistent with the licensing requirements of the applicable Ohio state
licensing board shall be required.
(n) Attending physicians only: submit
information summarizing clinical research activities with each
application.
(o) Attestation of
current OARRS account for all applicants who have a DEA registration.
(4) The applicant for
reappointment shall be required to submit any reasonable evidence of current
ability to perform the clinical privileges requested. The clinical department
chief shall review and evaluate the reappointment application and the
supporting documentation. The clinical department chief shall evaluate all
matters relevant to recommendation, including: the applicant's professional
competence; clinical judgment; clinical or technical skills; ethical conduct;
participation in medical staff affairs, if applicable; compliance with the
bylaws, rules and regulations of the medical staff, the Wexner medical center
board, and the board of trustees of the Ohio state university; cooperation with
the CHRI hospitals personnel and the use of the CHRI hospital's facilities for
patients; relations with other physicians other health professionals or other
staff; maintenance of a professional attitude toward patients; and the
responsibility to the CHRI and the public.
(5) The clinical department chief shall
submit a report of those findings along with a recommendation on reappointment
to the applicant's respective CHRI department chairperson and/or division
director. Licensed allied health professional applicants will have their
clinical department chief's report submitted to the subcommittee of the
credentials committee charged with review of application for associates to the
medical staff. The department chairperson and/or division director shall review
the reappointment application and forward to the medical director of
credentialing with a recommendation for reappointment. The medical director of
credentialing shall forward the reappointment forms and the recommendations of
the clinical department chief and department chairperson and/or division
director to the credentials committee. The credentials committee shall review
the request for reappointment in the same manner, and with the same authority,
as an original application for medical staff membership. The credentials
committee shall review all aspects of the reappointment application including
source verification of the member's quality assurance record for continuing
membership qualifications and for continuing clinical privileges.
The credentials committee shall review each member's performance-based profile to ensure that all medical staff members deliver the same level of quality of care with similar delineated clinical privileges across all clinical departments and across all categories of medical staff membership.
(6) The
credentials committee shall forward its recommendations to the medical director
of credentialing at least thirty days prior to the end of the period of
appointment for the individual. The medical director of credentialing shall
transmit the completed reappointment application and recommendation of the
credentials committee to the medical staff administrative committee.
(7) Failure of the member to submit a
reappointment application shall be deemed a voluntary resignation from the
medical staff and shall result in automatic termination of membership and all
clinical privileges at the end of the medical staff member's current
appointment period, action which shall not be subject to a hearing or appeal
pursuant to rule
3335-111-06 of the
Administrative Code. A request for reappointment subsequently received from a
member who has been automatically terminated shall be processed as a new
appointment.
(8) Failure of the
clinical department chief to act in a timely manner on an application for
reappointment shall be the same as provided in paragraph (E)(7) of this
rule.
(9) The medical staff
administrative committee shall review each request for reappointment in the
same manner and with the same authority as an original application for
appointment to the medical staff and shall accept, reject, or modify the
request for reappointment in the same manner and with the same authority as an
original application. The recommendation of the medical staff administrative
committee regarding reappointment shall be communicated by the medical director
of credentialing, along with the recommendation of the director of medical
affairs, to the quality and professional affairs committee of the Wexner
medical center board, and thereafter to the Wexner medical center board. When
the Wexner medical center board has acted, the chair of the Wexner medical
center board shall instruct the director of medical affairs to transmit the
final decision to the clinical department chief, the applicant, and the
department chairperson and/or division director.
(10) When the decision of the medical staff
administrative committee results in a decision of non-reappointment or
reduction, suspension, or revocation of clinical privileges, the medical staff
administrative committee shall instruct the medical director of credentialing
to give written notice to the affected member of the decision, the stated
reason for the decision, and the member's right to a hearing pursuant to rule
3335-111-06 of the
Administrative Code. This notification and an opportunity to exhaust the appeal
process shall occur prior to an adverse decision unless the provisions outlined
in paragraph (C) of rule 3335-111-06 of the Administrative Code apply. The
notice by the medical director of credentialing shall be sent certified return
receipt mail to the affected member's last known address as determined by the
Ohio state university records.
(11)
If the affected member of the medical staff does not make a written request for
a hearing to the director of medical affairs within thirty-one days after
receipt of the adverse decision, it shall be deemed a waiver of the right to
any hearing or appeal as provided in rule
3335-111-06 of the
Administrative Code to which the staff member might otherwise have been
entitled on the matter. If a timely, written request for hearing is made, the
procedures set forth in rule
3335-111-06 of the
Administrative Code shall apply.
(G) Resumption of clinical activities
following a leave of absence:
(1) A member of
the medical staff or credentialed provider shall request a leave of absence in
writing for good cause shown such as medical reasons, educational and research
reasons or military service to the chief of clinical service and the director
of medical affairs. Such leave of absence shall be granted at the discretion of
the chief of the clinical service and the director of medical affairs provided,
however, such leave shall not extend beyond the term of the member's or
credentialed provider's current appointment. A member of the medical staff or
credentialed provider's who is experiencing health problems that may impair his
or her ability to care for patients has the duty to disclose such impairment to
his or her chief of clinical department and the director of medical affairs and
the member or credentialed provider's shall be placed on immediate medical
leave of absence until such time the member or credentialed provider's can
demonstrate to the satisfaction of the director of medical affairs that the
impairment has been sufficiently resolved and can request for reinstatement of
clinical activities. During any leave of absence, the member or credentialed
provider's shall not exercise his or her clinical privileges, and medical staff
responsibilities and prerogatives shall be inactive.
(2) The member or credentialed provider's
must submit a written request for the reinstatement of clinical privileges to
the chief of the clinical service. The chief of the clinical service shall
forward his recommendation to the credentialing committee which, after review
and consideration of all relevant information, shall forward its recommendation
to the medical staff administrative committee and the quality and professional
affairs committee of the Wexner medical center board. The credentials
committee, the director of medical affairs, the medical director of
credentialing, the chief of the clinical service or the medical staff
administrative committee shall have the authority to require any documentation,
including advice and consultation from the member's or credentialed provider's
treating physician or the committee for practitioner health that might have a
bearing on the medical staff member's or credentialed provider's ability to
carry out the clinical and educational responsibilities for which the medical
staff is seeking privileges. Upon return from a leave of absence for medical
reasons the medical staff member or credentialed provider's must demonstrate
his or her ability to exercise his or her clinical privileges upon return to
clinical activity.
(3) All members
or credentialed provider's of the medical staff who take a leave of absence for
medical or non-medical reasons must be in good standing on the medical staff
upon resumption of clinical activities. No member shall be granted leave of
absence in excess of his or her current appointment and the usual procedure for
appointment and reappointment, including deadlines for submission of
application as set forth in this rule will apply irrespective of the nature of
the leave. Absence extending beyond his or her current term of failure to
request reinstatement of clinical privileges shall be deemed a voluntary
resignation from the medical staff and of clinical privileges, and in such
event, the member or credentialed provider shall not be entitled to a hearing
or appeal.
Notes
Promulgated Under: 111.15
Statutory Authority: 3335.
Rule Amplifies: 3335.08
Prior Effective Dates: 10/18/1993, 05/26/1995, 05/30/1996, 03/20/1998, 02/18/2000, 09/28/2000, 01/07/2001, 08/19/2002, 10/04/2002, 10/17/2002, 03/08/2004, 11/28/2005, 08/06/2007, 03/06/2009, 11/24/2009, 08/06/2010, 03/15/2011, 08/03/2011, 09/20/2012, 07/31/2013, 06/30/2014, 04/27/2015, 06/23/2016, 09/18/2016, 11/12/2020
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