The medical staff of the CHRI shall be divided into honorary,
physician scholar, attending, associate attending, clinical attending,
consulting medical staff and limited designations. All medical staff members
with admitting privileges may admit patients in accordance with state law and
criteria for standards of care established by the medical 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 as outlined
in the list maintained in the chief medical officer's office, but are
otherwise subject to the provisions of university bylaws.
(C) Attending medical staff.
(1) Qualifications:
The attending staff shall consist of those regular faculty
members of the colleges of medicine and dentistry who are licensed or certified
in the state of Ohio, whose practice is at least seventy-five per cent oncology
and with a proven career commitment to oncology as demonstrated by the majority
of the following:
Training, current board certification (as specified in
paragraph (A)(5) of rule
3335-111-04 of the
Administrative Code), publications, grant funding, other funding and experience
(as deemed appropriate by the chief executive officer and the department
chairperson and/or division director); and who satisfy the requirements and
qualifications for membership set forth in rule
3335-111-04 of the
Administrative Code.
(2)
Prerogatives:
Attending staff members may:
(a) Admit patients consistent with the
balanced teaching and patient care responsibilities of the CHRI. When, in the
judgment of the director of medical affairs, a balanced teaching program is
jeopardized, following consultation with the chief executive officer, the
clinical department chief and with the concurrence of a majority of the medical
staff administrative committee, the director of medical affairs may restrict
admissions. Imposition of such restrictions shall not entitle the attending
staff member to a hearing or appeal pursuant to rule
3335-111-06 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 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, clinical departments and
committees of which they are 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:
An attending staff member shall:
(a) Meet the basic responsibilities set forth
in rules
3335-111-02 and
3335-111-03 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 CHRI for whom he or she
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 staff functions as may be required from
time to time.
(d) Satisfy the
requirements set forth in rule
3335-111-13 of the
Administrative Code for attendance at medical staff meetings and meetings of
those committees of which they are a member.
(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 that the limited staff member is
competent to perform under supervision.
(f) Supervise other licensed allied health
professionals as necessary in accordance with accreditation standards and state
law. It is the responsibility of the attending physician to authorize each
licensed allied health professional to perform only those services which the
licensed allied health professional is privileged to perform.
(g) Take call as assigned by the clinical
department chief.
(E) Clinical attending staff.
(1) Qualifications:
The clinical attending staff shall consist of those clinical
faculty members of the colleges of medicine and dentistry who have training,
expertise, and experience in oncology, as determined by the chief executive
officer in consultation with the department chairperson and/or division
director and who satisfy the requirements and qualifications for membership set
forth in rule
3335-111-04 of the
Administrative Code.
(2)
Prerogatives:
The clinical attending staff may:
(a) Admit patients which complement the
research and clinical teaching program. At times when hospital beds or other
resources are in short supply, patient admissions of clinical staff shall be
subordinate to those of attending or associate attending staff.
(b) Be free to exercise such clinical
privileges as are granted pursuant to university bylaws.
(c) Attend meetings as non-voting members of
the medical staff and any medical staff or hospital education programs. The
clinical attending staff may not hold elected office in the medical staff
organization.
(3)
Responsibilities:
(a) Meet the basic
responsibilities set forth in rules
3335-111-02 and
3335-111-03 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 CHRI for whom the member
is providing care, or arrange a suitable alternative for such care and
supervision including the supervision of interns, residents and fellows
assigned to their service.
(c)
Actively participate in such quality evaluation and monitoring activities as
required by the staff and discharge such staff functions as may be required
from time to time.
(d) Satisfy the
requirements set forth in rule
3335-111-13 of the
Administrative Code for attendance at medical staff meetings and meetings of
those committees of which they are a member.
(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 allied health
professionals as necessary in accordance with accreditation standards and state
law. It is the responsibility of the attending physician to authorize each
licensed allied health professional to perform only those services which the
licensed allied health professional is privileged to perform.
(F) Consulting medical
staff.
(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
3335-111-04 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 to James patients only at the request of
attending or associate attending 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 hospitals of
the Ohio state university. The practitioner shall also hold at such other
hospital the same privileges, without restriction, that he/she is requesting at
the James cancer hospital. 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 associate attending medical staff member.
(b) Have access to all medical records and be
entitled to utilize the facilities of the Ohio state university hospitals and
James cancer hospital incidental to the clinical privileges granted pursuant to
university bylaws.
(c) Not admit
patients to the Ohio state university hospitals or James cancer
hospital.
(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 clinical department
chief.
(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
3335-111-02 and
3335-111-03 of the
Administrative Code.
(b) Be exempt
from all medical staff dues.
(G) Limited staff.
Limited staff are not considered 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, limited
staff are bound by the terms of university bylaws, rules and regulations of the
medical staff and the limited staff agreement.
(1) Qualifications:
The limited staff shall consist of doctors of medicine,
osteopathic physicians, dentists and practitioners of podiatry or psychology
who are accepted in good standing by a program director into a postdoctoral
graduate medical education program and appointed to the limited staff in
accordance with university bylaws. The limited staff shall maintain compliance
with the requirements of state law, including regulations adopted by the Ohio
state medical board, or the limited staff member's respective licensing
board.
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:
The limited staff shall:
(a) Be responsible to respond to all
questions and 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 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 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,
associate attending or clinical attending medical staff. The limited staff
member shall follow all rules and regulations of the service to which he or she
is assigned, as well as the general rules of the CHRI pertaining to limited
staff.
(d) Serve as full members of
the various medical staff committees in accordance with established committee
composition as described in university bylaws and/or 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 subspecialty 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 department chief, program director, teaching faculty or evaluation
committee in accordance with accreditation standards and policies and
procedures of the approved training programs.
(f) 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 academic department or training program and approved by the
program director and the Ohio state university's 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
3335-111-05 and
3335-111-06 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. The appointment 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 associate dean for graduate medical education, 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, associate attending or clinical attending 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,
associate attending or clinical attending medical staff member. The care they
extend will be governed by these 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, associate attending or clinical attending
medical staff member. Any concerns or problems that arise in the limited staff
member's performance should be directed to the attending, associate attending
or clinical attending 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, associate attending or clinical attending medical
staff member.
(b) All records of
limited staff member cases must document involvement of the attending,
associate attending or clinical attending 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) Clinical privileges.
(1) Delineation of clinical privileges:
(a) Every person practicing at the CHRI 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 allied health professional by
the Wexner medical center board after recommendation from the medical staff
administrative committee.
(b) Each
clinical department and CHRI department and/or division shall develop specific
clinical criteria and standards for the evaluation of privileges with emphasis
on invasive or therapeutic procedures or treatment which represent 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.
(c) 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.
(d) 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 medical director of
credentialing. 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 qualifications and competence in the clinical privileges requested
and shall have the burden of production of adequate information for the proper
evaluation of qualifications.
(e)
The applicant's request for clinical privileges and the recommendation of the
clinical department chief shall be forwarded to the credentials committee and
shall be processed in the same manner as applications for appointment and
reappointment pursuant to rule
3335-111-04 of the
Administrative Code.
(f) 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
practitioner's 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.
(g) 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.
(h) Medical staff members authorize the CHRI
and clinics to share amongst themselves 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 CHRI.
(i) Medical staff members authorize the CHRI
to release, in good faith and without malice, information 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 and special privileges:
(a) Temporary privileges may be extended to a
doctor of medicine, osteopathic medicine, dental surgery, psychologist,
podiatry or to a licensed allied health 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 not 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 boards.
(c)
Temporary privileges granted for locum tenens may be exercised for a maximum of
one hundred twenty days, consecutive or not, any time during the
twenty-four
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)
Practitioners exercising temporary privileges shall abide by medical staff
bylaws, rules and regulations, and hospital and medical staff
policies.
(f) Special privileges
upon receipt of a written request for specific temporary clinical privileges
and the approval of the clinical department chief, the chairperson of the
academic department and the director of medical affairs, an appropriately
licensed or certified practitioner of documented competence, who is not an
applicant for medical staff membership, may be granted special clinical
privileges for the care of one or more specific patients. Such privileges shall
be exercised in accordance with the conditions specified in rule
3335-111-04 of the
Administrative Code.
(g) The
temporary and special privileges must also be in conformity with accrediting
bodies' standards and the rules and regulations of 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, eligible
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
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 CHRI 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:
(i) Be responsible for any medical
problems that the patient has while an inpatient of the CHRI;
and
(ii) Shall confirm the findings,
conclusions and assessment of risk prior to high-risk diagnosis or therapeutic
interventions defined by the medical staff.
(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 CHRI; and
(ii)
Shall confirm the findings, conclusions and assessment
of risk prior to high-risk diagnosis or therapeutic interventions defined by
the medical staff.
(b)(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.
(c)(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 CHRI, 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 CHRI. In ambulatory
settings, psychologists shall diagnose and treat their patient's 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 CHRI 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.
(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 CHRI; and
(ii) Shall confirm
the findings, conclusions and assessment of risk prior to high-risk diagnoses
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 CHRI 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)
Licensed allied health professionals:
(a)
Clinical privileges may be exercised by licensed allied health 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 of
members of the medical staff.
(b) A licensed allied health professional as
used herein, shall not be eligible for medical staff membership but shall be
eligible to exercise those clinical privileges granted pursuant to university
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 allied health professionals may perform all or part of the
medical history and physical examination of the patient. Licensed health care
professionals with privileges are subject to FPPE and OPPE.
(c) Licensed allied health 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
3335-111-04 of the
Administrative Code.
(d) Licensed
allied health professionals are not members of the medical staff but may write
admitting orders for patients of the CHRI 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 allied health professionals are not
members of the medical staff and shall not be eligible to hold office, to vote
on medical staff affairs, or to serve on standing committees of the medical
staff unless specifically authorized by the medical staff administrative
committee.
(e) Each licensed allied
health professional shall be individually assigned to a clinical department and
shall be supervised by or collaborate with one or more members of the medical
staff as required by Ohio law. The licensed health care professional's clinical
privileges are contingent upon the collaborating/supervising medical staff
member's privileges. In the event that the collaborating/supervising medical
staff member loses privileges or resigns, the licensed allied health care
professionals whom he or she has supervised shall be placed on administrative
hold until another collaborating/ supervising medical staff member is assigned.
The new collaborating/supervising medical staff member shall be assigned in
less than thirty days.
(f) Licensed
allied health 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 allied health professional:
(i)
Current license, certification, or other legal credential required by Ohio
law;
(ii) Certificate of authority,
standard care arrangement/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 allied health professional subcommittee and the quality management
department of the Ohio state university Wexner medical center;
(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; and
(ix) Ability to
work with members of the medical staff and the CHRI employees.
(h) The applicant shall have the
burden to produce documentation with sufficient adequacy to assure the medical
staff and the CHRI that any patient cared for by the licensed allied health
professional seeking clinical privileges shall be given quality care, and that
the efficient operation of the CHRI will not be disrupted by the applicant's
care of patients in the CHRI.
(i)
By applying for clinical privileges as a licensed allied health 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 CHRI 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 CHRI policies
that the CHRI may from time to time put into effect;
(ii) The applicant releases from liability
all individuals and organizations who provide information to the CHRI regarding
the applicant and all members of the medical staff, the CHRI staff and the
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 CHRI;
(iv) The applicant shall not make any
statement or take any action that might cause a patient to believe that the
licensed allied health professional is a member of the medical staff;
and
(v) The applicant shall obtain
and continue to maintain professional liability insurance in such amounts
required by the medical staff.
(j) Licensed allied health care professionals
shall be subject to quality review and corrective action as outlined in this
paragraph for violation of these 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 medical
director of quality or the chief quality officer. All requests shall be in
writing and shall be submitted to the chief quality officer. The chief quality
officer, unless delegated to the medical director of quality, shall appoint a
three-person committee to review and make recommendations concerning
appropriate action. The committee shall consist of at least one licensed allied
health care professional and one medical staff member. The committee shall make
a written recommendation to the chief quality officer, unless delegated to the
medical director of quality, who may accept, reject, or modify the
recommendation. The chief quality officer, unless delegated to the medical
director of quality shall forward his or her recommendation to the director of
medical affairs for final determination.
(k) Appeal process.
(i) A licensed allied 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 allied health care
professional shall be deemed to have waived the right to appeal and to have
conclusively accepted the decision of the director of medical
affairs.
(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 allied health care professional under review. The
licensed allied 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 allied 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 allied 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 allied 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 allied 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 allied health care professional as determined by university
records. The chief quality officer shall also notify in writing the senior vice
president for health sciences, the dean of the college of medicine, the chief
executive officer of the CHRI and the vice president for health services and
the chief of the applicable clinical department or departments. The chief
quality officer, unless delegated to the medical director of quality, shall
take immediate steps to implement the final decision.
(9) Emergency privileges:
In the 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 CHRI 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 that 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 director of medical affairs or the medical director of credentialing 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 director of medical affairs temporary privileges are granted
thereafter.
(11)
Telemedicine:
Telemedicine involves the use of electronic communication or
other communication technologies to provide or support clinical care at a
distance. Diagnosis and treatment of a patient may now be performed via
telemedicine link.
(a) A member of the
medical staff who wishes to utilize electronic technologies (telemedicine) to
render care must so indicate on the application for clinical privileges
form.
(b) A member of the medical
staff may request to exercise via telemedicine the same clinical privileges he
or she has already been granted. The credentials committee, the chief of the
clinical service, medical director of credentialing, the director of medical
affairs or the medical staff administrative committee, and the Wexner medical
center board shall have the prerogative of requiring documentation or making a
determination of the appropriateness of the exercise of a particular
specialty/subspecialty via telemedicine.
