Ohio Administrative Code › Title 3335 - Ohio State University › Chapter 3335-111 - CHRI In General › Section 3335-111-04 - Membership

Current through all regulations passed and filed through July 1, 2024
(A)
			 Qualifications.
(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
			 education and training 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 
			 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.
The medical staff
				administrative committee will review the recommendation
(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.
(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.
(9) Any staff member
			 whose membership has been terminated pursuant to paragraph (A)(4)
									or (A)(5)
			  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.
(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.