Ohio Administrative Code › Title 3335 - Ohio State University › Chapter 3335-111 - CHRI In General › Section 3335-111-12 - Amendments and adoption

Current through all regulations passed and filed through July 1, 2024
(A)
			 Medical staff responsibility
The medical staff bylaws committee shall have the initial
				responsibility to formulate, review at least biennially, and recommend to the
				quality and professional affairs committee of the Wexner medical center board
				any medical staff bylaws, rules, regulations, policies, procedures, and
				amendments as needed. Amendments to the bylaws shall be effective when approved
				by the university board of trustees. Amendments to the rules and regulations
				shall be effective when approved by the Wexner medical center board.
Such responsibility shall be exercised in good faith, in a
				timely manner and in accordance with applicable laws and regulatory standards.
				This applies as well to the review, adoption, and amendment of the related
				rules, policies, and protocols developed to implement the various sections of
				the medical staff bylaws.
The organized medical staff shall also have the ability to
				propose amendments to the medical staff bylaws, rules and regulations and
				policies and procedures and propose them directly to the quality and
				professional affairs committee of the Wexner medical center board.
If the voting members of the organized medical staff propose to
				adopt amendments to the bylaws, rules and regulations or policies, they must
				first communicate the proposal to the medical staff administrative committee.
				When the medical staff administrative committee proposes to adopt amendments to
				the bylaws, rules and regulations or policies, it communicates the proposal to
				the organized medical staff.
Conflict between the organized medical staff and the medical
				staff administrative committee will be managed by allowing communication
				directly from the medical staff to the quality and professional affairs
				committee of the Wexner medical center board on issues including, but not
				limited to: amendments to the bylaws and the adoption of new rules and
				regulations or policies. Medical staff members may communicate with the quality
				and professional affairs committee of the Wexner medical center board by
				submitting their communication in writing to the chief of staff, who shall then
				communicate on their behalf to the quality and professional affairs committee
				of the Wexner medical center board at its next regularly scheduled meeting for
				final determination.
In cases of urgent need to update the medical staff bylaws or
				rules and regulations in order to comply with law, statute, federal regulation,
				or accreditation standard, the medical staff administrative committee and the
				quality and professional affairs committee of the Wexner medical center board
				may provisionally approve an urgent amendment without prior notification to the
				medical staff. The medical staff shall be immediately notified by the medical
				staff administrative committee. The medical staff shall have the opportunity
				for review of and vote on the provisional amendment. If the medical staff votes
				in favor of the provisional amendment it shall stand. If there is conflict over
				the provisional amendment, process for resolving conflict between the organized
				medical staff and the medical staff administrative committee shall be
				implemented.
(B) Methods of
			 adoption and amendment to the medical staff bylaws.
Proposed amendments to these bylaws may be originated by the
				medical staff bylaws committee, medical staff administrative committee or by a
				petition signed by twenty-five per cent of attending medical staff
				members.
Each attending medical staff member will be eligible to vote on
				the proposed amendment via 
				secure  ballot in a manner
				determined by the medical staff administrative committee. All attending medical
				staff members shall receive at least fourteen days
				advance notice of the changes to be adopted:
(1) The medical staff receives a simple
			 majority of the votes cast by those members eligible to vote;
(2) Amendments so adopted shall be effective
			 when approved by the university board of trustees.