Ohio Administrative Code › Title 3335 - Ohio State University › Chapter 3335-43 - Medical Staff Members › Section 3335-43-04 - Membership

Current through all regulations passed and filed through July 1, 2024
(A)
			 Qualifications.
(1) Membership on the medical
			 staff of the Ohio state university hospitals 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, the Wexner medical center board 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, 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 procedures as all other
			 applicants for the medical staff.
(2) All members of the medical staff of the
			 Ohio state university hospitals shall, except as specifically provided in
			 university bylaws, 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. All members, except for physician scholar medical staff,
			 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 privileges shall
			 comply with provisions of state law and the regulations of the 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 university hospitals will be given the high quality of medical care
			 provided at university hospitals, shall be qualified for membership on the
			 medical staff of the Ohio state university hospitals.
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 chief medical officer of the medical center,
				medical directors, 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. All members of the medical staff and
				licensed health care professionals will comply with medical staff and the Ohio
				state university policies regarding employee and medical staff health and
				safety; uncompensated care; and will comply with appropriate administrative
				directives and policies to avoid disrupting those operations of the Ohio state
				university hospitals which adversely impact overall patient care or which
				adversely impact the ability of the Ohio state university hospitals 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 Wexner medical center to meet
				accreditation standards, federal 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 privileges 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.
(3) All members of the medical
			 staff and credentialed providers must maintain continuous uninterrupted
			 enrollment with all governmental health care 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 programs.
(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 part, in any federal or state government
			 reimbursement program, shall result in immediate lapse of membership on the
			 medical staff of the Ohio state university hospitals and the immediate lapse of
			 clinical privileges at the Ohio state university hospitals 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.
(4) An applicant
			 for membership shall at the time of appointment or reappointment, be and remain
			 board certified in his or her primary are of practice at the Ohio state
			 university hospitals. This board certification must be approved by at least one
			 of the American board of medical specialties, or other applicable certifying
			 boards, including certifying boards if applicable for doctors of osteopathy,
			 podiatry, psychology, and dentistry. All applicants must be and remain
			 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 requirements. Recertification will be assessed at
			 reappointment. Failure to meet or maintain board certification shall result in
			 immediate termination of membership on the medical staff of the Ohio state
			 university hospitals.
(5) 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.
(6)
									Waiver requests for the threshold eligibility
			 requirements listed in paragraphs (A)(3) to (A)(5) 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 of
			 demonstrating 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
			 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 quality and professional affairs committee of the Ohio state university
			 medical center and the Wexner medical center board regarding whether to grant
			 or deny the request for a waiver and the basis for its
			 recommendation.
(d)
										The Ohio state university Wexner medical center board's
			 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 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.
(e)
										Waiver requests
			 for the threshold eligibility requirement listed in paragraph (A)(3) of this
			 rule may only be considered for applicants who have voluntarily opted out of
			 governmental health care programs. Applicants who have been excluded or
			 suspended shall be ineligible to request a waiver.
(f)
										Waivers to
			 requirements prescribed by regulatory, accrediting, or other external agencies
			 will not be granted.
(7) Any medical staff
			 member whose membership has been terminated pursuant to paragraph (A)(3) or
			 (A)(4) of this rule shall not be entitled to request a hearing and appeal in
			 accordance with rule
			 3335-43-06 of the Administrative
			 Code. Any licensed health care professional whose clinical privileges have been
			 terminated pursuant to paragraph (A)(4) of this rule may not request an appeal
			 in accordance with paragraph (G)(3) of rule
			 3335-43-07 of the Administrative
			 Code.
(8) No applicant shall
			 be entitled to medical staff membership and or clinical privileges merely by
			 the virtue of fulfilling the listed qualifications or holding a previous
			 appointment to the medical staff.