Ohio Administrative Code › Title 3335 - Ohio State University › Chapter 3335-111 - CHRI In General › Section 3335-111-05 - Peer review and corrective action

Current through all regulations passed and filed through July 1, 2024
(A)
								Informal peer
			 review.
(1)
									All
			 medical staff members agree to cooperate in informal peer review activities
			 that are solely intended to improve the quality of medical care provided to
			 patients at the CHRI.
(2)
									Information indicating a need for informal review,
			 including patient complaints, disagreements, questions of clinical competence,
			 inappropriate conduct and variations in clinical practice identified by the
			 clinical departments or divisions and medical staff committees shall be
			 referred to the chair of the practitioner evaluation committee.
(3)
									The practitioner
			 evaluation committee chair or his or her designee may obtain information or
			 opinions from medical staff members or credentialed providers as well as
			 external peer review consultants pursuant to criteria outlined in these bylaws.
			 The information or opinions from the informal peer review may be presented to
			 the practitioner evaluation committee or another designated peer review
			 committee.
(4)
									Following the assessment by the practitioner evaluation
			 committee chair or his or her designee, the practitioner evaluation committee
			 may make recommendations for educational actions of additional training,
			 sharing of comparative data or monitoring or provide other forms of guidance to
			 the medical staff member to assist him or her in improving the quality of
			 patient care. Such actions are not regarded as adverse, do not require
			 reporting to any governmental or other agency, and do not invoke a right to any
			 hearing.
(5)
									At the conclusion of the evaluation, the practitioner
			 evaluation committee chair or his or her designee submits a report to the
			 applicable clinical department chief and the director of medical affairs. The
			 clinical department chief and the director of medical affairs shall evaluate
			 the matter to determine the appropriate course of action. They shall make an
			 initial written determination on whether:
(a)
										The matter
			 warrants no further action;
(b)
										Informal
			 resolution under this paragraph is appropriate. The clinical department chief
			 and the director of medical affairs shall determine whether to include
			 documentation of the informal resolution in the medical staff member's file. If
			 documentation is included in the member's file, the affected member shall have
			 an opportunity to review it and may make a written response which shall also be
			 placed in the file. Informal review under this paragraph is not a procedural
			 prerequisite to the initiation of formal peer review under paragraph (B) of
			 this rule; or
(c)
										Formal peer review under paragraph (B) of this rule is
			 warranted. In cases where the clinical department chief and director of medical
			 affairs cannot agree, the matter shall be submitted and determined as set forth
			 in paragraph (B) of this rule.