Ohio Administrative Code › Title 3335 - Ohio State University › Chapter 3335-43 - Medical Staff Members › Section 3335-43-10 - Administration of the medical staff of the Ohio state university hospitals

Current through all regulations passed and filed through July 1, 2024
(A) Chief medical
			 officer.
The chief clinical officer functions as the chief medical
				officer as referred to herein university bylaws. The chief medical officer is
				the senior medical officer for the medical center with the responsibility and
				authority for all health and medical care delivered at the medical center. The
				chief medical officer is responsible for overall quality improvement and
				clinical leadership throughout the medical center, physician alignment, patient
				safety and medical staff development. The appointment, scope of authority, and
				responsibilities of the chief medical officer shall be as outlined in the Ohio
				state university Wexner medical center board bylaws.
(B) Chief quality officer.
The chief quality and patient safety officer of the Ohio state
				university Wexner medical center is referred to herein university bylaws as the
				chief quality officer. The chief quality officer reports to the chief medical
				officer. The chief quality officer works collaboratively with clinical
				leadership of the medical center, including the director of medical affairs for
				the James cancer hospital, nursing leadership and hospital administration. The
				chief quality officer provides leadership in the development and measurement of
				the medical center's approach to quality, patient safety and reduction of
				adverse events. The chief quality officer communicates and implements
				strategic, operational and programmatic plans and policies to promote a culture
				where patient safety is an important priority for medical and hospital
				staff.
(C) Medical
			 directors.
The medical directors of the hospitals of the Ohio state
				university report to the chief executive officer or the executive director of
				the respective hospital and chief medical officer. Each medical director will
				collaborate with the chief quality officer, the chief medical officer and the
				clinical department chiefs to develop, execute and monitor the quality and
				safety programs of the hospital. The appointment, scope of authority, and
				responsibilities of the medical directors for the Ohio state university
				hospitals shall be further outlined in the Ohio state university Wexner medical
				center board bylaws.
(D)
			 Medical staff committees.
(1) Appointments:
Appointments to all medical staff committees except the medical
				staff administrative committee, nominating committee and all health system
				committees, shall be made jointly by the chief of staff, chief of staff-elect,
				and the hospital medical directors with medical staff administrative committee
				ratification. Representatives from the Ohio state university hospitals to
				health system committees shall be appointed jointly by the chief medical
				officer of the health system and the medical director. Unless otherwise
				provided by university bylaws, all appointments to medical staff committees
				shall be for two years and may be renewed. The chief of staff, chief medical
				officer, medical director, and the chief executive officer of the Ohio state
				university hospitals may serve on any medical staff committee as an ex-officio
				member without vote.
(2)
			 Meetings:
Each medical staff committee shall meet at the call of its
				chairperson and at least quarterly. Committees shall maintain records of
				proceedings and minutes of meetings and shall forward all recommendations and
				actions taken to the chief medical officer who shall promptly communicate them
				to the medical staff administrative committee. The chairperson shall control
				the committee agenda, attendance of staff and guests, and conduct of the
				proceedings. A simple majority of appointed voting members shall constitute a
				quorum.
(3) Peer review
			 committees:
The medical staff as a whole and each committee provided for by
				medical staff bylaws is hereby designated as a peer review committee in
				accordance with the laws of the state of Ohio. The medical staff through its
				committees shall be responsible for evaluating, maintaining and/or monitoring
				the quality and utilization of patient care services provided by the Ohio state
				university hospitals.