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Ohio Administrative Code (Last Updated: January 12, 2021) |
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3335 Ohio State University |
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Chapter3335-97. Committees of the University Wexner Medical Center |
3335-97-03. Quality and professional affairs committee
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(A) Responsibilities. The quality and professional affairs committee shall be responsible for the following specific duties:
(1) Reviewing and evaluating the patient safety and quality improvement programs of the university Wexner medical center, including, but not limited to, the hospitals, clinics, ambulatory care facilities, and physician office facilities;
(2) Overseeing all patient care activity in all facilities that are a part of the university Wexner medical center, including, but not limited to, the hospitals, clinics, ambulatory care facilities, and physicians' office facilities;
(3) Monitoring quality assurance performance in accordance with the standards set by the university Wexner medical center;
(4) Monitoring the achievement of accreditation and licensure requirements;
(5) Reviewing and recommending to the university Wexner medical center board changes to the medical staff bylaws and medical staff rules and regulations;
(6) Reviewing and approving clinical privilege forms;
(7) Reviewing and approving membership and granting appropriate clinical privileges for the credentialing of practitioners recommended for membership and clinical privileges by the university hospitals medical staff administrative committee and the James medical staff administrative committee;
(8) Reviewing and approving membership and granting appropriate clinical privileges for the expedited credentialing of such practitioners that are eligible by satisfying minimum approved criteria as determined by the university Wexner medical center board and are recommended for membership and clinical privileges by the university hospitals medical staff administrative committee and the James medical staff administrative committee;
(9) Reviewing and approving reinstatement of clinical privileges for a practitioner after a leave of absence from clinical practice;
(10) Conducting peer review activities and recommending professional review actions to the university Wexner medical center board;
(11) Reviewing and resolving any petitions by the medical staffs for amendments to any rule, regulation or policy presented by the chief of staff on behalf of the medical staff pursuant to the medical staff bylaws and communicating such resolutions to the university hospitals medical staff administrative committee and the James medical staff administrative committee for further dissemination to the medical staffs; and
(12) Such other responsibilities as assigned by the chair of the university Wexner medical center board.
(B) Composition. The committee shall consist of: no fewer than four voting members of the university Wexner medical center board, appointed annually by the chair of the university Wexner medical center board, one of whom shall be appointed as chair of the committee. The executive vice president and chancellor for health affairs; the chief executive officer of the Ohio state university health system; chief clinical officer of the medical center; the chief administrative officer of the Ohio state university health system, the director of medical affairs of the James; the medical director of credentialing for the James; the chief of the medical staff of the university hospitals; the chief of the medical staff of the James; the associate dean of graduate medical education; the chief quality and patient safety officer; the chief nurse executive for the Ohio state university health system; and the chief nursing officer for the James shall serve as ex-officio, voting members. Such other members as appointed by the chair of the university Wexner medical center board, in consultation with the chair of the quality and professional affairs committee.
(C) Review and recommendation. The chief clinical officer of the medical center and the chief of staff for the medical staff of university hospitals shall present and make recommendations to the quality and professional affairs committee only with respect to those actions involving the university hospitals. The director of medical affairs of the James, the medical director of credentialing for the James and chief of staff for the medical staff of the James shall present and make recommendations to the quality and professional affairs committee only with respect to those actions involving the James.
(D) Voting. With respect to items coming before the quality and professional affairs committee as detailed in paragraph (A) of this rule, at least two voting, non-public members of the university Wexner medical center board must be present. Any action taken by this committee pursuant to the responsibilities as defined in paragraphs (A) (1) to (A)(11) of rule 3335-97-03 of the Administrative Code shall be taken only by the voting, non-public, committee members and approved by a majority vote thereof. The chief quality and patient safety officer shall recuse themselves from voting on matters defined in paragraphs (A)(7) and (A)(10) of rule 3335-97-03 of the Administrative Code.
(E) Meetings. The committee shall meet at least quarterly ( four times per calendar year) or at the call of the chair of the committee and shall advise the university Wexner medical center board of its activities regularly. The committee shall act on behalf of the university Wexner medical center board in order to maintain the continuity of operations of the hospitals of the Ohio state university and the university hospitals and the James medical staffs; to review and to approve medical staff membership and to grant appropriate clinical privileges for practitioners in accordance with applicable laws, accreditation requirements, bylaws and rules established by the university board of trustees, university Wexner medical center board and university hospitals and the James medical staffs. Meetings shall be conducted in accordance with the state laws of Ohio and open meetings laws.