3364-10-03. Standard of care committee

(A) Policy statement

The university of Toledo ("UT") will create and maintain a standard of care committee ("committee") as part of its litigation management process that will review standard of care issues that allegedly resulted in claims. In order to improve patient safety and reduce future risk exposures to UT and the university of Toledo physicians, limited liability company ("UTP"), the committee will communicate any standard of care or patient safety concerns to the medical staff peer review committee.

(B) Purpose of policy

The committee supports legal defense by evaluating the care provided in litigation claims and determining if there were any standard of care issues. The committee improves patient safety and reduces future risk by referring any standard of care or patient safety concerns to the medical staff peer review committee.

(C) Committee functions

(1) Case reviews will be done by the office of legal affairs on all lawsuits filed against UT, UTP, affiliated practitioners who participate in the university insurance program, residents, students or employees of UT. One hundred eighty-day letters and potential claims will be reviewed as appropriate in accordance with rule 3364-10-16 of the Administrative Code (professional liability claims reporting and management policy).

(2) The committee will discuss each case presented to determine whether:

(a) The standard of care was met;

(b) The standard of care was met, but there are concerns; or

(c) The standard of care was not met.

(3) The committee will assess responsibility of any standard of care issues and allocate the portion of responsibility amongst the parties.

(4) The office of legal affairs-health science campus ("HSC") will direct the committee's determination to the proper channels, including the claims management committee.

(5) All issues with regard to a finding that the standard of care was not met will be provided to the medical staff peer review committee. Action will be taken as appropriate by the medical staff peer review committee to educate and improve patient safety and quality of care.

(D) Committee membership

Members of the standard of care committee will be:

Executive vice president for clinical affairs (chair);

UTP president;

UTP vice president;

UTMC chief executive officer;

Chief of staff;

Vice chief of staff;

Chief medical officer;

A minimum of six hospital medical staff members representative of the clinical services offered by UTMC (appointed by the committee chair);

Chief administrative officer for quality and patient safety;

Chief nursing officer;

(11) Deputy general counsel*;

(12) Risk management*.

* Non-voting members

(E) Meetings

The committee will meet monthly or as often as necessary. Attendance of five attending physicians constitutes a quorum.

The UTP president will serve as committee chair in the absence of the executive vice president for clinical affairs.

(F) Protected information

The committee performs quality assurance activities and is an integral part of university's peer review and quality assurance process. Those sections of the Revised Code pertaining to immunity and confidentiality of peer review and quality assurance committees apply to the committee. The committee also supports legal counsel in litigation preparation, defense, and resolution decisions. The activities of this committee, including any information, data, reports, or records are part of peer review records as well as attorney-client privileged/work product, and are protected from disclosure.

(G) Definitions

(1) Claims mean any of the following against any person or entity insured by the university insurance program:

(a) Lawsuits - summons and complaints served, regardless of which court the action was filed.

(b) One-hundred eighty-day letters (Ohio) or notices of intent (Michigan) that give notice of consideration of suing or requests from an attorney or patient for medical records where the request form indicates that the party is considering filing a lawsuit.

(c) Any written demands for compensation by patient, family or legal representative.

(2) Potential claim means any procedure or treatment which may have contributed to:

(a) An event that has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition, including but not limited to unexpected deaths or unexpected outcomes of a serious nature:

(i) Unanticipated neurological, sensory or systemic deficits: including but not limited to brain damage, spinal cord injury, paralysis or nerve injury, organ failure or sepsis;

(ii) Severe burns, including but not limited to thermal, chemical, radiological or electrical, resulting in extensive hospitalization and/or skin grafting;

(iii) Severe internal injuries, lacerations, infectious processes, foreign body retentions, or sensory or reproductive organ injuries; or

(iv) Substantial disabilities, including fractures, amputations or disfigurements.

(b) Any outcome that is classified as a sentinel event (per policy 3364-100-50-38 of the UT medical center (sentinel events/adverse events)) and requires a root cause analysis to be performed.

Effective: 3/23/2020
Promulgated Under: 111.15
Statutory Authority: 3364
Rule Amplifies: 3364
Prior Effective Dates: 10/26/2018