Ohio Administrative Code|Rule 3335-111-07 | Categories of the medical staff.

                                                
The medical staff of the CHRI shall be divided into
		honorary, physician scholar, attending, associate attending, clinical
		attending, consulting medical staff and limited designations. All medical staff
		members with admitting privileges may admit patients in accordance with state
		law and criteria for standards of care established by the medical staff.
		Medical staff members who do not wish to obtain any clinical privileges shall
		be exempt from the requirements of medical malpractice liability insurance, DEA
		registration, demonstration of recent active clinical practice during the last
		two years and specific annual education requirements as outlined in the list
		maintained in the chief medical officers office, but are otherwise
		subject to the provisions of university bylaws.
(A) Honorary staff.
The honorary staff will be composed of those
		  individuals who are recognized for outstanding reputation, notable scientific
		  and professional contributions, and high professional stature in an oncology
		  field of interest. The honorary staff designation is awarded by the Wexner
		  medical center board on the recommendation of the chief executive officer of
		  the CHRI, executive vice president for health sciences, department chairperson
		  and/or division director, or the credentials committee after approval by the
		  medical staff administrative committee. This is a lifetime appointment.
		  Honorary staff are not entitled to patient care privileges.
(B) Physician scholar medical
		  staff.
(1) Qualifications: The
			 physician scholar medical staff shall be composed of those faculty members of
			 the colleges of medicine and dentistry who are recognized for outstanding
			 reputation, notable scientific and professional contributions, and high
			 professional stature. This medical staff category includes but is not limited
			 to emeritus faculty members. Nominations may be made to the chair of the
			 credentialing committee who shall present the candidate to the medical staff
			 administrative committee for approval.
(2) Prerogatives: Members
			 of the physician scholar medical staff shall have access to the CHRI and shall
			 be given notice of all medical staff activities and meetings. Members of the
			 physician scholar medical staff shall enjoy all rights of an attending medical
			 staff member except physician scholar members shall not possess clinical
			 privileges.
(3) Physician scholar
			 medical staff must have either a full license or an emeritus registration by
			 the state medical board of Ohio.
(C) Attending medical staff.
(1) Qualifications:
The attending staff shall consist of those
			 regular faculty members of the colleges of medicine and dentistry who are
			 licensed or certified in the state of Ohio, whose practice is at least
			 seventy-five per cent oncology and with a proven career commitment to oncology
			 as demonstrated by the majority of the following:
Training, current board certification (as
			 specified in paragraph (A)(5) of rule 3335-111-04 of the Administrative Code),
			 publications, grant funding, other funding and experience (as deemed
			 appropriate by the chief executive officer and the department chairperson
			 and/or division director); and who satisfy the requirements and qualifications
			 for membership set forth in rule 3335-111-04 of the Administrative Code.
(2) Prerogatives:
Attending staff members may:
(a) Admit patients consistent with the balanced teaching and
				patient care responsibilities of the CHRI. When, in the judgment of the
				director of medical affairs, a balanced teaching program is jeopardized,
				following consultation with the chief executive officer, the clinical
				department chief and with the concurrence of a majority of the medical staff
				administrative committee, the director of medical affairs may restrict
				admissions. Imposition of such restrictions shall not entitle the attending
				staff member to a hearing or appeal pursuant to rule 3335-111-06 of the
				Administrative Code.
(b) Be free to exercise such clinical privileges as are granted
				pursuant to university bylaws.
(c) Vote on all matters presented at general and special meetings
				of the medical staff and committees of which he or she is a member unless
				otherwise provided by resolution of the medical staff, clinical department or
				committee and approved by the medical staff administrative
				committee.
(d) Hold office in the medical staff organization, clinical
				departments and committees of which they are a member, unless otherwise
				provided by resolution of the medical staff, clinical department or committee
				and approved by the medical staff administrative committee.
(3) Responsibilities:
An attending staff member shall:
(a) Meet the basic responsibilities set forth in rules
				3335-111-02 and 3335-111-03 of the Administrative Code.
(b) Retain responsibility within the members area of
				professional competence for the continuous care and supervision of each patient
				in the CHRI for whom he or she is providing care, or arrange a suitable
				alternative for such care and supervision.
(c) Actively participate in such quality evaluation and
				monitoring activities as required by the medical staff, and discharge such
				staff functions as may be required from time to time.
(d) Satisfy the requirements set forth in rule 3335-111-13 of the
				Administrative Code for attendance at medical staff meetings and meetings of
				those committees of which they are a member.
(e) Supervise members of the limited staff in the provision of
				patient care in accordance with accreditation standards and policies and
				procedures of approved clinical training programs. It is the responsibility of
				the attending physician to authorize each member of the limited staff to
				perform only those services that the limited staff member is competent to
				perform under supervision.
(f) Supervise other licensed allied health professionals as
				necessary in accordance with accreditation standards and state law. It is the
				responsibility of the attending physician to authorize each licensed allied
				health professional to perform only those services which the licensed allied
				health professional is privileged to perform.
(g) Take call as assigned by the clinical department
				chief.
(D) Associate attending
		  staff.
(1) Qualifications:
The associate attending staff shall consist of
			 those regular faculty members of the colleges of medicine and dentistry who do
			 not qualify for attending staff appointment.
(2) Prerogatives:
The associate attending staff may:
(a) Admit patients consistent with the balanced teaching and
				patient care responsibilities of the institution. When, in the judgment of the
				director of medical affairs, a balanced teaching program is jeopardized,
				following consultation with the chief executive officer, the clinical
				department chief and with the concurrence of a majority of the medical staff
				administrative committee, the director of medical affairs may restrict
				admissions. Imposition of such restrictions shall not entitle the associate
				attending staff member to a hearing or appeal pursuant to rule 3335-111-06 of
				the Administrative Code.
(b) Be free to exercise such clinical privileges as are granted
				pursuant to the bylaws.
(c) Vote on all matters presented at general and special meetings
				of the medical staff and committees of which he or she is a member unless
				otherwise provided by resolution of the staff, clinical department or committee
				and approved by the medical staff administrative committee.
(d) The associate attending staff member may not vote on
				amendments to the bylaws.
(3) Responsibilities:
Associate attending staff members shall:
(a) Meet the basic responsibilities set forth in rules
				3335-111-02 and 3335-111-03 of the Administrative Code. 
(b) Retain responsibility within the members care area of
				professional competence for the continuous care and supervision of each patient
				in the CHRI for whom the member is providing care, or arrange a suitable
				alternative for such care and supervision including the supervision of interns,
				residents and fellows assigned to their service.
(c) Actively participate in such quality evaluation and
				monitoring activities as required by the staff and discharge such staff
				functions as may be required from time to time.
(d) Satisfy the requirements set forth in rule 3335-111-13 of the
				Administrative Code for attendance at medical staff meetings and meetings of
				those committees of which they are a member.
(E) Clinical attending
		  staff.
(1) Qualifications:
The clinical attending staff shall consist of
			 those clinical faculty members of the colleges of medicine and dentistry who
			 have training, expertise, and experience in oncology, as determined by the
			 chief executive officer in consultation with the department chairperson and/or
			 division director and who satisfy the requirements and qualifications for
			 membership set forth in rule 3335-111-04 of the Administrative Code.
(2) Prerogatives:
The clinical attending staff may:
(a) Admit patients which complement the research and clinical
				teaching program. At times when hospital beds or other resources are in short
				supply, patient admissions of clinical staff shall be subordinate to those of
				attending or associate attending staff.
(b) Be free to exercise such clinical privileges as are granted
				pursuant to university bylaws.
(c) Attend meetings as non-voting members of the medical staff
				and any medical staff or hospital education programs. The clinical attending
				staff may not hold elected office in the medical staff
				organization.
(3) Responsibilities:
(a) Meet the basic responsibilities set forth in rules
				3335-111-02 and 3335-111-03 of the Administrative Code.
(b) Retain responsibility within the members area of
				professional competence for the continuous care and supervision of each patient
				in the CHRI for whom the member is providing care, or arrange a suitable
				alternative for such care and supervision including the supervision of interns,
				residents and fellows assigned to their service.
(c) Actively participate in such quality evaluation and
				monitoring activities as required by the staff and discharge such staff
				functions as may be required from time to time.
(d) Satisfy the requirements set forth in rule 3335-111-13 of the
				Administrative Code for attendance at medical staff meetings and meetings of
				those committees of which they are a member.
(e) Supervise members of the limited staff in the provision of
				patient care in accordance with accreditation standards and policies and
				procedures of approved clinical training programs. It is the responsibility of
				the attending physician to authorize each member of the limited staff to
				perform only those services which the limited staff member is competent to
				perform under supervision.
(f) Supervise other licensed allied health professionals as
				necessary in accordance with accreditation standards and state law. It is the
				responsibility of the attending physician to authorize each licensed allied
				health professional to perform only those services which the licensed allied
				health professional is privileged to perform. 
(F) Consulting medical staff.
(1) Qualifications.
The consulting medical staff shall consist of
			 those faculty members of the colleges of medicine and dentistry who:
(a) Satisfy the requirements and qualifications for membership
				set forth in rule 3335-111-04 of the Administrative Code.
(b) Are consultants of recognized professional ability and
				expertise who provide a service not readily available from the attending
				medical staff. These practitioners provide services to James patients only at
				the request of attending or associate attending members of the medical
				staff.
(c) Demonstrate participation on the active medical staff at
				another accredited hospital requiring performance improvement/quality
				assessment activities similar to those of the hospitals of the Ohio state
				university. The practitioner shall also hold at such other hospital the same
				privileges, without restriction, that he/she is requesting at the James cancer
				hospital. An exception to this qualification may be made by the Wexner medical
				center board provided the practitioner is otherwise qualified by education,
				training and experience to provide the requested service.
(2) Prerogatives:
Consulting medical staff members may:
(a) Exercise the clinical privileges granted for consultation
				purposes on an occasional basis when requested by an attending or associate
				attending medical staff member.
(b) Have access to all medical records and be entitled to utilize
				the facilities of the Ohio state university hospitals and James cancer hospital
				incidental to the clinical privileges granted pursuant to university
				bylaws.
(c) Not admit patients to the Ohio state university hospitals or
				James cancer hospital.
(d) Not vote on medical staff policies, rules and regulations, or
				bylaws, and may not hold office.
(e) Must actively participate in such quality evaluation and
				monitoring activities as required by the medical staff and as outlined in the
				medical staff policy entitled "consulting medical staff member
				policy."
(f) Attend medical staff meetings, but shall not be entitled to
				vote at such meetings or hold office.
(g) Attend department meetings, but shall not be entitled to vote
				at such meetings or serve as clinical department chief.
(h) Serve as a non-voting member of a medical staff committee;
				provided, however, that he/she may not serve as a committee chair or as a
				member of the medical staff administrative committee.
(3) Responsibilities.
Each member of the consulting medical staff
			 shall:
(a) Meet the basic responsibilities set forth in rules
				3335-111-02 and 3335-111-03 of the Administrative Code.
(b) Be exempt from all medical staff dues.
(G) Limited staff.
Limited staff are not considered members of the
		  medical staff, do not have delineated clinical privileges, and do not have the
		  right to vote in general medical staff elections. Except where expressly
		  stated, limited staff are bound by the terms of university bylaws, rules and
		  regulations of the medical staff and the limited staff agreement.
(1) Qualifications:
The limited staff shall consist of doctors of
			 medicine, osteopathic physicians, dentists and practitioners of podiatry or
			 psychology who are accepted in good standing by a program director into a
			 postdoctoral graduate medical education program and appointed to the limited
			 staff in accordance with university bylaws. The limited staff shall maintain
			 compliance with the requirements of state law, including regulations adopted by
			 the Ohio state medical board, or the limited staff members respective
			 licensing board.
Members of the limited staff shall possess a
			 valid training certificate or an unrestricted Ohio license from the applicable
			 state board based on eligibility criteria defined by that state board. All
			 members of the limited staff shall be required to successfully obtain an Ohio
			 training certificate prior to beginning training within a program.
(2) Responsibilities:
The limited staff shall:
(a) Be responsible to respond to all questions and complete all
				forms as may be required by the credentials committee.
(b) Participate fully in the teaching programs, conferences, and
				seminars of the clinical department in which he or she is appointed in
				accordance with accreditation standards and policies and procedures of the
				graduate medical education committee and approved clinical training
				programs.
(c) Participate in the care of all patients assigned to the
				limited staff member under the appropriate supervision of a designated member
				of the attending medical staff in accordance with accreditation standards and
				policies and procedures of the clinical training programs. The clinical
				activities of the limited staff shall be determined by the program director
				appropriate for the level of education and training. Limited staff shall be
				permitted to perform only those services that they are authorized to perform by
				the member of the attending medical staff based on the competence of the
				limited staff to perform such services. The limited staff may admit or
				discharge patients only when acting on behalf of the attending, associate
				attending or clinical attending medical staff. The limited staff member shall
				follow all rules and regulations of the service to which he or she is assigned,
				as well as the general rules of the CHRI pertaining to limited
				staff.
(d) Serve as full members of the various medical staff committees
				in accordance with established committee composition as described in university
				bylaws and/or rules and regulations of the medical staff. The limited staff
				member shall not be eligible to vote or hold elected office in the medical
				staff organization, but may vote on committees to which the limited staff
				member is assigned.
(e) Be expected to make regular satisfactory professional
				progress including anticipated certification by the respective specialty or
				subspecialty program of post- doctoral training in which the limited staff
				member is enrolled. Evaluation of professional growth and appropriate
				humanistic qualities shall be made on a regular schedule by the clinical
				department chief, program director, teaching faculty or evaluation committee in
				accordance with accreditation standards and policies and procedures of the
				approved training programs.
(f) Appeal by a member of the limited staff of probation, lack of
				promotion, suspension or termination for failure to meet expectations for
				professional growth or failure to display appropriate humanistic qualities or
				failure to successfully complete any other competency as required by the
				accreditation standards of an approved training program will be conducted and
				limited in accordance with written guidelines established by the respective
				academic department or training program and approved by the program director
				and the Ohio state universitys graduate medical education committee as
				delineated in the limited staff agreement and by the graduate medical education
				policies.
Alleged misconduct by a member of the limited
				staff, for reasons other than failure to meet expectations of professional
				growth as outlined in this paragraph, shall be handled in accordance with rules
				3335-111-05 and 3335-111-06 of the Administrative Code.
(3) Failure to meet
			 reasonable expectations:
Termination of employment from the limited
			 staff members residency or fellowship training program shall result in
			 automatic termination of the limited staff members appointment pursuant
			 to university bylaws.
(4) Temporary
			 appointments:
(a) Limited staff members who are Ohio state university faculty
				may be granted an early commencement or an extension of appointment upon the
				recommendation of the chief of the clinical department, with prior concurrence
				of the associate dean for graduate medical education, when it is necessary for
				the limited staff member to begin his or her training program prior to or
				extend his or her training program beyond a regular appointment period. The
				appointment shall not exceed sixty days.
(b) Temporary appointments may be granted upon the recommendation
				of the chief of the clinical department, with prior concurrence of the
				associate dean for graduate medical education, for limited staff members who
				are not Ohio state university faculty but who, pursuant to education affiliate
				agreements approved by the university, need to satisfy approved graduate
				medical education clinical rotation requirements. These appointments shall not
				exceed a total of one hundred twenty days in any given post-graduate year. In
				such cases, the mandatory requirement for a faculty appointment may be waived.
				All other requirements for limited staff member appointment must be
				satisfied.
(5) Supervision:
Limited staff members shall be under the
			 supervision of an attending, associate attending or clinical attending medical
			 staff member. Limited staff members shall have no privileges as such but shall
			 be able to care for patients under the supervision and responsibility of their
			 attending, associate attending or clinical attending medical staff member. The
			 care they extend will be governed by these bylaws and the general rules and
			 regulations of each clinical department. The practice of care shall be limited
			 by the scope of privileges of their attending, associate attending or clinical
			 attending medical staff member. Any concerns or problems that arise in the
			 limited staff members performance should be directed to the attending,
			 associate attending or clinical attending medical staff member or the director
			 of the training program.
(a) Limited staff members may write admission, discharge and
				other orders for the care of patients under the supervision of the attending,
				associate attending or clinical attending medical staff member.
(b) All records of limited staff member cases must document
				involvement of the attending, associate attending or clinical attending medical
				staff member in the supervision of the patients care to include
				co-signature of the admission order history and physical, operative report, and
				discharge summary.
(H) Associates to the medical staff.
(1) Qualifications:
Licensed health care professionals are those
			 professionals who possess a license, certificate or other legal credential
			 required by Ohio law to provide direct patient care in a hospital setting, but
			 who are not acting as licensed independent practitioners.
(2) Due
			 process:
Licensed health care professionals are subject
			 to corrective action for violation of university rules, their certificate of
			 authority, standard care agreement, utilization plan or the provisions of their
			 licensure, including professional ethics. Corrective action may be requested by
			 any member of the medical staff, the clinical department chief, the chairperson
			 of an academic department, the department chairperson and/or division director,
			 the medical director of credentialing or the director of medical affairs. All
			 requests shall be in writing and be submitted to the director of medical
			 affairs.
The director of medical affairs shall appoint a
			 three-person committee to review the situation and recommend appropriate
			 corrective action, including termination or suspension of clinical privileges.
			 The committee shall consist of at least one licensed health care professional
			 licensed in the same field as the individual being reviewed, if available, and
			 one medical staff member. The committee shall make a written recommendation to
			 the director of medical affairs, who may accept, reject or modify the
			 recommendation. The decision of the director of medical affairs shall be
			 final.
(I) Temporary medical staff appointment.
(1) Outside peer review.
			 When peer review activities are being conducted by someone other than a current
			 member of the medical staff, the chief medical officer or director of medical
			 affairs may admit a practitioner to the medical staff for a limited period of
			 time. Such membership is solely for the purpose of conducting peer review in a
			 particular evaluation and this temporary membership automatically expires upon
			 the members completion of duties in connection with such peer review.
			 Such appointment does not include clinical privileges, and is for a limited
			 purpose.
(2) Proctoring. Temporary
			 privileges may be extended to visiting physician or visiting medical faculty
			 for special clinical or educational activities as permitted by the Ohio state
			 medical or dental board. When medical staff members require proctoring for the
			 purposes of gaining experience to become credentialed to perform a procedure, a
			 visiting medical faculty or visiting physician may apply for temporary
			 privileges pursuant to the medical staff proctoring policy.
(J) Clinical privileges.
(1) Delineation of
			 clinical privileges:
(a) Every person practicing at the CHRI by virtue of medical
				staff membership, faculty appointment, contract or under authority granted in
				university bylaws shall, in connection with such practice, be entitled to
				exercise only those clinical privileges specifically applied for and granted to
				the staff member or other licensed allied health professional by the Wexner
				medical center board after recommendation from the medical staff administrative
				committee.
(b) Each clinical department and CHRI department and/or division
				shall develop specific clinical criteria and standards for the evaluation of
				privileges with emphasis on invasive or therapeutic procedures or treatment
				which represent significant risk to the patient or for which specific
				professional training or experience is required. Such criteria and standards
				are subject to the approval of the medical staff administrative committee and
				the Wexner medical center board.
(c) Requests for the exercise and delineation of clinical
				privileges must be made as part of each application for appointment or
				reappointment to the medical staff on the forms prescribed by the medical staff
				administrative committee. Every person in an administrative position who
				desires clinical privileges shall be subject to the same procedure as all other
				applicants. Requests for clinical privileges must be submitted to the chief of
				the clinical department in which the clinical privileges will be exercised.
				Clinical privileges requested other than during appointment or reappointment to
				the medical staff shall be submitted to the chief of the clinical department
				and such request must include documentation of relevant training or experience
				supportive of the request.
(d) The chief of the clinical department shall review each
				applicants request for clinical privileges and shall make a
				recommendation regarding clinical privileges to the medical director of
				credentialing. Requests for clinical privileges shall be evaluated based upon
				the applicants education, training, experience, demonstrated competence,
				references, and other relevant information including the direct observation and
				review of records of the applicants performance by the clinical
				department in which the clinical privileges are exercised. Whenever possible,
				the review should be of primary source information. The applicant shall have
				the burden of establishing qualifications and competence in the clinical
				privileges requested and shall have the burden of production of adequate
				information for the proper evaluation of qualifications.
(e) The applicants request for clinical privileges and the
				recommendation of the clinical department chief shall be forwarded to the
				credentials committee and shall be processed in the same manner as applications
				for appointment and reappointment pursuant to rule 3335-111-04 of the
				Administrative Code.
(f) Medical staff members who are granted new or initial
				privileges are subject to FPPE, which is a six-month period of focused
				monitoring and evaluation of practitioners professional performance.
				Following FPPE medical staff members with clinical privileges are subject to
				ongoing professional practice evaluation (OPPE), which information is factored
				into the decision to maintain existing privileges, to revise existing
				privileges, or to revoke an existing privilege prior to or at the time of
				renewal. FPPE and OPPE are fully detailed in medical staff policies that were
				approved by the medical staff administrative committee and the Wexner medical
				center board.
(g) Upon resignation, termination or expiration of the medical
				staff members faculty appointment or employment with the university for
				any reason, such medical staff appointment and clinical privileges of the
				medical staff member shall automatically expire.
(h) Medical staff members authorize the CHRI and clinics to share
				amongst themselves credentialing, quality and peer review information
				pertaining to the medical staff members clinical competence and/or
				professional conduct. Such information may be shared at initial appointment
				and/or reappointment and at any time during the medical staff members
				medical staff appointment to the medical staff of the CHRI.
(i) Medical staff members authorize the CHRI to release, in good
				faith and without malice, information to managed care organizations, regulating
				agencies, accreditation bodies and other health care entities for the purposes
				of evaluating the medical staff members qualifications pursuant to a
				request for appointment, clinical privileges, participation or other
				credentialing or quality matters.
(2) Temporary and special
			 privileges:
(a) Temporary privileges may be extended to a doctor of medicine,
				osteopathic medicine, dental surgery, psychologist, podiatry or to a licensed
				allied health professional upon completion of an application prescribed by the
				medical staff administrative committee, upon recommendation of the chief of the
				clinical department, and approval by the director of medical affairs. The
				director of medical affairs has been delegated responsibility by the Wexner
				medical center board to grant approval of temporary privileges. The temporary
				privileges granted shall be consistent with the applicants training and
				experience and with clinical department guidelines. Prior to granting temporary
				privileges, primary source verification of licensure and current competence
				shall be required. Temporary privileges shall be limited to situations which
				fulfill an important patient care need and shall not be granted for a period
				not to exceed one hundred twenty days.
(b) Temporary privileges may be extended to visiting medical
				faculty or for special activity as provided by the Ohio state medical or dental
				boards.
(c) Temporary privileges granted for locum tenens may be
				exercised for a maximum of one hundred twenty days, consecutive or not, any
				time during the twenty-four month period following the date they are
				granted.
(d) Practitioners granted temporary privileges will be restricted
				to the specific delineations for which the temporary privileges are granted.
				The practitioner will be under the supervision of the chair of the clinical
				department while exercising any temporary privileges granted.
(e) Practitioners exercising temporary privileges shall abide by
				medical staff bylaws, rules and regulations, and hospital and medical staff
				policies.
(f) Special privileges upon receipt of a written request for
				specific temporary clinical privileges and the approval of the clinical
				department chief, the chairperson of the academic department and the director
				of medical affairs, an appropriately licensed or certified practitioner of
				documented competence, who is not an applicant for medical staff membership,
				may be granted special clinical privileges for the care of one or more specific
				patients. Such privileges shall be exercised in accordance with the conditions
				specified in rule 3335-111-04 of the Administrative Code.
(g) The temporary and special privileges must also be in
				conformity with accrediting bodies standards and the rules and
				regulations of professional boards of Ohio.
(3) Expedited
			 privileges:
If the Wexner medical center board is not
			 scheduled to convene in a timeframe that permits the timely consideration of
			 the recommendation of a complete application by the medical staff
			 administrative committee, eligible applicants may be granted expedited
			 privileges by the quality and professional affairs committee of the Wexner
			 medical center board. Certain restrictions apply to the appointment and
			 granting of clinical privileges via the expedited process. These include but
			 are not limited to: an involuntary termination of medical staff membership at
			 another hospital, involuntary limitation, or reduction, denial or loss of
			 clinical privileges, a history of professional liability actions resulting in a
			 final judgment against the applicant, or a challenge by a state licensing
			 board.
(4) Podiatric
			 privileges:
(a) Practitioners of podiatry may admit patients to the CHRI if
				such patients are being admitted solely to receive care that a podiatrist may
				provide without medical assistance, pursuant to the scope of the professional
				license of the podiatrist. Practitioners of podiatry must, in all other
				circumstances co-admit patients with a member of the medical staff who is a
				doctor of medicine or osteopathic medicine. A member of the medical staff who
				is a doctor of medicine or osteopathy shall:
(i) Be responsible for
				  any medical problems that the patient has while an inpatient of the CHRI;
				  and
(ii) Shall confirm the
				  findings, conclusions and assessment of risk prior to high-risk diagnosis or
				  therapeutic interventions defined by the medical staff.
(b) Practitioners of podiatry shall be responsible for the
				podiatric care of the patient including the podiatric history and physical
				examination and all appropriate elements of the patients
				record.
(c) The podiatrist shall be responsible to the chief of the
				department of orthopaedics.
(5) Psychology
			 privileges:
(a) Psychologists shall be granted clinical privileges based upon
				their training, experience and demonstrated competence and judgment consistent
				with their license to practice. Psychologists shall not prescribe drugs, or
				perform surgical procedures, or in any other way practice outside the area of
				their approved clinical privileges or expertise unless otherwise authorized by
				law.
(b) Psychologists may not admit patients to the CHRI, but may
				diagnose and treat a patients psychological illness as part of the
				patients comprehensive care while hospitalized. All patients admitted
				for psychological care shall receive the same medical appraisal as all other
				hospitalized patients. A member of the medical staff who is a doctor of
				medicine or osteopathic medicine shall admit the patient and shall be
				responsible for the history and physical and any medical care that may be
				required during the hospitalization, and shall determine the appropriateness of
				any psychological therapy based on the total health status of the patient.
				Psychologists may provide consultation within their area of expertise on the
				care of patients within the CHRI. In ambulatory settings, psychologists shall
				diagnose and treat their patients psychological illness. Psychologists
				shall ensure that their patients receive referral for appropriate medical
				care.
(c) Psychologists shall be responsible to the chief of the
				clinical department in which they are appointed.
(6) Dental
			 privileges:
(a) Practitioners of dentistry, who have not been granted
				clinical privileges as oral and maxillofacial surgeons, may admit patients to
				the CHRI if such patients are being admitted solely to receive care which a
				dentist may provide without medical assistance, pursuant to the scope of the
				professional license of the dentist. Practitioners of dentistry must, in all
				other circumstances, co-admit patients with a member of the medical staff who
				is a doctor of medicine or osteopathic medicine.
(b) A member of the medical staff who is a doctor of medicine or
				osteopathy:
(i) Shall be responsible
				  for any medical problems that the patient has while an inpatient of the CHRI;
				  and
(ii) Shall confirm the
				  findings, conclusions and assessment of risk prior to high-risk diagnoses or
				  therapeutic interventions defined by the medical staff.
(c) Practitioners of dentistry shall be responsible for the
				dental care of the patient including the dental history and physical
				examination and all appropriate elements of the patients
				record.
(7) Oral and
			 maxillofacial surgical privileges:
All patients admitted to the CHRI for oral and
			 maxillofacial surgical care shall receive the same medical appraisal as all
			 other hospitalized patients. Qualified oral and maxillofacial surgeons shall
			 admit patients, shall be responsible for the plan of care for the patients,
			 shall perform the medical history and physical examination, if they have such
			 privileges, in order to assess the medical, surgical, and anesthetic risks of
			 the proposed operative and other procedure(s), and shall be responsible for the
			 medical care that may be required at the time of admission or that may arise
			 during hospitalization.
(8) Licensed allied
			 health professionals:
(a) Clinical privileges may be exercised by licensed allied
				health professionals who are duly licensed in the state of Ohio and who are
				either:
(i) Members of the
				  faculty of the Ohio state university, or
(ii) Employees of the
				  Ohio state university whose employment involves the exercise of clinical
				  privileges, or
(iii) Employees of
				  members of the medical staff.
(b) A licensed allied health professional as used herein, shall
				not be eligible for medical staff membership but shall be eligible to exercise
				those clinical privileges granted pursuant to university bylaws and in
				accordance with applicable Ohio state law. If granted such privileges under
				this rule and in accordance with applicable Ohio state law, other licensed
				allied health professionals may perform all or part of the medical history and
				physical examination of the patient. Licensed health care professionals with
				privileges are subject to FPPE and OPPE.
(c) Licensed allied health professionals shall apply and re-apply
				for clinical privileges on forms prescribed by the medical staff administrative
				committee and shall be processed in the same manner as provided in rule
				3335-111-04 of the Administrative Code.
(d) Licensed allied health professionals are not members of the
				medical staff but may write admitting orders for patients of the CHRI when
				granted such privileges under this rule and in accordance with applicable Ohio
				state law. If such privileges are granted, the patient will be admitted under
				the medical supervision of the responsible medical staff member. Licensed
				allied health professionals are not members of the medical staff and shall not
				be eligible to hold office, to vote on medical staff affairs, or to serve on
				standing committees of the medical staff unless specifically authorized by the
				medical staff administrative committee.
(e) Each licensed allied health professional shall be
				individually assigned to a clinical department and shall be supervised by or
				collaborate with one or more members of the medical staff as required by Ohio
				law. The licensed health care professionals clinical privileges are
				contingent upon the collaborating/supervising medical staff members
				privileges. In the event that the collaborating/supervising medical staff
				member loses privileges or resigns, the licensed allied health care
				professionals whom he or she has supervised shall be placed on administrative
				hold until another collaborating/ supervising medical staff member is assigned.
				The new collaborating/supervising medical staff member shall be assigned in
				less than thirty days.
(f) Licensed allied health professionals must comply with all
				limitations and restrictions imposed by their respective licenses,
				certifications, or legal credentials as required by Ohio law, and may only
				exercise those clinical privileges granted in accordance with provisions
				relating to their respective professions.
(g) Only applicants who can document the following shall be
				qualified for clinical privileges as a licensed allied health
				professional:
(i) Current license,
				  certification, or other legal credential required by Ohio law;
(ii) Certificate of
				  authority, standard care arrangement/agreement, or utilization
				  plan;
(iii) Education,
				  training, professional background and experience, and professional
				  competence;
(iv) Patient care quality
				  indicators definition for initial appointment. This data will be in a format
				  determined by the licensed allied health professional subcommittee and the
				  quality management department of the Ohio state university Wexner medical
				  center;
(v) Adherence to the
				  ethics of the profession for which an individual holds a license,
				  certification, or other legal credential required by Ohio law;
(vi) Evidence of required
				  immunization;
(vii) Evidence of good
				  personal and professional reputation as established by peer
				  recommendations;
(viii) Satisfactory
				  physical and mental health to perform requested clinical privileges;
				  and
(ix) Ability to work with
				  members of the medical staff and the CHRI employees.
(h) The applicant shall have the burden to produce documentation
				with sufficient adequacy to assure the medical staff and the CHRI that any
				patient cared for by the licensed allied health professional seeking clinical
				privileges shall be given quality care, and that the efficient operation of the
				CHRI will not be disrupted by the applicants care of patients in the
				CHRI.
(i) By applying for clinical privileges as a licensed allied
				health professional, the applicant agrees to the following terms and
				conditions:
(i) The applicant has
				  read the bylaws and rules and regulations of the medical staff of the CHRI and
				  agrees to abide by all applicable terms of such bylaws and any applicable rules
				  and regulations, including any subsequent amendments thereto, and any
				  applicable CHRI policies that the CHRI may from time to time put into
				  effect;
(ii) The applicant
				  releases from liability all individuals and organizations who provide
				  information to the CHRI regarding the applicant and all members of the medical
				  staff, the CHRI staff and the Wexner medical center board and the Ohio state
				  university board of trustees for all acts in connection with investigating and
				  evaluating the applicant;
(iii) The applicant shall
				  not deceive a patient as to the identity of any practitioner providing
				  treatment or service in the CHRI;
(iv) The applicant shall
				  not make any statement or take any action that might cause a patient to believe
				  that the licensed allied health professional is a member of the medical staff;
				  and
(v) The applicant shall
				  obtain and continue to maintain professional liability insurance in such
				  amounts required by the medical staff.
(j) Licensed allied health care professionals shall be subject to
				quality review and corrective action as outlined in this paragraph for
				violation of these bylaws, their certificate of authority, standard of care
				agreement, utilization plan, or the provisions of their licensure, including
				professional ethics. Review may be requested by any member of the medical
				staff, a chief of the clinical department, or by the medical director of
				quality or the chief quality officer. All requests shall be in writing and
				shall be submitted to the chief quality officer. The chief quality officer,
				unless delegated to the medical director of quality, shall appoint a
				three-person committee to review and make recommendations concerning
				appropriate action. The committee shall consist of at least one licensed allied
				health care professional and one medical staff member. The committee shall make
				a written recommendation to the chief quality officer, unless delegated to the
				medical director of quality, who may accept, reject, or modify the
				recommendation. The chief quality officer, unless delegated to the medical
				director of quality shall forward his or her recommendation to the director of
				medical affairs for final determination.
(k) Appeal process.
(i) A licensed allied
				  health care professional may submit a notice of appeal to the chairperson of
				  the quality and professional affairs committee within thirty days of receipt of
				  written notice of any adverse corrective action pursuant to university
				  bylaws.
(ii) If an appeal is not
				  so requested within the thirty-day period, the licensed allied health care
				  professional shall be deemed to have waived the right to appeal and to have
				  conclusively accepted the decision of the director of medical
				  affairs.
(iii) The appellate
				  review shall be conducted by the chief of staff, the chair of the licensed
				  health care professionals subcommittee and one medical staff member from the
				  same discipline as the licensed allied health care professional under review.
				  The licensed allied health care professional under review shall have the
				  opportunity to present any additional information deemed relevant to the review
				  and appeal of the decision.
(iv) The affected
				  licensed allied health care professional shall have access to the reports and
				  records, including transcripts, if any, of the hearing committee and of the
				  medical staff administrative committee and all other material, favorable or
				  unfavorable, that has been considered by the chief quality officer. The
				  licensed allied health care professional shall submit a written statement
				  indicating those factual and procedural matters with which the member
				  disagrees, specifying the reasons for such disagreement. This written statement
				  may cover any matters raised at any step in the procedure to which the appeal
				  is related, and legal counsel may assist in its preparation. Such written
				  statement shall be submitted to the review committee no later than seven days
				  following the date of the licensed allied health care professionals
				  notice of appeal.
(v) New or additional
				  matters shall only be considered on appeal at the sole discretion of the
				  quality and professional affairs committee.
(vi) Within thirty days
				  following submission of the written statement by the licensed allied health
				  care professional, the chief of staff shall make a final recommendation to the
				  chair of the quality and professional affairs committee of the Wexner medical
				  center board. The quality and professional affairs committee of the Wexner
				  medical center board shall determine whether the adverse decision will stand or
				  be modified and shall recommend to the Ohio state university Wexner medical
				  center board that the adverse decision be affirmed, modified or rejected, or to
				  refer the matter back to the review committee for further review and
				  recommendation. Such referral to the review committee may include a request for
				  further investigation.
(vii) Any final decision
				  by the Wexner medical center board shall be communicated by the chief quality
				  officer and by certified return receipt mail to the last known address of the
				  licensed allied health care professional as determined by university records.
				  The chief quality officer shall also notify in writing the senior vice
				  president for health sciences, the dean of the college of medicine, the chief
				  executive officer of the CHRI and the vice president for health services and
				  the chief of the applicable clinical department or departments. The chief
				  quality officer, unless delegated to the medical director of quality, shall
				  take immediate steps to implement the final decision.
(9) Emergency
			 privileges:
In the case of an emergency, any member of the
			 medical staff to the degree permitted by the members license or
			 certification and regardless of department or medical staff status shall be
			 permitted to do everything possible to save the life of a patient using every
			 facility of the CHRI necessary, including the calling for any consultation
			 necessary or desirable. After the emergency situation resolves, the patient
			 shall be assigned to an appropriate member of the medical staff. For the
			 purposes of this paragraph, an "emergency" is defined as a
			 condition that would result in serious permanent harm to a patient or in which
			 the life of a patient is in immediate danger and any delay in administering
			 treatment would add to that danger.
(10) Disaster
			 privileges:
Disaster privileges may be granted in order to
			 provide voluntary services during a local, state or national disaster in
			 accordance with hospital/medical staff policy and only when the following two
			 conditions are present: the emergency management plan has been activated and
			 the hospital is unable to meet immediate patient needs. Such privileges may be
			 granted by the director of medical affairs or the medical director of
			 credentialing to fully licensed or certified, qualified individuals who at the
			 time of the disaster are not members of the medical staff. These privileges
			 will be limited in scope and will terminate once the disaster situation
			 subsides or at the discretion of the director of medical affairs temporary
			 privileges are granted thereafter.
(11) Telemedicine:
Telemedicine involves the use of electronic
			 communication or other communication technologies to provide or support
			 clinical care at a distance. Diagnosis and treatment of a patient may now be
			 performed via telemedicine link. 
(a) A member of the medical staff who wishes to utilize
				electronic technologies (telemedicine) to render care must so indicate on the
				application for clinical privileges form.
(b) A member of the medical staff may request to exercise via
				telemedicine the same clinical privileges he or she has already been granted.
				The credentials committee, the chief of the clinical service, medical director
				of credentialing, the director of medical affairs or the medical staff
				administrative committee, and the Wexner medical center board shall have the
				prerogative of requiring documentation or making a determination of the
				appropriateness of the exercise of a particular specialty/subspecialty via
				telemedicine.