“Variance" means an alternative requirement in place of a requirement of this chapter.
“Waiver" means an exception from a requirement of this chapter.
(2) Requirements for waivers and variances.
A hospital may ask the department to grant a waiver or variance. The department may grant the waiver or variance if the department finds that the waiver or variance will not adversely affect the health, safety or welfare of any patient and that:
Strict enforcement of a requirement would result in unreasonable hardship on the hospital or on a patient; or
An alternative to a rule, which may involve a new concept, method, procedure or technique, new equipment, new personnel qualifications or the conduct of a pilot project, is in the interests of better care or management.
All applications for the grant of a waiver or variance shall be made in writing to the department, specifying the following:
If the request is for a variance, the specific alternative action which the facility proposes;
The department may require additional information from the hospital prior to acting on the request.
The department shall grant or deny each request for waiver or variance in writing. Notice of a denial shall contain the reasons for denial.
The terms of a requested variance may be modified upon agreement between the department and the hospital.
The department may impose whatever conditions on the granting of a waiver or variance it considers necessary.
A hospital may contest the department's action on the hospital's application for a waiver or variance by requesting a hearing as provided by ch. 227
The hospital shall sustain the burden of proving that the denial of a waiver or variance is unreasonable.
The department may revoke a waiver or variance, subject to the hearing requirement in par. (c)
The department determines that the waiver or variance is adversely affecting the health, safety or welfare of the patients;
The hospital has failed to comply with the variance as granted or with a condition of the waiver or variance;
The person who has received the certificate of approval notifies the department in writing that the hospital wishes to relinquish the waiver or variance and be subject to the rule previously waived or varied; or
DHS 124.04 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88.
The hospital shall have an effective governing body or a designated person who functions as the governing body which is legally responsible for the operation and maintenance of the hospital.
The governing body shall adopt by-laws. The by-laws shall be in writing and shall be available to all members of the governing body. The by-laws shall:
Stipulate the basis upon which members are selected, their terms of office and their duties and requirements;
Specify to whom responsibilities for operation and maintenance of the hospital, including evaluation of hospital practices, may be delegated, and the methods established by the governing body for holding these individuals responsible;
Provide for the designation of officers, if any, their terms of office and their duties, and for the organization of the governing body into committees;
Provide mechanisms for the formal approval of the organization, by-laws and rules of the medical staff.
The governing body shall meet at regular intervals as stated in its by-laws.
Meetings shall be held frequently enough for the governing body to carry on necessary planning for hospital growth and development and to evaluate the performance of the hospital, including the care and utilization of physical and financial assets and the procurement and direction of personnel.
Minutes of meetings shall reflect pertinent business conducted, and shall be distributed to members of the governing body.
The governing body shall appoint committees. There shall be an executive committee and others as needed.
The number and types of committees shall be consistent with the size and scope of activities of the hospital.
The executive committee or the governing body as a whole shall establish policies for the activities and general policies of the various hospital services and committees established by the governing body.
Written minutes or reports which reflect business conducted by the executive committee shall be maintained for review by the governing body.
Other committees, including the finance, joint conference, and plant and safety management committees, shall function in a manner consistent with their duties as assigned by the governing body and shall maintain written minutes or reports which reflect the performance of these duties. If the governing body does not appoint a committee for a particular area, a member or members of the governing body shall assume the duties normally assigned to a committee for that area.
(d) Medical staff liaison.
The governing body shall establish a formal means of liaison with the medical staff by means of a joint conference committee or other appropriate mechanism, as follows:
A direct and effective method of communication with the medical staff shall be established on a formal, regular basis, and shall be documented in written minutes or reports which are distributed to designated members of the governing body and the active medical staff under s. DHS 124.12 (3) (a)
Liaison shall be a responsibility of the joint conference committee, the executive committee or designated members of the governing body.
(e) Medical staff appointments.
The governing body shall appoint members of the medical staff in accordance with s. 50.36 (3)
, Stats., as follows:
A formal procedure shall be established, governed by written rules covering application for medical staff membership and the method of processing applications;
The procedure related to the submission and processing of applications shall involve the administrator, the credentials committee of the medical staff or its counterpart, and the governing body;
The selection of physicians, dentists and podiatrists and definition of their medical, dental or podiatric privileges, both for new appointments and reappointments, shall be based on written criteria;
Action taken by the governing body on applications for medical staff appointments shall be in writing;
Written notification of applicants shall be made by either the governing body or its designated representative;
Applicants selected for medical staff appointment shall sign an agreement to abide by the medical staff by-laws and rules; and
The governing body shall establish a procedure for appeal and hearing by the governing body or a committee designated by the governing body if the applicant or the medical staff wishes to contest the decision on an application for medical staff appointment.
(f) Appointment of chief executive officer.
The governing body shall appoint a chief executive officer for the hospital. The governing body shall annually review the performance of the chief executive officer.
(g) Patient care.
The governing body shall establish a policy which requires that every patient be under the care of a physician, dentist or podiatrist. The policy shall provide that:
A person may be admitted to a hospital only on the recommendation of a physician, dentist or podiatrist, with a physician designated to be responsible for the medical aspects of care; and
A member of the house staff or another physician shall be on duty or on call at all times.
The governing body shall be responsible for providing a physical plant equipped and staffed to maintain the needed facilities and services for patients.
The governing body shall receive periodic written reports from appropriate inside and outside sources about the adequacy of the physical plant and equipment and the personnel operating the physical plant and equipment, as well as about any deficiencies.
The governing body shall arrange financing for the physical plant and for staffing and operating the hospital, and shall adopt an annual budget for the institution.
The governing body shall ensure that the hospital maintains an effective, ongoing program coordinated with community resources to facilitate the provision of follow-up care to patients who are discharged.
The governing body shall ensure that the hospital has current information on community resources available for continuing care of patients following their discharge.
Be reviewed periodically for timely initiation of discharge planning on an individual patient basis;
Provide that every patient receive relevant information concerning continuing health needs and is appropriately involved in his or her own discharge planning;
Be reviewed at least once a year and more often if necessary to ensure the appropriate disposition of patients; and
Allow for the timely and effective transmittal of all appropriate medical, social, and economic information concerning the discharged patient to persons or facilities responsible for the subsequent care of the patient.
Every hospital shall have written policies established by the governing board on patient rights and responsibilities which shall provide that:
A patient may not be denied appropriate hospital care because of the patient's race, creed, color, national origin, ancestry, religion, sex, sexual orientation, marital status, age, newborn status, handicap or source of payment;
Patients shall be treated with consideration, respect and recognition of their individuality and personal needs, including the need for privacy in treatment;
The patient's medical record, including all computerized medical information, shall be kept confidential;
The patient or any person authorized by law shall have access to the patient's medical record;
Every patient shall be entitled to know who has overall responsibility for the patient's care;
Every patient, the patient's legally authorized representative or any person authorized in writing by the patient shall receive, from the appropriate person within the facility, information about the patient's illness, course of treatment and prognosis for recovery in terms the patient can understand;
Every patient shall have the opportunity to participate to the fullest extent possible in planning for his or her care and treatment;
Every patient or his or her designated representative shall be given, at the time of admission, a copy of the hospital's policies on patient rights and responsibilities;
Except in emergencies, the consent of the patient or the patient's legally authorized representative shall be obtained before treatment is administered;