DHS 124.07(6)
(6) Records of health assessments. The hospital's employee health program shall include maintenance of an updated record of each employee's health assessments.
DHS 124.07 History
History: Cr.
Register, January, 1988, No. 385, eff. 2-1-88.
DHS 124.08(1)(1)
Program. The hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the prevention, control and investigation of infections and communicable diseases.
DHS 124.08(2)(a)(a) Purpose. The governing body or medical staff shall establish an infection control committee to carry out surveillance and investigation of infections in the hospital and to implement measures designed to reduce these infections to the extent possible.
DHS 124.08(2)(b)
(b) Composition. The infection control committee shall be a hospital or medical staff committee which shall include members from the medical and nursing staffs, the laboratory service and the hospital's administrative staff.
DHS 124.08(2)(c)1.
1. Establish techniques and systems for discovering and isolating infections occurring in the hospital;
DHS 124.08(2)(c)2.
2. Establish written infection control policies and procedures which govern the use of aseptic technique and procedures in all areas of the hospital;
DHS 124.08(2)(c)3.
3. Establish a method of control used in relation to the sterilization and disinfection of instruments, medications, and other items requiring sterility and disinfection. There shall be a written policy requiring identification of sterile items and specified time periods in which sterile items shall be reprocessed;
DHS 124.08(2)(c)4.
4. Establish policies specifying when individuals with specified infections or contagious conditions, including carriers of infectious organisms, shall be relieved from or reassigned duties. These individuals shall remain relieved or reassigned until there is evidence that the disease or condition no longer poses a significant risk to others; and
DHS 124.08(2)(c)5.
5. Annually review infection control policies, procedures, systems and techniques.
DHS 124.08(3)
(3) Education. The hospital shall provide training to all appropriate hospital personnel on the epidemiology, etiology, transmission, prevention and elimination of infection, as follows:
DHS 124.08(3)(a)
(a) Aseptic technique. All appropriate personnel shall be educated in the practice of aseptic techniques such as handwashing and scrubbing practices, personal hygiene, masking, dressing, gloving and other personal protective equipment, techniques, disinfecting and sterilizing techniques and the handling and storage of patient care equipment and supplies.
DHS 124.08(3)(b)
(b) Orientation and inservice. New employees shall receive appropriate orientation and on-the-job training, and all employees shall participate in a continuing inservice program. This participation shall be documented.
DHS 124.08(4)(a)(a) Inspection and cleaning. There shall be regular inspection and cleaning of air intake sources, screens and filters, with special attention given to high risk areas of the hospital as determined by the infection control committee.
DHS 124.08(4)(b)
(b) Sanitary environment. A sanitary environment shall be maintained to avoid sources and transmission of infection.
DHS 124.08(4)(c)
(c) Disposal of wastes. Proper facilities shall be maintained and techniques used for incineration or sterilization of infectious wastes, and sanitary disposal of all other wastes.
DHS 124.08(4)(d)1.1. Handwashing facilities shall be provided in patient care areas for the use of hospital personnel.
DHS 124.08(4)(d)2.
2. Handwashing facilities in patient care areas used by physicians and hospital staff shall be equipped with special valves that do not require direct hand contact. Provision of wrist-actuated, spade-type handles or foot pedals shall be considered minimal compliance with this rule.
DHS 124.08(4)(e)
(e) Sterilizing and disinfecting services. Sterilizing services shall be available at all times.
DHS 124.08(4)(f)1.1. Soiled linen may not be sorted in any section of the nursing unit or common hallway.
DHS 124.08(4)(f)2.
2. Soiled linen shall be placed immediately in a container available for this purpose and sent to the laundry promptly.
DHS 124.08(5)
(5) Reporting disease. Hospitals shall report cases and suspected cases of reportable communicable disease to local public health officers and to the department pursuant to
ch. DHS 145.
DHS 124.08 History
History: Cr.
Register, January, 1988, No. 385, eff. 2-1-88; correction in (5) made under s. 13.93 (2m) (b) 7., Stats.,
Register, January, 1999, No. 517;
CR 04-040: am. (2) (c) 3., (3) (a), (4) (c), and (f) 2.
Register November 2004 No. 587, eff. 12-1-04; correction in (5) made under s. 13.92 (4) (b) 7., Stats.,
Register January 2009 No. 637.
DHS 124.09(1)(1)
Purpose. The hospital shall maintain a health sciences library to meet the needs of hospital staff.
DHS 124.09(2)
(2) Contents. The materials in the health sciences library shall be organized, easily accessible, and available at all times to the medical and hospital staff. The library shall contain current textbooks, journals, and nonprint media pertinent to services offered in the hospital.
DHS 124.09 History
History: Cr.
Register, January, 1988, No. 385, eff. 2-1-88.
DHS 124.10(1)(1)
Responsibility of the governing body. The governing body shall ensure that the hospital has a written quality assurance program for monitoring and evaluating the quality of patient care and the ancillary services in the hospital on an ongoing basis. The program shall promote the most effective and efficient use of available health facilities and services consistent with patient needs and professionally recognized standards of health care.
DHS 124.10(2)
(2) Responsibilities of the chief executive officer and the chief of the medical staff. As part of the quality assurance program, the chief executive officer and chief of the medical staff shall ensure that:
DHS 124.10(2)(a)
(a) The hospital's quality assurance program is implemented and effective for all patient care related services;
DHS 124.10(2)(b)
(b) The findings of the program are incorporated into a well defined method of assessing staff performance in relation to patient care; and
DHS 124.10(2)(c)
(c) The findings, actions and results of the hospital's quality assurance program are reported to the governing body as necessary.
DHS 124.10(3)
(3) Evaluation of care to be problem-focused. Monitoring and evaluation of the quality of care given patients shall focus on identifying patient care problems and opportunities for improving patient care.
DHS 124.10(4)
(4) Evaluation of care to use variety of resources. The quality of care given patients shall be evaluated using a variety of data sources, including medical records, hospital information systems, peer review organization data and, when available, third party payer information.
DHS 124.10(5)
(5) Activities. For each of the monitoring and evaluation activities, a hospital shall document how it has used data to initiate changes that improve quality of care and promote more efficient use of facilities and services. Quality assurance activities shall:
DHS 124.10(5)(a)
(a) Emphasize identification and analysis of patterns of patient care and suggest possible changes for maintaining consistently high quality patient care and effective and efficient use of services;
DHS 124.10(5)(b)
(b) Identify and analyze factors related to the patient care rendered in the facility and, where indicated, make recommendations to the governing body, chief executive officer and chief of the medical staff for changes that are beneficial to patients, staff, the facility and the community; and
DHS 124.10(5)(c)
(c) Document the monitoring and evaluation activities performed and indicate how the results of these activities have been used to institute changes to improve the quality and appropriateness of the care provided.
DHS 124.10(6)
(6) Evaluation of the program. The chief executive officer shall ensure that the effectiveness of the quality assurance program is evaluated by clinical and administrative staffs at least once a year and that the results are communicated to the governing body.
DHS 124.10 History
History: Cr.
Register, January, 1988, No. 385, eff. 2-1-88.
DHS 124.10 Note
Note: See the table of Appellate Court Citations for Wisconsin appellate cases citing s. HSS 124.10.
DHS 124.11(1)(a)(a) Requirement. Every hospital shall have in operation a written utilization review plan designed to ensure that quality patient care is provided in the most appropriate, cost-effective manner. The utilization review program shall address potential over-utilization and under-utilization for all categories of patients, regardless of source of payment.
DHS 124.11(1)(b)
(b) Description of plan. The written utilization review plan shall include at least the following:
DHS 124.11(1)(b)1.
1. A delineation of the responsibilities and authority of persons involved in the performance of utilization review activities, including members of the medical staff, any utilization review committee, non-physician health care professionals, administrative personnel and, when applicable, any qualified outside organization contracting to perform review activities specified in the plan;
DHS 124.11(1)(b)2.
2. A conflict of interest policy stating that reviews may not be conducted by any person who has a proprietary interest in any hospital or by any person who was professionally involved in the care of the patient whose case is being reviewed;
DHS 124.11(1)(b)3.
3. A confidentiality policy applicable to all utilization review activities, including any findings and recommendations;
DHS 124.11(1)(b)4.
4. A description of the process by which the hospital identifies and resolves utilization-related problems, such as examining the appropriateness and medical necessity of admissions, continued stays and supportive services, as well as delays in the provision of supportive services. The following activities shall be incorporated into the process:
DHS 124.11(1)(b)4.c.
c. Documentation of specific actions taken to correct aberrant practice patterns or other utilization review problems; and
DHS 124.11(1)(b)5.
5. The procedures for conducting review, including the time period within which the review is to be performed following admission and in assigning continued stay review dates; and
DHS 124.11(1)(c)
(c) Responsibility for performance. The plan shall be approved by the medical staff, administration and governing body. The medical staff shall be responsible for performance of utilization review. The chief executive officer and hospital administrative staff shall ensure that the plan is effectively implemented.
DHS 124.11(2)(a)(a) Written measurable criteria that have been approved by the medical staff shall be used in reviews.
DHS 124.11(2)(b)
(b) Non-physician health care professionals may participate in the development of review criteria for their professional fields and in the conduct of reviews of services provided by their peers.
DHS 124.11(2)(c)
(c) Determinations regarding the medical necessity and appropriateness of care provided shall be based upon information documented in the medical record.
DHS 124.11(2)(d)
(d) The attending physician shall be notified whenever it is determined that an admission or continued stay is not medically necessary, and shall be afforded the opportunity to present his or her views before a final determination is made. At least 2 physician reviewers shall concur on the determination when the attending physician disagrees.
DHS 124.11(2)(e)
(e) Written notice of any decision that an admission or continued stay is not medically necessary shall be given to the appropriate hospital department, the attending physician and the patient no later than 2 days after the determination.
DHS 124.11(3)
(3) Records and reporting. Records shall be kept of hospital utilization review activities and findings. Regular reports shall be made to the executive committee of the medical staff and to the governing body. Recommendations relevant to hospital operations and administration shall be reported to administration.
DHS 124.11 History
History: Cr.
Register, January, 1988, No. 385, eff. 2-1-88.
DHS 124.11 Note
Note: See the table of Appellate Court Citations for Wisconsin appellate cases citing s. HSS 124.11.
DHS 124.12(1)(1)
Definition. In this section, "privileges"means the right to provide care to hospital patients in the area in which the person has expertise as a result of education, training and experience.
DHS 124.12(2)(a)(a) Organization and accountability. The hospital shall have a medical staff organized under by-laws approved by the governing body. The medical staff shall be responsible to the governing body of the hospital for the quality of all medical care provided patients in the hospital and for the ethical and professional practices of its members.
DHS 124.12(2)(b)
(b) Responsibility of members. Members of the medical staff shall comply with medical staff and hospital policies. The medical staff by-laws shall prescribe disciplinary procedures for infraction of hospital and medical staff policies by members of the medical staff. There shall be evidence that the disciplinary procedures are applied where appropriate.
DHS 124.12(3)(a)(a) Active staff. Regardless of any other categories of medical staff having privileges in the hospital, a hospital shall have an active staff which performs all the organizational duties pertaining to the medical staff. Active staff membership shall be limited to individuals who are currently licensed to practice medicine, podiatric medicine or dentistry. These individuals may be granted membership in accordance with the medical staff by-laws and rules, and in accordance with the by-laws of the hospital. A majority of the members of the active staff shall be physicians.
DHS 124.12(3)(b)
(b) Other staff. The medical staff may include one or more categories defined in the medical staff by-laws in addition to the active staff.
DHS 124.12(4)(a)1.1. Medical staff appointments shall be made by the governing body, taking into account recommendations made by the active staff.
DHS 124.12(4)(a)2.
2. The governing body shall ensure at least biennially that members of the medical staff are qualified legally and professionally for the positions to which they are appointed.
DHS 124.12(4)(a)3.
3. The hospital, through its medical staff, shall require applicants for medical staff membership to provide, in addition to other medical staff requirements, a complete list of all hospital medical staff memberships held within the 5 years prior to application.
DHS 124.12(4)(a)4.
4. Hospital medical staff applications shall require reporting of any malpractice action, any previously successful or currently pending challenge to licensure in this or another state, and any loss or pending action affecting medical staff membership or privileges at another hospital. The application shall permit use of the information only for purposes of determining eligibility for medical staff membership, and shall release the hospital from civil liability resulting from this use of the information. Pending actions may not be used as the sole criterion to deny membership or privileges.
DHS 124.12(4)(b)1.1. To select its members and delineate their privileges, the hospital medical staff shall have a system, based on definite workable standards, for evaluation of each applicant by a credentials committee which makes recommendations to the medical staff and to the governing body.
