DHS 124.12(4)(c)3. 3. Reappointments shall be made at least biennially and recorded in the minutes or files of the governing body. Reappointment policies shall provide for a periodic appraisal of each member of the staff, including consideration at the time of reappointment of information concerning the individual's current licensure, health status, professional performance, judgment and clinical and technical skills. Recommendations for reappointments shall be noted in the minutes of the meetings of the appropriate committee.
DHS 124.12(4)(c)4. 4. Temporary staff privileges may be granted for a limited period if the individual is otherwise properly qualified for membership on the medical staff.
DHS 124.12(4)(c)5. 5. A copy of the scope of privileges to be accorded the individual shall be distributed to appropriate hospital staff. The privileges of each staff member shall be specifically stated or the medical staff shall define a classification system. If a system involving classification is used, the scope of the categories shall be well-defined, and the standards which must be met by the applicant shall be clearly stated for each category.
DHS 124.12(4)(c)6. 6. If categories of hospital staff membership are established for allied health personnel not employed by the hospital, the necessary qualifications, privileges and rights shall be delineated in accordance with the medical staff by-laws.
DHS 124.12(5) (5)By-laws.
DHS 124.12(5)(a) (a) Adoption and purpose. By-laws shall be adopted by the medical staff and approved by the governing body to govern and enable the medical staff to carry out its responsibilities. The by-laws of the medical staff shall be a precise and clear statement of the policies under which the medical staff regulates itself.
DHS 124.12(5)(b) (b) Content. Medical staff by-laws and rules shall include:
DHS 124.12(5)(b)1. 1. A descriptive outline of medical staff organization;
DHS 124.12(5)(b)2. 2. A statement of the necessary qualifications which each member must possess to be privileged to work in the hospital, and of the duties and privileges of each category of medical staff;
DHS 124.12(5)(b)3. 3. A procedure for granting and withdrawing privileges to each member;
DHS 124.12(5)(b)4. 4. A mechanism for appeal of decisions regarding medical staff membership and privileges;
DHS 124.12(5)(b)5. 5. A definite and specific statement forbidding the practice of the division of fees between medical staff members;
DHS 124.12(5)(b)6. 6. Provision for regular meetings of the medical staff;
DHS 124.12(5)(b)7. 7. Provision for keeping timely, accurate and complete records;
DHS 124.12(5)(b)8. 8. Provision for routine examination of all patients upon admission and recording of the preoperative diagnosis prior to surgery;
DHS 124.12(5)(b)9. 9. A stipulation that a surgical operation is permitted only with the consent of the patient or the patient's legally authorized representative except in emergencies;
DHS 124.12(5)(b)10. 10. Statements concerning the request for and performance of consultations, and instances in which consultations are required; and
DHS 124.12(5)(b)11. 11. A statement specifying categories of personnel duly authorized to accept and implement medical staff orders. All orders shall be recorded and authenticated. All verbal and telephone orders shall be authenticated by the prescribing member of the medical staff in writing within 24 hours of receipt.
DHS 124.12(6) (6)Governance.
DHS 124.12(6)(a) (a) General. The medical staff shall have the numbers and kinds of officers necessary for the governance of the staff.
DHS 124.12(6)(b) (b) Officers. Officers shall be members of the active staff and shall be elected by the active staff, unless this is precluded by hospital by-laws.
DHS 124.12(7) (7)Meetings.
DHS 124.12(7)(a) (a) Number and frequency. The number and frequency of medical staff meetings shall be determined by the active staff and clearly stated in the by-laws of the medical staff.
DHS 124.12(7)(b) (b) Attendance. Attendance records shall be kept of medical staff meetings. Attendance requirements for each individual member shall be clearly stated in the by-laws of the medical staff.
DHS 124.12(7)(c) (c) Purpose. Full medical staff meetings shall be held to conduct the general business of the medical staff and to review the significant findings identified through the quality assurance program.
DHS 124.12(7)(d) (d) Minutes. Adequate minutes of all meetings shall be kept that are sufficient to document for those members who did not attend the meeting the general nature of the business conducted, the decisions reached, and the findings and recommendations of the medical staff.
DHS 124.12(8) (8)Committees.
DHS 124.12(8)(a) (a) Establishment. The medical staff shall establish committees of the medical staff and is responsible for their performance.
DHS 124.12(8)(b) (b) Executive committee. The medical staff shall have an executive committee to coordinate the activities and general policies of the various departments, act for the staff as a whole under limitations that may be imposed by the staff, and receive and act upon the reports of all other medical staff committees.
DHS 124.12(9) (9)Administrative structure.
DHS 124.12(9)(a) (a) Services. Hospitals may create services to fulfill medical staff responsibilities. Each autonomous service shall be organized and function as a unit.
DHS 124.12(9)(b) (b) Chief of service. Each service shall have a chief appointed in accordance with the medical staff by-laws. The chief of service shall be a member of the service and be qualified by training and experience to serve as chief of service. The chief of service shall be responsible for:
DHS 124.12(9)(b)1. 1. The administration of the service;
DHS 124.12(9)(b)2. 2. The quality of patient care;
DHS 124.12(9)(b)3. 3. Making recommendations to the hospital's administrative staff and governing board concerning the qualifications of the members of the service;
DHS 124.12(9)(b)4. 4. Making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and any other matters concerning patient care;
DHS 124.12(9)(b)5. 5. Arranging and implementing inpatient and outpatient programs, which include organizing, engaging in educational activities and supervising and evaluating the clinical work;
DHS 124.12(9)(b)6. 6. Enforcing the medical staff by-laws and rules within the service;
DHS 124.12(9)(b)7. 7. Cooperating with the hospital's administrative staff on purchase of supplies and equipment;
DHS 124.12(9)(b)8. 8. Formulating special rules and policies for the service;
DHS 124.12(9)(b)9. 9. Maintaining the quality of the medical records; and
DHS 124.12(9)(b)10. 10. Representing the service in a medical advisory capacity to the hospital's administrative staff and governing body.
DHS 124.12 History History: Cr. Register, January, 1988, No. 385, eff. 2-1-88.
subch. IV of ch. DHS 124 Subchapter IV — Services
DHS 124.13 DHS 124.13Nursing services.
DHS 124.13(1)(1)Nursing service.
DHS 124.13(1)(a)(a) Requirement. The hospital shall have a nursing service.
DHS 124.13(1)(b) (b) Administration.
DHS 124.13(1)(b)1.1. The nursing service shall be directed by a registered nurse with appropriate education and experience to direct the service. A registered nurse with administrative authority shall be designated to act in the absence of the director of the nursing service. Appropriate administrative staffing of the nursing service shall be provided on all shifts.
DHS 124.13(1)(b)2. 2. There shall be a written plan showing the flow of administrative authority throughout the nursing service, with delineation of the responsibilities and duties of each category of nursing staff.
DHS 124.13(1)(b)3. 3. The delineation of responsibilities and duties for each category of nursing staff shall be in the form of a written job description for each category.
DHS 124.13(1)(c) (c) Staffing.
DHS 124.13(1)(c)1.1. An adequate number of registered nurses shall be on duty at all times to meet the nursing care needs of the patients. There shall be qualified supervisory personnel for each service or unit to ensure adequate patient care management.
DHS 124.13(1)(c)2. 2. The number of nursing personnel for all patient care services of the hospital shall be consistent with nursing care needs of the hospital's patients.
DHS 124.13(1)(c)3. 3. The staffing pattern shall ensure the availability of registered nurses to assess, plan, implement and direct the nursing care for all patients on a 24-hour basis.
DHS 124.13(2) (2)Patient care.
DHS 124.13(2)(a) (a) Care planning.
DHS 124.13(2)(a)1.1. All nursing care shall be planned and directed by registered nurses. A registered nurse shall be immediately available to give direct patient care when needed.
DHS 124.13(2)(a)2. 2. A registered nurse who is not occupied in the operating room, delivery room or emergency room shall be available at all times to render direct care.
DHS 124.13(2)(b) (b) Care determinants.
DHS 124.13(2)(b)1.1. A registered nurse shall assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the preparation and competence of the available nursing staff.
DHS 124.13(2)(b)2.a.a. The ratio of registered nurses to patients and the ratio of registered nurses to other allied health care personnel shall be determined by the seriousness of patient illness or injury, the patient census, and the complexity of care that must be provided, and shall be adequate to provide proper care and supervision of staff performance.
DHS 124.13(2)(b)2.b. b. A registered nurse shall plan, supervise and evaluate the care of all patients, including the care assigned to other nursing personnel.
DHS 124.13(2)(b)2.c. c. There shall be other nursing personnel in sufficient numbers to provide nursing care not requiring the services of a registered nurse.
DHS 124.13(3) (3)Staff qualifications.
DHS 124.13(3)(a) (a) Qualifications.
DHS 124.13(3)(a)1.1. Individuals selected for the nursing staff shall be qualified by education, experience, and demonstrated ability for the positions to which they are appointed.
DHS 124.13(3)(a)2. 2. The educational and experiential qualifications of the director of nursing, the director of nursing assistants and nursing supervisors shall be commensurate with the scope and complexity of the services of the hospital.
DHS 124.13(3)(a)3. 3. The functions and qualifications of nursing personnel shall be clearly defined in relation to the duties and responsibilities delegated to them.
DHS 124.13(3)(a)4. 4. Personnel records, including application forms and verifications of credentials, shall be on file.
DHS 124.13(3)(a)5. 5. Nursing management shall make decisions about the selection and promotion of nursing personnel based on their qualifications and capabilities and shall recommend termination of employment when necessary.
DHS 124.13(3)(b) (b) Approval. There shall be a procedure to ensure that hospital nursing personnel for whom registration, a license or other approval is required by law have valid and current registration, licensure or other approval.
DHS 124.13(4) (4)Orientation and inservice.
DHS 124.13(4)(a) (a) Orientation. There shall be a comprehensive and thorough job orientation program for all nursing service personnel. The facility shall provide orientation to nursing service personnel before they provide care to patients.
DHS 124.13(4)(b) (b) Training. There shall be appropriate, ongoing training programs available to all nursing service personnel to augment their knowledge of pertinent new developments in patient care and to maintain current competence.
DHS 124.13(5) (5)Hospital relationships.
DHS 124.13(5)(a) (a) General. The nursing service shall have well-established working relationships with the medical staff and with other hospital staffs that provide and contribute to patient care.
DHS 124.13(5)(b) (b) Policies. Hospital policies affecting the nursing service shall be developed and reviewed with the participation of the director of nursing or designee. The nursing service shall be represented on hospital committees that affect patient care policies and practices.
DHS 124.13(6) (6)Documentation, staff meetings and evaluation.
DHS 124.13(6)(a)(a) Nursing care policies and procedures that reflect optimal standards of nursing practice shall be in writing and shall be reviewed and revised as necessary to keep pace with current knowledge. Written nursing care policies and procedures shall be available on each nursing unit.
DHS 124.13(6)(b) (b) There shall be a written nursing care plan for each patient which shall include the elements of assessment, planning, intervention and evaluation.
DHS 124.13(6)(c) (c) Documentation of nursing care shall be pertinent and concise and shall describe patient needs, problems, capabilities and limitations. Nursing interventions and patient responses shall be noted.
DHS 124.13(6)(d) (d) Meetings of the registered nursing staff shall be held at least bimonthly to discuss patient care, nursing service problems and administrative policies. Minutes of all meetings shall be kept and shall be available to all staff members.
DHS 124.13(6)(e) (e) The nursing service director shall ensure that there is ongoing review and evaluation of the nursing care provided for patients and shall ensure that nursing care standards and objectives are established and met.
DHS 124.13(6)(f) (f) When the nursing department is decentralized into clinical departmental services or clinical programs are established, the hospital shall have one administrator to whom the nursing directors shall be accountable and who has the responsibility for maintenance of one standard of nursing practice within the organization.
DHS 124.13(7) (7)Additional patient care requirements.
DHS 124.13(7)(a)(a) Definition. In this subsection, “circulating nurse" means a registered nurse who is present during an operation or infant delivery to provide emotional support to the patient, assist with the anesthesia induction and, throughout the surgical procedure or delivery, to coordinate the activities of the room, monitor the traffic in the room and maintain an accurate account of urine and blood loss and who, before the surgical procedure or delivery is completed, informs the recovery room of special needs and ensures that the sponge, needle and instrument counts have been done according to hospital policy.
DHS 124.13(7)(b) (b) Obstetrical. Every patient admitted in labor shall be assessed initially by a registered nurse. There shall be a circulating nurse at every infant delivery.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.