policies governing medical practices

T:\Bylaws and Policies\Aurora Oshkosh Policies Governing Medical 05-21-18.doc

POLICIES GOVERNING MEDICAL PRACTICES

AURORA MEDICAL CENTER

Oshkosh, Wisconsin

1 T:\Bylaws and Policies\Aurora Oshkosh Policies Governing Medical 05-21-18.doc

MEDICAL STAFF POLICY GOVERNING MEDICAL PRACTICES

Subject: Telemedicine ICU Privileges

Policy Statement: The Medical Center utilizes Aurora eICU® to provide an enhanced level of care to patients in Intensive Care Units via an electronic telemedicine link. This service meets the standards of the Joint Commission (“JCAHO”) related to telemedicine.

Guidelines:

A. The originating site for telemedicine ICU privileges shall be the Medical Center. The distant site shall be Aurora St. Luke’s Medical Center of Aurora Health Care Metro, Inc. (“ASLMC”), a JCAHO-accredited hospital.

B. Only physicians granted telemedicine ICU privileges at and in good standing on the Medical Staff of ASLMC shall be eligible for telemedicine ICU privileges at the Medical Center. A physician in good standing shall not:

1. Have received a suspension or curtailment of clinical privileges in the previous 12 months (other than an interim suspension for medical record completion delinquency);

2. Have entered into a monitoring or proctoring agreement with Medical Staff leadership;

3. Have entered into any other agreement to voluntarily restrict privileges or to restrict the right to apply for Medical Staff membership;

4. Be the subject of a formal investigation that has not concluded;

5. Have been denied Medical Staff membership; or

6. Have withdrawn an application for Medical Staff membership to avoid being denied Medical Staff membership.

C. Physicians on the Medical Staff at ASLMC who meet the privileging criteria established for telemedicine ICU privileges shall request such privileges at the Medical Center. Upon receipt of such a request:

1. The Medical Staff Services Department at the Medical Center will verify that the physician has telemedicine ICU privileges and is a member in good standing on the Medical Staff at ASLMC.

2. The Medical Center will process the privilege requests for telemedicine ICU privileges through its established credentialing and privileging


process, which results in a recommendation from the Medical Executive Committee to the Board of Directors for approval.

D. Telemedicine ICU privileges will be provided in accordance with a contract the physician or a telemedicine services organization with which the physician is affiliated enters into with Aurora Health Care, Inc. or an affiliate thereof.

E. Physicians who are granted telemedicine ICU privileges as their only privileges at the Medical Center shall be assigned to the Medical Center’s Telemedicine Medical Staff.

F. Physicians shall be deemed to have voluntarily resigned their Telemedicine Medical Staff membership and relinquished all clinical privileges (1) in accordance with Article IV Section 3.g. of the Medical Center’s Medical Staff Bylaws; and (2) when they fail to maintain membership in good standing at ASLMC.

G. The Medical Center shall evaluate physicians’ telemedicine ICU privileges at each reappointment utilizing performance-based data and quality data from ASLMC, the Aurora Health Care Telemedicine ICU Program, and the Medical Center.

H. The Medical Center, on an ongoing basis, shall share feedback with the Telemedicine ICU Program Director regarding the quality and effectiveness of the physicians’ interactions with ICU staff and attending physicians via the telemedicine ICU link. Such information shall be considered in evaluating the physicians’ eligibility for and maintenance of telemedicine ICU privileges.

I. Submission of photo identification and documentation of TB skin tests and rubella titers will not be required if telemedicine ICU privileges are the only privileges the physician exercises at the Medical Center. ASLMC shall be responsible for maintaining documentation regarding the physician’s TB skin tests and rubella titers.

References: JCAHO Standards MS. 06.01.03-06.01.13, 13.01.01 and 13.01.03,

2009

Form(s):

Medical Executive Committee Approval:

May 11, 2009

Board of Directors Approval:

May 26, 2009



Subject: Admission, Transfer and Discharge of Patients Policy Statement: It is the policy of the Medical Staff to ensure the following

guidelines for admission, transfer and discharge of patients are consistently observed.

Guidelines:

A. Admission

1. A patient shall be admitted to the Medical Center only by a member of the Active, Associate, or Courtesy Medical Staff in accordance with the privileges they have been granted.

B. Responsibility

1. An appointee to the Medical Staff shall be responsible for the care and treatment of each patient in the Medical Center, for the prompt completion and accuracy of those portions of the medical record for which he or she is responsible, for necessary special instructions, and for transmitting reports of the condition of the patient to the patient, to the referring practitioner, if any, and to relatives of the patient. Primary practitioner responsibility for these matters belongs to the admitting practitioner. When the admitting practitioner is a dentist, oral surgeon, or podiatrist, a physician shall be responsible for the medical care and treatment of such patient.

2. When primary responsibility for a patient’s care is transferred from the admitting or current attending practitioner to another Medical Staff appointee, documentation of the transfer of responsibility and acceptance of the same shall be entered on the order sheet and progress notes.

3. Each practitioner shall assure timely, adequate professional care for his or her patients in the Medical Center by being available or designating a qualified alternate practitioner with whom prior arrangements have been made to attend to practitioner’s patients when the practitioner is unavailable. The alternate shall possess the same or similar clinical privileges at the Medical Center as the practitioner and be qualified to provide any required emergency medical treatment or services and any interventional treatment or services to the practitioner’s patients. The practitioner shall notify his or her alternate of (i) when the practitioner expects to be unavailable and (ii) when the alternate shall accept responsibility for the practitioner’s patients. Failure to notify the alternate of unavailability shall be considered a serious breach of these Policies Governing Medical Practices and may be a basis for disciplinary action. If


there is no qualified alternate available, the practitioner shall continue to provide twenty-four (24) hour care to practitioner’s patients.

a. Each appointee to the Medical Staff who will be out of town or unavailable in case of emergency shall indicate, in writing on the Integrated Progress Note, the name of the practitioner who shall be assuming responsibility for the care of the patient during such practitioner’s absence. In the absence of such designation, the Administrator, the Chief of Staff or the applicable Clinical Chairperson has the authority to call any appointee to the Medical Staff with the requisite clinical privileges to assume care of the patient.

C. Admission Diagnoses

1. Except in an emergency, no patient shall be admitted to the Medical Center until a provisional diagnosis or valid reason for admission has been stated. In the case of an emergency, such statement shall be recorded as soon as possible.

D. Emergency Admissions

1. Practitioners admitting patients as emergency admissions shall be prepared to justify the admission as a bona fide emergency. The history and physical examination shall clearly justify the patient being admitted on an emergency basis and these findings shall be recorded on the medical record as soon as possible after admission.

E. Frequency of Patient Attendance

1. All hospitalized patients will be seen on at least a daily basis by the attending physician, or his or her alternate or advanced practice professional. An advanced practice professional must have a current supervisory or collaborative agreement in place with the attending physician. For regular inpatient admissions, physicians should see their patients and document on a daily basis or may assign an alternate practitioner or advanced practice professional in their absence as defined above. For patients admitted to a nursing unit from the ER, the attending physician should see that patient within twelve (12) hours of admission. For patients admitted to the ICU from the ER, the attending physician should see that patient within six (6) hours of admission. These time frames are guidelines, and certain circumstances will require greater urgency.


F. Appointment of Staff Member

1. Each patient shall be attended by the physician, dentist, oral surgeon, or podiatrist of the patient’s choice, within the scope and limits of the practitioner’s privileges. A patient seeking admission to the Medical Center who does not or cannot designate his or her choice of a practitioner shall be referred to the member of the Medical Staff on emergency call who shall then arrange for appropriate care.

G. Admission Information

1. Practitioners admitting patients shall be held responsible for giving such information regarding the patient’s condition, including but not limited to alcohol or drug use or mental illness, as may be necessary to assure the protection of other patients and Medical Center personnel and Medical Staff from patients who maybe a source of danger to themselves or others, from any cause whatever.

2. All gunshot wounds, poisonings, self-inflicted wounds and attempted suicides, child abuse and animal bites shall be reported, if required by law, to the appropriate law enforcement agency.

H. Continued Stay

1. The attending practitioner is required to document the need for continued hospitalization after specific periods of stay as identified by the utilization review plan and/or criteria developed for concurrent review. This documentation shall contain an adequate written record of the reason for continued hospitalization (a simple reconfirmation of the patient’s diagnosis is not sufficient). This documentation may also contain:

a. The estimated period of time the patient shall need to remain in the Medical Center; and

b. Plans for post-hospital care.

I. Transfer

1. A patient shall be transferred to another medical care facility only upon the order of the attending practitioner, only after arrangements have been made for admission with the other facility, including its consent to receiving the patient, and only after the patient is considered sufficiently stabilized for transport. Patients who are not stabilized may be transferred to another facility if the attending physician certifies that the benefits outweigh the risks of the transfer. Such certification shall contain a summary of the risks and benefits upon which it is based. A transfer demanded by an emergency or critically ill patient or his or her family is


not permitted until the attending physician has explained the seriousness of the condition and the risks of transfer.

2. All pertinent medical information necessary to ensure continuity of care shall accompany the patient to the receiving facility.

J. Discharge

1. Patient shall be discharged only on an order of the attending practitioner. Should a patient leave the Medical Center against the advice of the attending practitioner, or without proper discharge, a notation of the incident shall be made in the patient’s medical record.

K. Death

1. In the event of a patient’s death, the deceased shall be pronounced dead by the attending physician or physician designee. The body shall not be released until the attending physician, or authorized alternate, has authorized such release. Exceptions shall be made in those instances of terminal disease wherein the patient’s course has been adequately documented to within a few hours of death. Except in cases of terminal illness, the physician shall be responsible for notifying immediate family of a patient death.

References: EMTALA 42 U.S.C. §1395dd 42 C.F.R. § 489.24 JCAHO Standards MS. 6, 2003

Form(s): Medical Executive Committee Approval:

October 22, 2003; March 14, 2005; April 14, 2014


October 23, 2003; April 1, 2005; April 21, 2014


PROVIDER ORDERS

POLICY STATEMENT

It is the policy of the Medical Staff to assure provider orders are properly entered, initiated, received and completed by appropriate staff in accordance with the following guidelines. All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

1. GENERALLY

1.1 Ordering Providers. Only a Practitioner or other individual acting within the scope of his/her license and the scope of his or her Clinical Privileges (as authorized by the Medical Center) is qualified to enter orders (the “Ordering Provider”). The Ordering Provider must ensure that the medical record contains documentation describing the diagnosis, condition or indication for each medication, diagnostic service, and therapeutic service ordered.1

1.2 Form, Legibility and Timeliness. All orders must include the patient’s complete name and medical record number and be entered into the medical record in full compliance with the form, legibility and timeliness requirements set forth in Aurora’s Medical Records Policy.

1.3 Symbols and Abbreviations. A list of unacceptable abbreviations, acronyms, symbols and dose designations shall be identified and approved by the Medical Executive Committee. An official record of such list is available at each nursing station, the Health Information Services Department and the Pharmacy Department. Only those symbols, abbreviations, acronyms and dose designations not on such list may be used.2

1.4 Incomplete, Unclear, Illegible or Unacceptable Orders.3 An order that is incomplete, unclear, illegible, contains unacceptable symbols or abbreviations, or is otherwise unacceptable will not be implemented until the order is clarified and, if appropriate, a new order issued. The Staff Member or Clinical Assistant responsible for implementation of the order shall contact the Ordering Provider for clarification and, if appropriate, issuance of a new order. Whenever possible, the Ordering Provider will re-issue the order with the clarifying details. If the Ordering Provider is not available, the Staff Member or Clinical Assistant responsible for implementation of the order shall contact one or more of the following individuals (listed in order of priority) for clarification: (a) the Ordering Provider’s designated alternate; (b) the patient’s attending physician; (c) an associate of the Ordering Provider who practices

1 JCS MM.04.01.01, EP 9 (Jan. 2010). 2 JCS NPSG.02.02.01, EP 3 (Jan. 2010). 3 JCS MM.04.01.01, EP 5 (Jan. 2010).


in the same specialty; (d) the Physician on call for the Ordering Provider’s service in the Emergency Department; and (e) the appropriate Clinical Chairperson.

1.5 Correction of Incomplete or Inaccurate Orders. An existing order may not be corrected, altered, added to, or modified in any way. If a change is necessary, the order must be discontinued and a new order must be entered by the Ordering Provider.

1.6 Non-Specific Orders Prohibited.4 The use of blanket or other non-specific orders is prohibited. All orders that are a resumption or continuation of a previous order must be re-entered in their entirety in the Computerized Physician Order Entry System (“CPOE”) by the Ordering Provider. Examples of unacceptable non-specific orders include, but are not limited to:

(a) “Continue previous medications”

(b) “Resume preoperative orders”

(c) “Resume orders from the floor”

(d) “Discharge on current medications”

(e) “Resume home medications”

(f) “Resume all previous orders for medications”

1.7 Authentication and Co-Signature.5

(a) Authentication. All orders must be dated, timed (using military time), and authenticated (by written signature, identifiable initials, or computer key) by the Ordering Provider.6 The use of an electronic signature is only acceptable if the individual has an attestation statement on file in the Health Information Services Department acknowledging that he or she is the only individual authorized to use the electronic signature. An order may not be authenticated by use of a rubber stamped signature.7 See also Section 2.4(d) regarding authentication of verbal orders.

(b) Co-Signature. In certain circumstances, orders must be co-signed by a Physician Medical Staff Member (e.g., certain entries by an Advanced Practice Professional must be co-signed by the Advanced Practice Professional’s supervising or collaborating Physician, and certain entries made by a Dentist or Podiatrist must

4 JCS MM.04.01.01, EP 8 (Jan. 2010). 5 42 CFR § 482.24(c)(1) (Interpretive Guidelines, effective October 17, 2008); JCS RC.01.02.01, EP 2 (2009) 6 42 CFR § 482.24(c)(1) (Interpretive Guidelines, effective October 17, 2008); JCS RC.01.01.01, EP 11; RC.01.02.01, EP 3-4 (Jan. 2010). 7 See CMS Manual System, Pub 100-08 Medicare Program Integrity, Transmittal 248, March 28, 2008; CMS MLN Matters Memo No. SE0829, CR 5971 Clarification related to Signature Requirements; CMS Memo, S&C-09-10, “Standing Orders” in Hospitals – Revisions to S&C Memoranda, October 24, 2008.


be co-signed by a Physician).8 Refer to Aurora’s Hospital Co-Signature Requirements Chart. The co-signing Physician accepts full professional and legal responsibility for the content of the order.

2. ENTRY OF ORDERS

2.1 Computerized Physician Order Entry. Except as otherwise provided in this Policy, all orders for medication, diagnostic services and therapeutic services must be entered into CPOE by the Ordering Provider.

2.2 Written Orders.

(a) Restrictions on Use of Written Orders. Written orders may NOT be used, unless:

i. a patient emergency precludes the Ordering Provider from directly entering and initiating the order in CPOE;

ii. the CPOE is not functioning;

iii. the Ordering Provider is unable to access CPOE because he/she is physically remote from the Medical Center and does not have access to CPOE; or

iv. the Ordering Provider is in the process of performing a procedure precluding direct order entry (e.g., OR/cath lab).

(b) Issuing a Written Order. A written order must be entered into the medical record on the physician order sheet.

2.3 Pre-Printed Order Sets.9 Pre-printed order sets may be used if they have been reviewed and approved under the Aurora Order Set Development and Governance System Policy.10 If an Ordering Provider uses a preprinted paper order set, the Ordering Provider must: (a) sign, date, and time the last page of the order set (the last page must identify the total number of pages in the order set); and (b) initial each place in the preprinted order set where changes, such as additions, deletions, or strike-outs of components that do not apply, have been made. It is not necessary to initial every preprinted box that is checked to indicate selection of an order option, as long as there are no changes made to the option(s) selected.

2.4 Verbal Orders.

(a) Restrictions on Use of Verbal Orders.

i. Verbal orders are strongly discouraged and should NOT be used, unless it would be permissible for the Ordering Provider to issue a written order (see

8 42 CFR § 482.24(c)(1) (Interpretive Guidelines, effective October 17, 2008). Aurora’s Hospital Co-Signature Requirements Chart. 9 42 CFR § 482.23(c)(2); CMS Transmittal 47, June 5, 2009. 10 JCS MM.04.01.01, EP 7 (Jan. 2010).


Section 2.2(a) above), but it is impossible or impractical for the Ordering Provider to write the order.11

ii. Verbal Orders are not to be used merely for the convenience of the Ordering Provider.12

iii. Verbal Orders may only be issued to an individual who is authorized to receive verbal orders. The following persons are authorized by the Medical Staff to receive verbal orders: physician assistants, registered nurses, chiropractors, respiratory therapists, pharmacists, physical therapists, occupational therapists, speech therapists, radiologic technicians, respiratory technicians, psychologists, dietitians and social workers. Such authorized individuals may receive a verbal order and enter it into the patient’s medical record, if the verbal order relates to the clinical area in which such authorized individual is trained.

iv. Only physician assistants and registered nurses are authorized to receive verbal Do Not Resuscitate orders. (Refer to the Medical Center’s DNR Policy.)

v. Only physician assistants, registered nurses, respiratory therapists, radiological technicians, and pharmacists are authorized to receive verbal orders for drugs and/or biologicals.

(b) Issuing a Verbal Order.

i. An Ordering Provider must communicate a verbal order, in person or over the telephone, only to a duly authorized individual and such verbal order must relate to the clinical area in which such authorized individual is trained.13

ii. The Ordering Provider must clearly enunciate the verbal order to the individual accepting the order. The following elements shall be included in all verbal orders:

Name of Ordering Provider;

Name of patient;

Age and weight of patient, when appropriate;

Date and time of order;

Purpose or indication for the order; and

All other elements required for the particular order (e.g., see Section 4.2 for minimum requirements of medication orders).

11 42 CFR § 482.23(c)(2)(i) (Interpretive Guidelines, effective October 17, 2008); JCS MM.04.01.01, EP 6 (Jan. 2010). 12 Department of Health and Human Services, Final Rule, Federal Register, November 27, 2006, page 68679. 13 42 CFR § 482.23(c)(2)(ii) (Interpretive Guidelines, effective October 17, 2008). An authorized person may receive a verbal order from an APNP. See Wisconsin Department of Health and Family Services, DQA Memo 07-019, October 30, 2007.


(c) Mandatory Read Back.14 The accepting individual shall write the complete order on an order sheet and shall read the entire order back to the Ordering Provider. The accepting individual must then receive confirmation from the Ordering Provider that he/she has received the correct order.15 Once confirmation is received, the accepting individual shall enter the verbal order into CPOE.16

(d) Authentication of Verbal Orders.

i. Verbal orders must be promptly authenticated in CPOE by the Ordering Provider (or a practitioner assuming care of the patient) as soon as possible, and in all events within forty-eight (48) hours17 (except for Verbal Do Not Resuscitate Orders which must be authenticated within twenty-four (24) hours) of the Ordering Provider’s communication of the verbal order.

ii. When an individual practitioner other than the Ordering Provider authenticates a verbal order, such individual accepts professional and legal responsibility for the order and validates that the order is complete, accurate, and final based on the patient’s condition. The authenticating provider should be responsible for the care of the patient and have knowledge of the patient’s hospital course, medical plan of care, condition and current status. An individual who does not possess this knowledge about the patient should not authenticate a verbal order.18

iii. A Physician Assistant (PA) or Advanced Practice Nurse Prescriber (APNP) may only authenticate a verbal order issued by another practitioner if all of the following requirements are met:

the PA or APNP has the authority to issue the order itself (if the PA or APNP is not authorized to issue the order in need of authentication, he or she cannot authenticate it);

the PA or APNP has physician-delegated functions with regard to the care of the patient; and

the PA or APNP has knowledge of the patient’s hospital course, medical plan of care, condition and current status.19

14 42 CFR § 482.23(c)(2)(i) (Interpretive Guidelines, effective October 17, 2008); JCS NPSG.02.01.01, EP 2 (Jan. 2010); 71 FR 68680. 15 JCS NPSG.02.01.01, EP 3 (Jan. 2010). 16 JCS NPSG.02.01.01, EP 1 (Jan. 2010). 17 Wis. Admin. Code DHS § 124.12(5)(b)11.; Although the code section provides that a verbal order must be authenticated within 24 hours, the Wisconsin Department of Health Services (DHS) has granted a variance providing that the authentication must occur within 48 hours. See Wisconsin Department of Health and Family Services, DQA Memo 07-019, October 30, 2007. 18 Wisconsin Department of Health and Family Services, DQA Memo 07-019, October 30, 2007. 19 Wisconsin Department of Health and Family Services, DQA Memo 07-019, October 30, 2007.


(e) Monitoring and Evaluation. The Medical Staff shall participate in performance monitoring and evaluation to identify, improve and reduce the likelihood of medical errors related to verbal orders.

3. REQUIREMENTS FOR CERTAIN TYPES OF ORDERS

3.1 Admission Orders. The admitting Practitioner (or his or her designated alternate) must enter and initiate in CPOE admitting orders to the nursing unit within one (1) hour of a patient’s admission to the admitting unit. At least two different Medical Center staff members will try to reach the admitting practitioner or his or her designated alternate to obtain admission orders. These attempts will be documented in the patient’s medical record. If the admitting Practitioner cannot be reached to obtain admission orders within one (1) hour of a patient’s admission to the admitting unit, the Medical Center staff will contact one or more of the following individuals (listed in priority) to obtain admission orders: (a) the admitting Practitioner’s designated alternate; (b) an associate of the admitting Practitioner; (c) the Physician on call for this service in the ED; and (d) the applicable Clinical Chairperson.

3.2 Orders for Therapeutic Services (Treatment). In addition to basic requirements for orders, all orders for therapeutic services shall include: (a) the purpose or indication, if appropriate; (b) the type of therapeutic service; (c) any specific requirements or instructions; and (d) the frequency and duration of therapeutic services.

3.3 Orders for Diagnostic Testing. In addition to basic requirements for orders, all orders for diagnostic testing shall include: (a) the reason, purpose or indication (orders for outpatient diagnostic tests must include the symptoms, diagnosis or ICD-10-CM code); (b) the type of testing; (c) any specific requirements or instructions; (d) the frequency, schedule and duration of testing; and (e) if the test requires the administration of medications or other substances (e.g., contrast dye), the order must include the necessary elements for medication orders. An order for imaging studies (X-ray, CT Scan, MRI, etc.) must include a concise statement describing the reason for the imaging study. 20

3.4 Medication Orders.

(a) Requirements.21 In addition to basic requirements for orders (form, timeliness, authentication), all orders for medications must include:

i. Drug name;

ii. Purpose, diagnosis, condition or indication (as applicable) if not elsewhere in the patient’s medical record (e.g., physician note), or if needed for purposes of clarification;

20 Wis. Admin. Code DHS § 124.18(e)(2). 21 JCS MM.04.01.01, EPs 2, 3, and 9 (Jan. 2010).


iii. Dosage form (e.g., tablets, capsules, inhalants);

iv. Exact strength or concentration;

v. Dose, frequency and route of administration (e.g., p.o., IV, IM, rectal, etc.);

vi. Quantity and/or duration; and

vii. Specific instructions for use.

(b) Acceptable Types of Medication Orders.22 The following types of medications orders are acceptable:

i. PRN (as needed) Orders: Orders acted upon based on the occurrence of a specific indication or symptom. Such orders should include the indications for use and specific time intervals.

ii. Standing Orders: A prewritten medication order and specific instructions to administer a medication to a patient in clearly defined circumstances.

iii. Automatic Stop Orders: Orders that include a date or time to discontinue a medication.

iv. Titrating Orders: Orders in which the dose is either progressively increased or decreased in response to the patient’s status. Whenever possible, such orders should include objective parameters for titration.

v. Taper Orders: Orders in which the dose is decreased by a particular amount with each dosing interval.

vi. Range Orders: Orders in which the dose or dosing interval varies over a prescribed range, depending upon certain objective criteria related to the patient’s status or situation (e.g., insulin dosages for specific blood glucose ranges).

vii. Other Orders: Orders for compounded drugs or drug mixtures not currently available, medication-related devices (nebulizers, catheters), investigational medications, herbal products, discharge or transfer medications.

(c) High Alert and Hazardous Medications.23 The Medical Center maintains a list of high-alert and hazardous medications and utilizes specific strategies for avoiding errors related to such medications. Orders must be written in accordance with the requirements set forth in such policies.

(d) Look-Alike or Sound-Alike Medications.24 Medications with look-alike or sound-alike names (“LASA medications”) may result in medication errors. The

22 JCS MM.04.01.01, EP 1 (Jan. 2010). 23 JCS MM.01.01.03 (Jan. 2010). 24 JCS MM.04.01.01, EP 4 (Jan. 2010).


Medical Center utilizes specific safety strategies to avoid errors related to LASA medications. A list of LASA medications shall be maintained by the Medical Center’s pharmacy.25 Staff Members shall comply with Aurora’s Look-Alike Sound-Alike Medications Policy.

(e) Medications that Require Weight-Based Dosing. Certain medications (including medications administered to pediatric patients) require weight-based dosing. The Medical Center maintains guidelines for weight-based dosing and all medication orders must be entered in compliance with such guidelines.26

(f) Labor-Inducing Medications. Only a Physician with OB privileges or a Certified Nurse Midwife may order the administration of a labor-inducing medication,27 and such orders must include parameters providing for the discontinuation of the labor-inducing medication by a registered nurse.28

(g) Formulary Drugs. Ordering Providers are encouraged to use Medical Center formulary drugs. In extenuating circumstances, non-formulary drugs shall be provided when ordered by the attending practitioner and when approved alternatives are unacceptable. All non-formulary medications shall be reviewed by the Aurora Pharmacy and Therapeutics Committee.

(h) Review. All medication orders shall be reviewed by the attending Practitioner at least every thirty (30) days.

(i) Automatic Cancellation. All existing medication orders shall be automatically cancelled when a patient undergoes a procedure requiring general anesthesia or moderate sedation. Following the procedure, an Ordering Provider must re-enter orders for each individual medication (as noted in Section 1.7, an order stating “resume previous medications” or other non-specific orders are unacceptable).29

(j) Stop Orders. The Medical Center’s stop order policy does not prevent the Ordering Provider from ordering medication for any reasonable length of time that the Ordering Provider may choose, and is intended to cover only those situations in which drug administration orders do not state a specific length of time or duration. If the following medications are ordered without specific limitations as to dosage and time, such medications shall be automatically discontinued as follows, unless specifically reordered by the attending Practitioner:

25 NPSG.03.03.01 (Jan. 2010). 26 JCS MM.04.01.01, EP 10 (Jan. 2010). 27 Wis. Admin. Code DHS § 124.20(5)(i)8.a. 28 Wis. Admin. Code DHS § 124.20(5)(i)8.c. 29 Wis. Admin. Code DHS § 124.15(7)(b).


Antibiotics 10 days

Controlled Substances 5 days

All pre-op and/or prenatal medication

must be renewed post- op/postpartum

Transfer medication orders must be renewed when transferring to a higher or lower level of care (e.g., transferring into or out of ICU)

IV Fluids 3 days

The Pharmacy Department shall notify the nursing station of any impending stop orders forty-eight (48) hours in advance of the effective time of the stop order. This will be done by generating a computerized stop order report. The stop order report shall be placed in the physician order section of the patient’s chart by the responsible clerk. It is the responsibility of the attending Practitioner to review the chart for stop order reports and to reorder the medication as necessary.

3.5 Standing Orders.

(a) All standing orders shall be listed on a “Physician Order Sheet” sheet that must be included in the patient’s medical record and signed and dated by the Ordering Provider or the attending Practitioner.

(b) Standing orders shall be followed in the absence of other specific orders by the Ordering Provider or the attending practitioner, insofar as the proper treatment of the patient will allow. Each Practitioner shall review his or her standing order regimens at least annually and revise as necessary. Notwithstanding the foregoing, new orders shall be entered and initiated in CPOE for each patient upon transfer into and out of the ICU/CCU, post-operatively and at each Medical Center admission, regardless of frequency of admission.

3.6 Transfer Orders. All orders for patients who presented to the Medical Center’s Emergency Department and will be transferred to another facility must be issued in accordance with Aurora’s EMTALA policy.

3.7 Discharge Orders. A discharge order must be entered into the medical record for all Medical Center inpatients and outpatients. If an Advanced Practice Professional issues the discharge order, such order must be co-signed by the patient’s admitting or attending Physician as provided in Aurora’s Hospital Co-Signature Requirements Chart. All orders for medications, therapeutic services, and diagnostic services intended for post discharge must be re-entered as discharge orders in their entirety by the Ordering Provider.


3.8 Blood Transfusion Orders. All orders for blood transfusions must be entered in accordance with the Medical Center’s policies on blood and blood components.

3.9 Restraint and Seclusion Orders. All orders for restraints and seclusion must be entered in accordance with the Medical Center’s policy regarding restraints and seclusion.

3.10 Do-Not-Resuscitate Orders. Do-Not-Resuscitate (DNR) orders must be entered in accordance with the Medical Center’s policy on withholding and withdrawal of treatment.

3.11 Therapeutic Diet Orders.

(a) A registered dietitian may issue the following for a patient’s nutritional care:

i. Changes in therapeutic diets (i.e., macro- and micro-nutrient levels, timing of meals, etc);

ii. Modification in diet textures;

iii. Nutrition supplements;

iv. Tube feedings when directed per a physician order, or changes in tube feeding products, rates, schedules, and flush;

v. Parenteral nutrition macro- and micro-nutrients, when directed by the attending physician;

vi. Weight, including daily weight;

vii. Collaboration with and referral to other allied health professionals including speech therapists and home health care;

viii. Nutrition education;

ix. Vitamin and mineral supplements;

x. Nutrient intake analysis;

xi. Nutrition-related lab work (i.e., prealbumin, potassium, etc.).

(b) A licensed speech therapist may recommend modifications in diet textures (e.g., order puree, the addition or deletion of thickener).


REFERENCES:

Federal Regulations and Other Guidance 42 CFR § 482.23 (Interpretive Guidelines, effective October 17, 2008). 42 CFR § 482.24 (Interpretive Guidelines, effective October 17, 2008). CMS Transmittal 47, June 5, 2009. CMS Manual System, Pub 100-08 Medicare Program Integrity, Transmittal 248,

March 28, 2008. CMS MLN Matters Memo No. SE0829, CR 5971 Clarification related to Signature

Requirements. CMS Memo, S&C-09-10, “Standing Orders” in Hospitals – Revisions to S&C

Memoranda, October 24, 2008. Department of Health and Human Services, Final Rule, Federal Register, November

27, 2006, page 68679.

Wisconsin Statutes None.

Wisconsin Administrative Code and Other Guidance Wis. Admin. Code DHS § 124.12. Wis. Admin. Code DHS § 124.15. Wis. Admin. Code DHS § 124.18. Wis. Admin. Code DHS § 124.20. Wisconsin Department of Health and Family Services, DQA Memo 07-019, October

30, 2007.

Joint Commission Standards JCS MM.01.01.03 (Jul. 2015). JCS MM.04.01.01 (Jul. 2015). JCS NPSG.02.01.01, EP 1 (Jul. 2015). JCS NPSG.03.03.01 (Jul. 2015). JCS RC.01.01.01 (Jul. 2015). JCS RC.01.02.01 (Jul. 2015).

FORM(S): None

MEDICAL EXECUTIVE COMMITTEE APPROVAL: 03/12/2018

BOARD OF DIRECTORS APPROVAL: 03/19/2018



Subject: Consultations Policy Statement: It is the policy of the Medical Staff to assure that a

consultation with a qualified Medical Staff or Advanced Practice Professional Staff Member is ordered when the attending practitioner’s expertise does not meet the clinical needs of the patient, or when the best interests of the patient will be thereby served.

Guidelines:

L. Except in an emergency, the circumstances which require consultation include, but are not limited to, the following:

1. Any patient known or suspected to be suicidal;

2. When required by this Policy or the rules of any clinical unit, including any intensive or special care units of the Medical Center;

3. Problems of critical illness in which any significant question exists of appropriate procedure or therapy;

4. When the patient is not a good risk for operation or treatment;

5. Cases of difficult or equivocal diagnosis or therapy;

6. When a surgery or procedure may interrupt a known or suspected pregnancy;

7. When the condition of the patient or scope of clinical problem exceeds the physician’s granted privileges;

8. When required by state law; and

9. When requested by the patient or family.

M. Definition of a Consultant

1. Any qualified Practitioner or Advanced Practice Professional (per the restriction in B(2) below) may be called as a consultant regardless of such Practitioner or Advanced Practice Professional’s Medical Staff or Advanced Practice Professional Staff category assignment. A consultant shall be a recognized specialist in the applicable area as evidenced by certification by the appropriate specialty or subspecialty board or by a comparable degree of competence based on equivalent training and extensive experience. In either case, a consultant shall have demonstrated


the skill and judgment requisite for evaluation and treatment of the condition or problem presented and have been granted the appropriate level of Clinical Privileges.

2. Qualified Advanced Practice Professionals may be called as an independent consult in the following two specialties only: Palliative Care and Wound Care.

N. Medical Record Documentation

1. Appropriate documentation on the use and results of consultants shall be maintained as follows:

a. When requesting consultation, the attending practitioner shall indicate in writing on the consultation record the reason for the request and the extent of involvement in the care of the patient expected from the consultant, e.g., “for consultation and opinion only,” “for consultation, orders, and follow-up about a particular problem.”

b. The consultant shall prepare and sign a report of the consultant’s findings, opinions and recommendations that reflects an actual examination of the patient and the medical record. Such report shall become part of the patient’s medical record. When operative procedures are involved, the consultation report should be recorded prior to surgery.

c. In cases of elective consultation when the attending practitioner elects not to follow the advice of the consultant, he or she shall either seek the opinion of a second consultant or record in the progress notes such attending practitioner’s reasons for electing not to follow the consultant’s advice.

d. In cases of required consultation when the attending practitioner does not agree with the consultant, he or she shall either seek the opinion of a second consultant or refer the matter to the applicable Clinical Chairperson for final advice. If the attending practitioner obtains the opinion of a second consultant and does not agree with it either, the attending practitioner shall refer the matter to the applicable Clinical Chairperson, for final advice.

O. Request for Consultation

1. The physician requesting the consultation shall be responsible for: (a) providing the consulting Practitioner or Advanced Practice Professional


with adequate information to enable the consulting physician to provide the consultation; and (b) ensuring that the consultation occurs as requested.

P. Response to Request for Consultation

1. The consulting Practitioner or Advanced Practice Professional shall be responsible for responding to a request for consultation within twenty-four (24) hours of his or her receipt of the request, unless otherwise directed by the requesting physician.

References: Wis. Admin. Code HFS § 124.12(5)(b)(10) JCAHO Standards MS. 2.20 and LD.3.50, 2007

Form(s): Medical Executive Committee Approval:

October 22, 2003 March 14, 2005 February 12, 2007 May 14, 2018


October 23, 2003 April 1, 2005 February 23, 2007 May 21, 2018



Subject: Medical Records/Patient Health Information Policy Statement: It is the policy of the Medical Staff to maintain complete and

accurate medical records and to use and disclose patients’ health information in accordance with the requirements set forth below.

Guidelines:

Q. The attending practitioner and other Medical Staff members, as applicable, shall be responsible for the preparation of a complete and legible medical record for each patient. The record’s content shall be pertinent, legible, accurate, timely and current. The record shall include, as appropriate:

1. Emergency care, treatment, and services provided to the patient before his or her arrival, if any;

2. Documentation and findings of assessments;

3. Identification data (i.e., the patient’s name, sex, address, date of birth, occupation, and authorized representative, if any; the legal status of the patient if receiving behavioral health care services; and the patient’s language and communication needs);

4. Personal and family medical histories;

5. Description and history of present complaint and/or illness;

6. History and physical examination report;

7. Conclusions or impressions drawn from medical history and physical exam;

8. Diagnosis, diagnostic impression, or conditions (the final diagnosis without the use of symbols or abbreviations);

9. Reason(s) for admission of care, treatment and services;

10. Goals of the treatment and treatment plan;

11. Diagnostic and therapeutic orders;

12. Diagnostic and therapeutic procedures, tests, results and reports (including but not limited to clinical laboratory, pathology, radiology, radiotherapy,


tissue, EEG, ECG, consultation, pre- and post-anesthesia, operative and postoperative);

13. Progress notes and other clinical observations, including results of therapy;

14. Reassessments and plan of care revisions, when indicated;

15. Relevant observations;

16. Treatment provided;

17. Response to care, treatment, and services provided;

18. Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia;

19. Allergies to foods and medicines;

20. Medications ordered or prescribed;

21. Doses of medications administered, including the strength, dose, or rate of administration, administration devices used, access site or route, known drug allergies, and adverse drug reactions;

22. Relevant diagnoses/conditions established during the course of care, treatment, and services;

23. Advance directives, if any;

24. Evidence of appropriate informed consent;

25. Condition on transfer (if applicable), including any instructions to the patient or recipient hospital, including any forms or information required by the Medical Center policies regarding EMTALA compliance;

26. Discharge summary, including condition on discharge, and instructions, if any, to the patient or significant other on post-hospital care;

27. Medications dispensed or prescribed on discharge;

28. Autopsy report, if performed;

29. Anatomical gift information, if applicable;

30. Records of communications with the patient regarding care, treatment, and services (e.g., telephone calls or e-mail, if applicable); and


31. Patient generated information, if applicable (e.g., information entered into the record over the Web or in pre-visit computer systems).

B. General History and Physical Examinations Requirements

1. The physician who admits the patient to the Medical Center shall be ultimately responsible for the completion of the history and physical examination (“H&P”) and required updates, although a different Medical Staff member or qualified Advanced Practice Professional may perform the H&P. In addition, the admitting practitioner shall personally write an admission note within twenty-four (24) hours of admission, indicating the reason for hospitalization and the diagnostic/therapeutic plan. When a H&P (or update) and an initial admission note are not recorded and available on the medical record before an operative or invasive procedure, the procedure will not be permitted unless a Medical Staff member or qualified Advanced Practice Professional documents in the medical record that the procedure is being performed as an emergency.

2. When an attending physician who is a Medical Staff member chooses to

utilize a H&P performed by a physician who is not a Medical Staff member, the attending physician does so accepting full responsibility for the content and timeliness of the H&P, and the attending physician or a qualified Advanced Practice Professional must perform an update as set forth in Section C.2. or D.2. below, as applicable. In addition, an update to the H&P need not be performed by the same practitioner who performed the original H&P within the past thirty (30) days, but a Medical Staff member or qualified Advanced Practice Professional performing the update accepts responsibility for the content of the entire H&P.

C. Inpatient H&P

1. A H&P shall be recorded in the medical record either: (1) within twenty-four (24) hours of an inpatient admission; or (2) prior to surgery (except emergency situations); whichever occurs first.

2. If a complete H&P has been performed and recorded by a Medical Staff member or qualified Advanced Practice Professional within thirty (30) days of an inpatient admission, a durable legible copy may be used in the patient’s inpatient hospital record, but must contain an update of the patient’s condition based upon an assessment performed within twenty-four (24) hours of the inpatient admission or prior to surgery (except emergency situations) whichever occurs first. An appropriate update of the patient, including a physical examination, is conducted to: (1) update any


components of the patient’s current medical status that may have changed since the prior H&P; (2) address any areas where more current data is needed; or (3) confirm the necessity of any procedures or care. The update is documented in the patient’s medical record and attached to the H&P. If a H&P is more than thirty (30) days old, it will need to be repeated.

3. The H&P is good for the entire length of the inpatient stay. However, if a

procedure is performed on an inpatient before the dictated H&P or update is available on the medical record, a pre-procedure H&P or update must be handwritten and documented in the medical record by a Medical Staff member or qualified Advanced Practice Professional before the procedure is initiated.

R. Required Elements of Inpatient H&P

a. Reason for admission b. Physical assessment c. Review of systems d. Co-morbid conditions e. Mental status f. Medical history, including past response to treatment, known allergies,

current medications and dosages, relevant social and family history appropriate to the age of the patient;

g. Diagnostic impression; and h. Treatment plan and goals.

S. Outpatient H&P

1. A H&P shall be recorded in the medical record prior to the procedure. If a complete H&P has been performed and recorded by a Medical Staff member or qualified Advanced Practice Professional within thirty (30) days of an outpatient admission, a durable legible copy may be used in the patient’s outpatient hospital record, but must contain an update of the patient’s condition based upon an assessment performed prior to the procedure. An appropriate update of the patient, including a physical examination, is conducted to: (1) update any components of the patient’s current medical status that may have changed since the prior H&P; (2) address any areas where more current data is needed; or (3) confirm the necessity of any procedures or care. The update is documented in the patient’s medical record and attached to the H&P. If a H&P is more than thirty (30) days old, it will need to be repeated.

2. The H&P is good for the entire length of the outpatient stay. However, if


a procedure is performed on an outpatient before the dictated H&P or update is available on the medical record, a pre-procedure H&P or update must be handwritten and documented in the medical record by a Medical Staff member or qualified Advanced Practice Professional before the procedure is initiated.

3. Required Elements Outpatient H&P

a. Chief Complaint b. History c. Allergies d. Medications e. Physical exam (essential elements) f. Physical exam (as pertinent to specific procedure) g. Treatment plan and goals

T. Dental, Oral and Maxillofacial, and Podiatric Surgery

1. A Dentist, Podiatrist or Oral Surgeon who possesses H&P privileges may independently complete and sign an H&P prior to a procedure. If the Dentist, Podiatrist or Oral Surgeon has admission privileges, but is not privileged to perform H&P’s, the Dentist, Podiatrist or Oral Surgeon shall consult with a Medical Staff Physician regarding the completion of the pre-procedure H&P. A physician shall be responsible for the H&P when the admitting practitioner is a dentist or podiatrist. Dentists are responsible for the part of their patient’s H&P that relates to dentistry. Podiatrists are responsible for the part of their patients’ H&P that relates to podiatry. Both the Dentist, Podiatrist or Oral Surgeon and the consulting Medical Staff Physician must sign the H&P, as applicable. .

2. Advanced Practice Professionals. If any portion of the H&P is performed or documented by an Advanced Practice Professional, refer to the Aurora System Hospital Co-Signature Requirements document for applicable co-signature requirements.

U. Surgery

1. H&P and required consultation reports shall be placed in the medical record before surgery.

2. All currently required laboratory, EKG, and x-ray studies shall be performed and documented prior to surgery using these guidelines:

a. EKG and x-ray results are accepted for thirty (30) days; and


b. Lab results are accepted for six (6) weeks, except pregnancy tests which must be performed the day of surgery.

3. The following anesthesia evaluations/examinations shall be conducted and documented in the medical record (if the evaluations/examinations are performed by a certified registered nurse anesthetist, they must be countersigned by either the supervising anesthesiologist and/or the surgeon):

a. Pre-anesthesia Evaluation. The anesthesia provider shall conduct a pre-anesthesia evaluation of the patient within forty-eight (48) hours prior to the patient’s transfer to the operating area and before preoperative medication has been administered, except in emergencies. The pre-anesthesia evaluation shall include, at a minimum: (1) pertinent information relative to the choice of anesthesia and the procedure anticipated; (2) notation of anesthesia risk; (3) pertinent previous drug, anesthesia and allergy history; (4) other pertinent anesthetic experience; (5) potential anesthetic problems; (6) ASA patient status classification; and (7) orders for preoperative medication.

b. Re-evaluation Examination. The anesthesia provider shall conduct a re-evaluation immediately prior to induction.

c. Intraoperative Anesthesia Examination. The anesthesia provider shall conduct an intraoperative anesthesia examination documenting pertinent events taking place during anesthesia. The intraoperative anesthesia examination shall include, at a minimum: (1) the patient’s name and hospital identification number; (2) name of practitioner who administered anesthesia, and as applicable, the name and profession of the supervising anesthesiologist or operating practitioner; (3) name, dosage, route and time of administration of drugs and anesthesia agents; (4) IV fluids; (5) blood or blood products, if applicable; (6) oxygen flow rate; (7) continuous recordings of patient status noting blood pressure, heart and respiration rate; and (8) any complications or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient’s response to treatment.

d. Post-anesthetic Follow-up Examination. The anesthesia provider shall conduct a post-anesthetic follow-up examination with findings recorded within forty-eight (48) hours after surgery. The post-anesthetic follow-up examination shall include, at a minimum: (1) the patient’s cardiopulmonary status; (2) level of consciousness; (3) any complications during post-anesthesia recovery; and (4) any follow-up care and/or observations.


4. A post-procedure note containing the following elements shall be recorded immediately after the procedure even if the procedure report is dictated:

a. Preoperative diagnosis;

b. Postoperative diagnosis;

c. Surgeon;

d. Surgical Assistant(s);

e. Procedures performed;

f. Findings during procedure;

g. Specimens removed;

h. Complications; and

i. Estimated blood loss, as appropriate.

V. Electrocardiograph Reports

1. Electrocardiograph reports shall be filed as a permanent record with the patient’s chart.

2. The attending physician may retain an unmounted record if so requested, but the original shall remain in the patient’s chart.

W. Progress Notes

1. Pertinent progress notes shall be recorded at the time of observation and shall be sufficient to permit continuity of care and transfer of the patient.

2. Final responsibility for an accurate description in the medical record of the patient’s progress rests with the attending practitioner.

3. Whenever possible, each of the patient’s clinical problems shall be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatment.

4. Progress notes by the attending practitioner shall be written at least daily on acutely and critically ill patients and on those where there is difficulty in diagnosis or management of the clinical problem.

X. Consultation Reports


1. Consultation reports shall show evidence of a review of the patient’s record, the consultant’s opinion, and the consultant’s recommendations. Consultation reports shall be authenticated by the consulting practitioner.

Y. Discharge Summary

1. A discharge summary shall be recorded for all patients. The physician who discharges the patient shall be ultimately responsible for the discharge summary although a different Medical Staff member may write it.

2. The discharge summary should include, but is not limited to:

a. Date of admission and discharge;

b. Reason for hospitalization;

c. Discharge diagnosis;

d. Condition on discharge;

e. Disposition on discharge;

f. Consultations;

g. Procedures performed/treatment rendered;

h. Significant findings including ancillary studies;

i. Information provided to the patient and family, as appropriate; and

j. Discharge instructions, including:

1) Medications

2) Activity

3) Diet, and

4) Follow-up.

Z. Abbreviations, acronyms, symbols and dose designations

1. A list of unacceptable abbreviations, acronyms, symbols and dose designations shall be identified and approved by the Medical Executive Committee. An official record of such list is available at each nursing station, the Health Information Services Department and the Pharmacy Department. Only those symbols, abbreviations, acronyms and dose designations not on such list may be used.


AA. Authentication of Clinical Entries

1. All clinical entries in the patient’s record shall be legible, accurately dated, timed and individually authenticated. “Authentication” means to establish authorship by written signature, identifiable initials or electronic signature.

2. The use of an electronic signature is only acceptable if the individual has an attestation statement on file in the Health Information Services Department acknowledging that he or she is the only individual authorized to use the electronic signature.

BB. Advanced Practice Professional Entries in the Medical Record

1. An Advanced Practice Professional may make medical record entries relating to acts for which the Advanced Practice Professional has been granted clinical privileges and in accordance with co-signature requirements, if any.

CC. Use and Disclosure of Patient Health Information

1. All Medical Staff members and Advanced Practice Professionals agree to comply with the Medical Center’s policies and procedures governing the use and disclosure of patient health information (commonly referred to as “Protected Health Information or PHI”), as may be amended from time to time.

2. The Medical Staff members and Advanced Practice Professionals of the Medical Center participate in an organized health care arrangement with Aurora Health Care, Inc. (“Aurora”). Participation means the Medical Staff members and Advanced Practice Professionals agree, when present at an Aurora facility, to abide by the privacy policies and practices as outlined in Aurora’s Notice of Privacy Practices (“Notice”). Participation also means such Notice, when provided to the patient with the patient’s acknowledgment (unless an exception applies), meets the federal notice requirement for both the practitioner and Aurora for care provided at an Aurora facility.

3. Inappropriate use and disclosure of Protected Health Information shall subject the practitioner to corrective action as outlined in the Medical Staff Bylaws and the Policies Governing Medical Practices.


References: Medicare Conditions of Participation, 42 C.F.R. §§ 482.22, 482.24, and 482.52

Health Insurance Portability and Accountability Act’s Privacy Regulations, 45 C.F.R. §§ 160 and 164

Wis. Stat. §§ 51.30, 146.81 et. seq. and 252.15 Wis. Admin. Code HFS §§ 124.12, 124.14 and

124.20(3)(b) and Chapter HFS 92 JCAHO Standards IM.3.10, 6.10, 6.20 and 6.50 and

MS.2.10, 2007 and National Patient Safety Goal 2B Form(s): Medical Executive Committee Approval:

October 22, 2003 March 14, 2005 February 11, 2008 February 8, 2010 May 14, 2018


October 23, 2003 April 1, 2005 February 29, 2008 February 23, 2010 May 21, 2018


MILW_9272712.5

Aurora Medical Center Laboratory Tissue Solution

Amputated Limbs Fresh to laboratory

Bone Biopsy Send in Formalin immediate WITH patient’s x-ray. If cultures are needed, send separate piece of bone in sterile specimen container.

Breast Tissue In container with 10% Formalin. Send to lab immediately. If frozen section or gross examination is needed, send fresh.

Bronch Brush - In normal saline > To Lavage - On ice always > Lab Lukens Trap - Washings > Immediately B & T Cell Markers Fresh in normal saline soaked gauze in sterile specimen container. (for Lymphoma) Send to lab immediately with H&P and Addressograph plate. Cervical Conization Send in Formalin in specimen container to lab immediately.

Cultures Urine Fresh in a sterile specimen cup to lab immediately.

Cultures Others In sterile cup, syringe, bronch trap, culture tube.

Cultures Suction In suction canister liner.

Cytology See Directory of Services for specific sites.

Frozen Sections Fresh. Put small specimens in normal saline soaked gauze to lab immediately.

Implanted Devices In plastic bag to lab or to patient as ordered.

Lymph Node Biopsies Fresh. Put small specimens in normal saline soaked gauze in sterile specimen container to lab immediately.

Muscle/Nerve Biopsy Notify lab two days prior to biopsy. Fresh in normal saline soaked gauze, not floating in normal saline. DO NOT squeeze with forceps. Copy of H&P. To lab immediately.

Pap Smear Clear slides, fixed for cytology.

Renal Biopsy Notify lab two days prior to biopsy. Fresh in normal saline soaked gauze, not floating in normal saline. DO NOT squeeze with forceps. Copy of H&P. To lab immediately.

Synovial Fluid In green top tube (from med. room or lab).

Teeth or Calculi In container dry and # of teeth on slip.

Tissue & Routine Biopsy Specs

In container with 10% Formalin.

Kidney & Ureteral Stones for Analysis

In a dry specimen container. DO NOT add formalin.

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Subject: Emergency Department On-Call Policy Statement: To define guidelines for those practitioners responsible to

cover emergency on-call for patients without a self designated primary care physician.

Guidelines:

A. All physicians, dentists, oral surgeons, and podiatrists who are members of the active staff are responsible to participate in emergency room back-up as requested to do so by the Medical Executive Committee. Other members of the non-active Medical Staff shall participate in emergency department back-up call if requested to do so by the Medical Executive Committee. General and vascular surgeons who are required to participate in emergency room back-up call are required to achieve and maintain Advanced Trauma Life Support (ATLS) certification in accordance with State of Wisconsin requirements for level 3 trauma centers. The following response times and requirements shall also apply to dentists, oral surgeons, and podiatrists if the Medical Center implements an on-call schedule for their services.

B. All physicians are required to respond via phone within fifteen (15) minutes of being paged and to provide instruction to the emergency staff.

C. All physicians are required to respond in person within thirty (30)) minutes of answering the page, if requested to so do, to care for the patient.

1. In the event the on-call physician does not answer or is unable to present to the Medical Center, attempts should be made to contact one of the on-call physician’s practicing partners within such specialty. In the event no other physician is available to present to the Medical Center, the patient should be prepared for transfer pursuant to Section E Below.

D. After initial notification from the ED, an on-call physician has the option of sending a licensed, non-physician practitioner (i.e. PA, APNP) as his/her representative to appear at the hospital and provide further assessment or stabilizing treatment to an individual. This determination is based on the following:

1. Individual’s medical needs

2. Capabilities of the hospital

3. Applicable State scope of practice laws

4. Hospital bylaws and policies

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However, the designated on-call physician is ultimately responsible for providing the necessary services to the individual in the ED regardless of who makes the in-person appearance. In the event that the treating physician disagrees with the on-call physician’s decision to send a representative and requests the actual appearance of the on-call physician, then the on-call physician is required under EMTALA to appear in person.

E. When it is necessary to transfer a patient because a Medical Staff member fails or refuses to appear within a reasonable time to provide necessary stabilizing treatment, the Emergency Department physician must list the name and address of such Medical Staff member in the transfer documentation sent to the receiving hospital in accordance with the Emergency Medical Treatment and Labor Act (“EMTALA”). Failure to do so is a violation of EMTALA that may result in penalties to the Medical Center and on-call Medical Staff member.

F. Emergency department on-call schedules shall be coordinated and distributed by the Medical Staff Services Office. Physicians who are unable to provide coverage for the emergency department on-call rotation schedule are responsible for making prior arrangements with a qualified practitioner who has the requisite clinical privileges at the Medical Center and who agrees to provide the coverage. The name(s) and phone number(s) of the physician(s) covering shall be given to the emergency department and Medical Staff Services Office.

References: EMTALA 42 U.S.C. § 1395dd EMTALA 42 C.F.R. § § 489.20 (r) and 489.24 (j) Wis. Admin. Code Chapter HFS 124.12 and

124.24(2)(c)(3) Form(s): Medical Executive Committee Approval:

October 22, 2003, July 19, 2004, April 12, 2010, February 10, 2014, September 8, 2014, October 13, 2014


Subject: Credentials Committee

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Policy Statement: It is the policy of the Medical Staff that the Credentials Committee shall take a leadership role in conducting reviews of the credentials for all Medical Staff and Allied Health Professionals requesting initial membership, privileges and re-appointment.

Guidelines:

A. Composition:

1. The Credentials Committee may consist of at least one active Medical Staff member from each clinical department appointed by the Medical Executive Committee.

2. The Chief of Staff shall designate one (1) of the members of the Credentials Committee to serve as the Chairperson.

3. The Administrator and the Manager of Medical Staff Services shall be invited to attend all meetings of the Credentials Committee.

B. Duties and Responsibilities:

The purpose and responsibilities of the Credentials Committee shall be:

1. To review the credentials of all applicants and to make recommendations to the Medical Executive Committee for staff appointment, assignments to departments and delineation of clinical privileges;

2. To review periodically all information available regarding the performance and clinical competence of staff appointees and other individuals with clinical privileges at the Medical Center and, as a result of such reviews, to make recommendations to the Medical Executive Committee for reappointments and renewal or changes in clinical privileges;

3. To report at each general Medical Executive Committee meeting and at other meetings as requested by the Medical Executive Committee; and

4. To perform such other duties as requested from time to time by the Medical Executive Committee.

C. Meetings:

The Credentials Committee shall meet as often as necessary, but in no event less than quarterly, to fulfill its responsibility and maintain a permanent record of its proceedings and actions. The Chairperson of the Credentials Committee may call special meetings of the Credentials Committee at any time.

D. Quorum:

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A quorum shall consist of at least fifty percent (50%) of the voting members of the Credentials Committee.

E. Voting requirements:

If a quorum exists, action on a matter shall be approved if the votes cast within the voting group favoring the action exceed the votes cast opposing the action, unless the Medical Staff Bylaws or any law, ordinance, or governmental rule or regulation requires a greater number of affirmative votes.

F. Attendance Requirements:

Members of the Credentials Committee are expected to attend at least seventy percent (70%) of the meetings held.

References: Bylaws Article VIII, Committees Section 3 Committee

Assignments Form(s): None Medical Executive Committee Approval:

April 5, 2004 April 11, 2005


April 30, 2004 April 29, 2005

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Subject: Bylaws Committee Policy Statement: It is the policy of the Medical Staff that the Bylaws

Committee shall review the Medical Staff Bylaws no less frequently than annually and report recommendations to the Medical Executive Committee and the Medical Staff.

Guidelines:

A. Composition:

1. The Bylaws Committee shall consist of at least two (2) but not more than six (6) active Medical Staff members appointed by the Chief of Staff.

2. The Chief of Staff shall designate one (1) of the members of the Bylaws Committee to serve as the Chairperson.

3. The Hospital Administrator and Manager of Medical Staff Services shall be invited to attend all meetings of the Bylaws Committee.

4. Nonmembers from both within and outside the Medical Center may be consulted by the Bylaws Committee to provide expertise as required for the Bylaws Committee to perform its duties.

B. Duties and Responsibilities:

1. Knowledge of Medical Staff's Governing Documents.

All members of the Bylaws Committee should be familiar with the governing documents of the Medical Staff which consist of the Medical Staff Bylaws and Policies Governing Medical Practices. In addition, the Bylaws Committee should be familiar with other applicable Medical Center policies, standards established by the Joint Commission on Accreditation of Health Care Organizations and other applicable legal requirements.

2. Review and Make Recommendations Regarding the Bylaws.

The Bylaws Committee shall review the Bylaws and proposed amendments to the Bylaws. Following its review, the Bylaws Committee shall report its recommendations to the Medical Executive Committee and to the Medical Staff at their next regular meetings or at special meetings called for such purpose.

3. Other Duties

The Bylaws Committee shall perform such other duties as requested from time to time by the Medical Executive Committee.

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C. Meetings:

The Bylaws Committee shall meet as often as necessary, but in no event less than annually, to fulfill its responsibility and maintain a written record of its proceedings and actions.

D. Quorum:

A quorum shall consist of at least fifty percent (50%) of the voting members of the Bylaws Committee.

E. Voting Requirements:

If a quorum exists, action on a matter shall be approved if the votes cast within the voting group favoring the action exceed the votes cast opposing the action, unless the Medical Staff Bylaws, the Policies Governing Medical Practices, or any law, ordinance, or governmental rule or regulation requires a greater number of affirmative votes.

F. Attendance Requirements:

Members of the Bylaws Committee are expected to attend at least seventy percent (70%) of the meetings held.

References: Medical Staff Bylaws Articles VIII and XIII Form(s): None Medical Executive Committee Approval:

June 14, 2004 April 11, 2005 December 11, 2017

Board of Directors Approval: June 25, 2004 April 29, 2005 December 18, 2017

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Subject: Cancer Committee

Purpose: It is the policy of the Medical Staff that the Cancer Committee shall be

responsible for goal setting, planning, initiating, implementing, evaluating and improving all cancer-related activities at the Medical Center.

Guidelines:

A. Composition

1. The Cancer Committee is a multidisciplinary committee of the Medical Center’s Medical Staff. The Cancer Committee shall include at least one (1) physician member from each of the following specialties: diagnostic radiology, pathology, general surgery, medical oncology and radiation oncology. In addition, the Cancer Committee shall include at least one (1) non-physician member from each of the following: cancer program administration, oncology nursing, social services, cancer registry and quality improvement.

2. Nonmembers from both within and outside the Medical Center may be consulted by the Cancer Committee to provide expertise as required for the Cancer Committee to perform its duties properly. Such consultants shall serve in a nonvoting capacity.

3. The Medical Executive Committee shall designate one (1) member of the Cancer Committee to serve as the Cancer Committee Chair and one (1) member to serve as the Cancer Liaison Physician who provides a direct link between the cancer program and the American College of Surgeons. The Cancer Committee Chair shall advise the Chief of Staff and the Medical Executive Committee of all cancer-related activities.

B. Duties and Responsibilities

The duties and responsibilities of the Cancer Committee are to: 1. Follow the requirements outlined in the most current Commission on

Cancer (“CoC”) Program Standards.

2. Be accountable for all cancer program activities at the Medical Center;

3. Designate one (1) coordinator for each of the four (4) areas of Cancer Committee activity: cancer conference, quality control of cancer registry data, quality improvement and community outreach;

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4. Develop annual goals and objectives for clinical, community outreach, quality improvement and programmatic endeavors related to cancer care;

5. Evaluate annual goals and objectives for clinical, community outreach, quality improvement and programmatic endeavors on an annual basis;

6. Establish the frequency, format and multidisciplinary attendance requirements for cancer conferences on an annual basis;

7. Ensure that the required number of cases is discussed at each cancer conference and that at least seventy-five percent (75%) of such cases are presented prospectively;

8. Monitor and evaluate the cancer conferences’ frequency, multidisciplinary attendance, total case presentation and prospective case presentation on an annual basis;

9. Establish and implement a plan to evaluate the quality of cancer registry data and activity on an annual basis;

10. Complete site-specific analysis that includes comparison and outcome data and disseminate the results of the analysis to the Medical Staff;

11. On an annual basis, review ten percent (10%) of the analytic caseload to ensure that American Joint Committee on Cancer (AJCC) staging is assigned by the managing physician and recorded on a staging form in the medical record on at least ninety percent (90%) of eligible analytic cases;

12. On an annual basis, monitor that a ten percent (10%) review of the analytic caseload is completed to ensure that ninety percent (90%) of cancer pathology reports include the scientifically validated data elements outlined in the College of American Pathologists (“CAP”) protocols;

13. Provide a formal mechanism to educate patients about cancer-related clinical trials;

14. Review the percentage of cases accrued to cancer-related clinical trials each year;

15. Monitor community outreach activities on an annual basis;

16. Offer one (1) cancer-related educational activity each year;

17. Complete and document the required studies that measure quality and outcomes:

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18. Implement two (2) improvements that directly affect patient care;

19. Review Cancer Registry policies and procedures; and

20. Perform such other duties as requested from time to time by the Medical Executive Committee.

C. Meetings

1. The Cancer Committee shall meet as often as necessary to fulfill its duties and responsibilities, but in no event less than quarterly each calendar year. The Cancer Committee Chair may call special meetings of the Cancer Committee at any time.

2. The Cancer Committee shall keep written minutes to document its findings, conclusions, recommendations, actions and any follow-up required.

References: American College of Surgeons Cancer Manual Form(s): Medical Executive Committee Approval:

August 13, 2007


August 24, 2007

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Subject: Peer Review Policy and Peer Review Committee Policy Statement: It is the policy of the Medical Staff and the Medical Center to

conduct peer review and evaluation of the quality of patient care provided by and the conduct of Medical Staff members and Allied Health Professional Staff members (collectively, “Member” or “Members”) through quality assessment and improvement activities. The peer review activities identified in this Policy are a major component in the Medical Center’s program to improve the quality of health care. Such activities will be conducted in a manner consistent with the Wisconsin Statutes §§ 146.37 and 146.38.

Guidelines:

A. Definitions

1. Any terms used in this policy have the same meaning and definition as those terms that are defined in the Medical Staff Bylaws. In addition, for the purpose of this Policy, the following words or phrases are defined as follows:

a. The term “peer” means a Medical Staff member who is in the same or similar specialty as the review subject.

b. The term “peer review” means the study, review, investigation, evaluation, or assessment of the training, experience, skill, professional conduct, qualifications, or current competence of one or more Members by one or more of his/her peers.

c. The term “external peer review” means the study, review, investigation, evaluation, or assessment of the training, experience, skill, professional conduct, qualifications, or current competence of one or more Members by an individual or individuals who are not Medical Staff members but who, in the case of peer review of a Medical Staff member shall: (i) have the same professional licensure (e.g., physician, dentist, podiatrist, etc.) as the Medical Staff member review subject; and (ii) are in the same or a similar specialty as the Medical Staff member review subject or are in a different specialty but the individual’s core or specialized training significantly overlaps the primary elements of the type of care or technique that will be subject to review.

d. The term “review subject” means the Medical Staff member or the Allied Health Professional Staff member whose services or conduct is being reviewed.

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e. The “standard of care” against which the review subject is measured means the standard of care of the Medical Staff of the Medical Center.

B. Peer Review Committee

1. The Peer Review Committee shall be composed of at least five (5), but no more than eight (8), Medical Staff members from different specialties or departments designated by the Medical Executive Committee to serve as the Peer Review Committee. The Medical Executive Committee shall designate one (1) of the Peer Review Committee members to serve as the Chairperson. The goal is not to have representation from every specialty, but rather to create a cadre of dedicated, clinically credible, and respected peer reviewers who are well trained in the peer review process. In addition, the Medical Center’s Quality Enhancement Director and Medical Director for Quality shall be invited to attend all meetings of the Peer Review Committee in a nonvoting capacity.

2. The Peer Review Committee shall perform case reviews and oversight functions related to physician performance in accordance with such guidelines as the Peer Review Committee shall implement from time to time.

3. Members of the Peer Review Committee shall act as initial physician reviewers. If additional clinical expertise is needed, the Peer Review Committee may request assistance from other Members as it deems appropriate.

4. Department Clinical Chairpersons are responsible for working with the Members in their department who are under review to implement recommendations of the Peer Review Committee.

5. The Peer Review Committee shall meet as needed at the call of its Chairperson.

6. A quorum shall consist of at least fifty percent (50%) of the voting members of the Peer Review Committee. If a quorum exists, action on a matter shall be approved if the votes cast within the voting group favoring the action exceed the votes cast opposing the action, unless the Medical Staff Bylaws, Policies Governing Medical Practices, Medical Center policies, or any law, ordinance, or governmental rule or regulation requires a greater number of affirmative votes.

C. General Procedures for Peer Review

1. Any person (including, without limitation, Members, patients, family members, etc.) may forward for peer review any issues or concerns relating to a Member’s training, experience, skill, professional conduct, qualifications, or current competence to the Medical Executive Committee, the Clinical Chairperson of the appropriate department, or the Medical Staff Chief of Staff. The issue or concern may be immediately referred to the Peer Review Committee.

2. A peer may decline to participate in peer review only if the Chief of Staff excuses him/her from service.

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3. Peer review will be based upon medical records and reports, participation by the review subject, and other information set forth in Sections D.2. and E.5. below and as determined necessary or relevant by the body conducting the peer review.

4. Unless the matter is submitted for external peer review, the peer review will generally be completed within sixty (60) days of the date the matter was referred to the Peer Review Committee. This timeframe may be used as a general guide, but may also be expanded on a case-by-case basis subject to the particular case in review.

5. When issues regarding a Member are identified during peer review, such Member shall be notified of the same in writing.

6. A written report containing findings and conclusions shall be made and filed in the Member’s quality assurance file for all focused peer review, external peer review, and ongoing peer review. Conclusions should reference, as appropriate, any literature and relevant clinical practice guidelines upon which the Peer Review Committee based its decision. Majority and minority opinions of the Peer Review Committee, if any, will be considered and included in the report. When follow-up action by another body is warranted, the report will also be forwarded to the appropriate person or committee for follow-up as is deemed appropriate.

7. In the event the initial peer review of a Medical Staff Member results in consideration of a request for a corrective action, and if the initial peer review body did not contain (i) a peer who is in the same or similar specialty as the review subject, or (ii) a peer who is in a different specialty but whose core or specialized training significantly overlaps the primary elements of the type of care or technique that will be subject to review, then further peer review will be undertaken involving at least one peer who meets the above qualifications.

8. The information resulting from peer review is used to determine whether to reappoint a Member and/or to continue, modify or revoke a Member’s existing clinical privilege(s). Such information is also integrated into performance improvement activities, consistent with the Medical Center’s policies and procedures that are intended to preserve the confidentiality and privilege of information. The Quality Enhancement Manager will complete the Practitioner Profile and submit the same to Medical Staff Services for the reappointment process.

D. Ongoing Peer Review

1. Ongoing peer review allows the Medical Center to identify professional practice trends that impact quality of care and patient safety. Such identification may require intervention by the Medical Staff. Ongoing peer review is factored into the decision to permit a Member to maintain existing privilege(s), to modify his or her existing privilege(s), or to revoke his or her existing privilege(s) prior to

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or at the time of reappointment and renewal or modification of clinical privileges.

2. Ongoing peer review may include, without limitation, periodic chart review, direct observation, monitoring of diagnostic and treatment techniques, and discussions with other individuals involved in the care of each patient (e.g., consulting physicians, assistants at surgery, nursing and administrative personnel, etc.).

3. It is the responsibility of the Peer Review Committee to conduct a primary retrospective review of selected completed records of discharged patients and other pertinent sources of medical data relating to patient care.

4. Each department shall develop objective criteria that reflect current knowledge and clinical experience to be used in monitoring and evaluating patient care. Pursuant to these criteria, the Peer Review Committee shall review and consider problems in:

a. Operative and other clinical procedure(s) performed and their outcomes;

b. Pattern of blood and pharmaceutical usage including, without limitation, use of blood and blood components;

c. Requests for tests and procedures;

d. Length of stay patterns;

e. Morbidity and mortality data;

f. Use of consultants;

g. Medical assessment and treatment of patients;

h. Use of medications;

i. Efficiency of clinical practice patterns;

j. Significant departures from established patterns of clinical practice;

k. The use of developed criteria for autopsies;

l. Sentinel event data;

m. Patient safety data; and

n. Such other instances as are believed to be important, such as patients currently in the Medical Center with unsolved clinical problems.

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5. The Peer Review Committee shall meet on a regular basis to review and analyze on a peer-group basis the quality of clinical performance and shall make recommendations to improve the quality of patient care.

E. Focused Peer Review

1. Focused peer review is a process whereby the Medical Center evaluates a specific aspect of a practitioner’s performance.

2. As of January 1, 2008, focused peer review shall be conducted for all Members upon obtaining clinical privileges at the Medical Center to validate their competency in performing the requested privileges at the Medical Center.

3. Focused peer review is also conducted whenever a question arises as to whether the care provided by or the conduct of a Member met or meets the standard of care and/or when a pattern of cases or circumstances arise that are potentially indicative of a problem with a Member’s clinical judgment, expertise, or professional conduct. Examples include, but are not limited to:

a. Cases referred by a Medical Staff department or the Peer Review Committee, as a result of ongoing peer review; and

b. Cases referred by a Member, Medical Center staff member or patient complaint;

c. Cases referred by the Utilization Review Committee;

d. Any sentinel event involving a Member; and

e. A pattern of cases or circumstances potentially indicative of a problem with a Member’s clinical judgment, expertise, or professional conduct.

4. Focused peer review is conducted through the appropriate Clinical Chairperson and/or the Peer Review Committee and shall continue until the Member demonstrates, to the satisfaction of the applicable Clinical Chairperson and/or the Peer Review Committee, appropriate clinical competence, practice behavior and ability to perform privileges. A peer’s participation in focused peer review shall not imply the peer’s participation in or direction of any given case of the Member being evaluated.

5. Focused peer review may include, without limitation, chart review, monitoring clinical practice patterns, simulation, proctoring, external peer review, and discussions with other individuals involved in the care of each patient (e.g., consulting physicians, assistants at surgery, nursing and administrative personnel, etc.).

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F. External Peer Review

1. External peer review may be performed whenever deemed appropriate. Examples include, but are not limited to:

a. Lack of internal expertise - An insufficient number of appropriate peers are available or able to serve as reviewers;

b. Litigation - The Medical Center faces a potential medical malpractice suit;

c. Conflict of interest - The internal reviewers submit conflicting or vague recommendations, or fail to reach a common understanding, that will affect a Member’s membership or privileges; and

d. Medical Staff recommendation - The Medical Executive Committee, the Peer Review Committee, and/or the applicable Clinical Chairperson may at any time request external peer review.

2. Due to the fact that external peer review is conducted by an individual who is not a member of the Medical Staff, the timing within which an external peer review shall be completed is determined on a case-by-case basis, depending upon the availability of the external reviewer, the scope of the review, and other relevant factors.

3. Results of external peer review will be forwarded to the applicable Clinical Chairperson, the Medical Executive Committee and/or the Peer Review Committee, as appropriate, for consideration in determining the standard of care.

G. Confidentiality and Immunity

1. All peer review shall be conducted in a manner consistent with applicable confidentiality laws. All peer review records and activities are confidential and shall not be disclosed except as required by law.

2. The peer review activities described in this Policy and conducted in good faith are intended to be protected by the civil immunity protections of Wisconsin Statutes § 146.37.

3. The confidentiality and immunity provisions of this Section G of this Policy apply to individuals involved in peer review activities as well as other individuals designated to assist in carrying out the peer review duties and responsibilities.

References: Medicare Conditions of Participation, 42 C.F.R. §§ 482.21 and 482.22(b)

Wis. Stat. §§ 146.37 and 146.38 Wis. Admin. Code HFS § 124.10

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JCAHO Standards MS. 3.10, 3.20, 4.30, 4.40 and 4.45, 2007 2005. Effective Peer Review: A Practical Guide to Contemporary

Design. HCPro, Inc.: Massachusetts. Form(s): Medical Executive Committee Approval:

October 22, 2003

April 11, 2005

February 13, 2006

May 13, 2008


October 23, 2003

April 29, 2005

March 31, 2006

May 30, 2008

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Subject: Distribution of Significant Amendments to the Medical Staff of Bylaws and Policies Governing Medical Practices and Compliance with Medical Center Policies

Policy Statement: It is the policy of this Medical Staff that amendments to the

Medical Staff bylaws and Policies Governing Medical Practices shall be circulated and that Medical Staff and Allied Health Professionals shall comply with Medical Center Policies.

Guidelines:

A. Amendments to the Medical Staff bylaws or Policies Governing Medical Practices are made in the manner described in the body of the Medical Staff bylaws. If significant changes are made to the Medical Staff bylaws or Policies Governing Medical Practices, Medical Staff members and other individuals who have delineated clinical privileges will be provided with revised texts of the written material by the Medical Staff Services Office.

B. All Medical Staff members and Allied Health Professionals shall comply with the Medical Staff bylaws and Policies Governing Medical Practices as well as other Medical Center policies, as same may be amended from time to time.

References: JCAHO Standards MS. 2.1 and MS. 2.4, 2003 Form(s): Medical Executive Committee Approval:

October 22, 2003 April 11, 2005


October 23, 2003 April 29, 2005

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Subject: Unenforceable Oral Agreements and Arrangements Policy Statement: The Medical Center is committed to establishing policies and

developing effective internal controls that will promote adherence to applicable legal requirements and ensure compliance with the principles and guidelines established under the Medical Center's Compliance Program. These ongoing efforts require Medical Center compliance with all laws, not only with respect to the delivery of health care, but also with respect to its business affairs and dealings with physicians.

Guidelines: In the event a written agreement is necessary to qualify for an exception and/or avoid liability under applicable law, including without limitation, the physician self referral prohibition statute, commonly referred to as the "Stark Law," no oral agreement or arrangement between the Medical Center and any physician (or a member of a physician's immediate family), pursuant to which any remuneration is to be provided to such physician (or a member of such physician's immediate family), shall be enforceable, and all such oral agreements and arrangements shall be considered null and void with no force and effect. Accordingly, except in rare circumstances defined as exceptions under the Stark Law as agreed to by the Medical Center and the applicable physician, all agreements and arrangements between the Medical Center and any physician (or a member of a physician's immediate family), pursuant to which any remuneration is to be provided to such physician (or a member of such physician's immediate family), must be in writing, signed by both parties, and meet the requirements of all applicable laws. For purposes of this Section 12.3.1, the terms "physician" and "member of a physician's immediate family" shall have the meanings prescribed to such terms in 42 CFR §411.351.

References: None Form(s): Medical Executive Committee Approval:

August 13, 2012


October 29, 2012

ADVANCED PRACTICE PROFESSIONALS

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POLICY STATEMENT

Advanced Practice Professionals may come to the Medical Center and provide direct patient care services in certain circumstances. This Policy describes the necessary qualifications of such providers, how such providers are granted the authority to perform direct patient care services at the Medical Center, the supervising and collaborating relationships that are required, how the competency of such providers will be assessed, and the process for revoking such providers’ authority to perform services at the Medical Center. All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

1. STAFF MEMBERSHIP

1.1. Advanced Practice Professionals. An Advanced Practice Professional is an individual, other than a Practitioner, who meets the qualifications for Staff Membership and Clinical Privileges, as set forth in the Medical Staff Bylaws, and has been appointed to the Advanced Practice Professional Staff.

1.2. Qualifications.

An Advanced Practice Professional must meet the qualifications for Staff Membership as set forth in the Medical Staff Bylaws.

1.3. Application, Staff Membership and Clinical Privileges. An Advanced Practice Professional must submit a complete application for Staff Membership to Medical Staff Services and shall be credentialed, privileged, and re-privileged through the Medical Staff process, as set forth in the Medical Staff Bylaws.30 An Advanced Practice Professional shall only be entitled to exercise those Clinical Privileges specifically granted to the Advanced Practice Professional in accordance with the credentialing and privileging process set forth in the Medical Staff Bylaws.

1.4. Compliance with Bylaws and Policies. Prior to the exercise of Clinical Privileges, each Advanced Practice Professional must acknowledge in writing that he or she shall be bound by and is obligated to comply with the Medical Staff Bylaws, the Policies Governing Medical Practices, and all other applicable Medical Center policies

1.5. Suspension or Termination of Clinical Privileges. An Advanced Practice Professional’s Clinical Privileges may be suspended or terminated as set forth in the Medical Staff Bylaws. Advanced Practice Professionals are subject to the corrective action process set forth in the Medical Staff Bylaws and are entitled to the rights applicable to Advanced Practice Professionals as set forth therein.

2. SUPERVISORY AND COLLABORATIVE RELATIONSHIPS

30 JCS HR.01.02.05, EP 10 (Jan. 2016).

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2.1. Advanced Practice Nurse (APN).

(a) An APN must have a current written collaborative agreement with one or more Physicians appointed to the Medical Staff and shall work in a collaborative relationship with such Physician(s).31 The collaborative agreement must be in a form acceptable to Medical Staff Services.

(b) The APN and the collaborating Physician(s) shall comply with the collaborative agreement and all other applicable requirements set forth by the Wisconsin Department of Regulation and Licensing and the Medical Center, and shall work in each other's presence whenever necessary to deliver health care services within the scope of the APN’s professional expertise. Collaborating Physician(s) shall co-sign the APN’s medical record entries in accordance with Aurora’s Hospital Co-Signature Requirements Chart.

(c) It is the responsibility of both the APN and the collaborating Physician(s) to provide prior written notice to and receive prior approval from Medical Staff Services of any changes to the collaborative agreement or relationship.

2.2. Physician Assistant (PA).

(a) A PA must have a current written supervision agreement with one or more Physicians appointed to the Medical Staff who will act as the PA’s supervising Physician(s).32 If the PA intends to prescribe medications, the PA must also have a PA prescription authorization form signed by a supervising Physician and evidence of annual written reviews of the PA's prescriptive practices by a Physician providing supervision.33 Both the supervision agreement and the prescription authorization form must be in a form acceptable to Medical Staff Services.

(b) The PA and the supervising Physician(s) shall comply with the supervisory and all other applicable requirements set forth by the Wisconsin Department of Regulation and Licensing and the Medical Center, and shall work in each other's presence whenever necessary to deliver health care services within the scope of the PA’s professional expertise. Supervising Physician(s) shall co-sign the PA’s medical record entries in accordance with Aurora’s Hospital Co-Signature Requirements Chart.

(c) No Physician may concurrently supervise more than four (4) PAs unless the physician submits a written plan for the supervision of more than four (4) PAs and the Wisconsin Medical Examining Board and the Medical Executive Committee approves the plan.34

31 Wis. Adm. Code N § 8.10(7). 32 Wis. Adm. Code Med §§ 8.07(1) and 8.10(1). 33 Wis. Adm. Code Med § 8.08(2)(i). 34 Wis. Adm. Code Med § 8.10(1).

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(d) The supervising Physician may designate another Physician to supervise the PA only if: (i) such designation is made in writing, and (ii) at all times the PA is able to readily identify the Physician currently providing supervision.35

(e) Supervising Physicians shall be available to the PA at all times for consultation either in person or within fifteen (15) minutes of contact by telecommunications or other electronic means.36

(f) It is the responsibility of both the PA and the supervising physician(s) to provide prior written notice to and receive prior approval from Medical Staff Services of any changes to the supervision agreement or relationship.

2.3. Psychologist. Psychologists shall coordinate care with each patient’s attending Physician, consulting Physicians, and other Medical Center staff caring for the patient. There are no specific supervision or collaboration requirements for Psychologists, however, certain medical record entries made by a Psychologist must be co-signed. Refer to Aurora’s Hospital Co-Signature Requirements Chart.

2.4. Scope and Standards of Practice. An Advanced Practice Professional’s practice may not exceed his or her educational training or experience and may not exceed the scope of practice of the collaborating or supervising Physician(s) (if any).37 In addition, an Advanced Practice Professional may provide services only within the scope of the Clinical Privileges granted to such Advanced Practice Professional in accordance with the Medical Staff Bylaws. Such Clinical Privileges shall not exceed those granted to the collaborating or supervising Physician(s) (if any).

2.5. Competency Assessment / Performance Evaluation. Advanced Practice Professionals shall be subject to the credentialing recredentialing, Focused Professional Practice Evaluation, and the Ongoing Professional Practice Evaluation processes set forth in the Medical Staff Bylaws and the Peer Review Policy.

2.6. Failure to Maintain Appropriate Relationship. The failure to maintain appropriate collaborative or supervisory relationships, complete necessary evaluations in a timely manner, or otherwise comply with this Policy, may serve as the basis for corrective action against the Advanced Practice Professional and any collaborating or supervising Physician(s) in accordance with the Medical Staff Bylaws.

35 Wis. Adm. Code Med § 8.07(3). 36 Wis. Adm. Code Med § 8.10(2). 37 Wis. Adm. Code Med § 8.07(1).

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REFERENCES:

Wisconsin Statutes & Administrative Code Wis. Adm. Code N § 8.10. Wis. Adm. Code Chapter Med 8.

Code of Federal Regulations None

Joint Commission Standards JCS HR.01.02.05 (Jul. 2015).

FORM(S):

MEDICAL EXECUTIVE COMMITTEE APPROVAL: 02-13-2017

BOARD OF DIRECTORS APPROVAL: 02-20-2017

IMPAIRED STAFF MEMBER

POLICY STATEMENT

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The organized Medical Staff and organization leaders have an obligation to protect patients, its Staff Members, and other persons present in the Medical Center from harm. Therefore, the Medical Staff designs a process that provides education about Staff Member health; addresses prevention of physical, psychiatric, and emotional illness; and facilitates confidential diagnosis, treatment, and rehabilitation of Staff Members who suffer from a potentially impairing condition. The purpose of the process is to facilitate rehabilitation, rather than discipline, by assisting a Staff Member to retain and to regain optimal professional functioning that is consistent with protection of patients, Staff Members and others present in the Medical Center. All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

1. GENERALLY

1.1 Definition. 1. A Staff Member may be considered impaired if the Staff Member’s professional

performance or conduct is adversely affected by age, loss of motor or cognitive skills, or physical or mental health disorders or illness, such as chemical dependency.

1.2 Guidelines. 2. The steps outlined in this Policy are guidelines and are not directives that create

any rights for the Staff Member. Notwithstanding anything to the contrary herein, if an impairment poses an imminent danger to the health, safety or welfare of any individual, the Staff Member shall be summarily suspended, pending further review, in accordance with the procedures specified in the Medical Staff Bylaws.

2. REFERRAL TO THE PRACTITIONER WELLNESS COMMITTEE

2.1 Communication of Practice and Conduct Concerns. 3. The Medical Staff actively encourages any individual (including a Staff

Member, Medical Center employee, patient, visitor, vendor or other person) who has or becomes aware of a question or concern related to the possible impairment of any Staff Member, to promptly communicate such question or concern in accordance with the Communication of Practice and Conduct Concerns Policy. The concern will be documented in accordance with such policy and referred to the Practitioner Wellness Committee as necessary.

2.2 Self-Referral. 4. All Staff Members are strongly encouraged to voluntarily seek the assistance of

the Practitioner Wellness Committee and may do so by contacting any member of the Practitioner Wellness Committee. The Practitioner Wellness Committee member who is contacted will proceed in accordance with the Communication of Practice or Conduct Concerns policy. A Staff Member, regardless of whether an Aurora employee or not, may confidentially contact the Aurora Employee Assistance Program (EAP) 24 hours a day, seven days per week by calling (800) 236-3231.

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3. REVIEW BY THE PRACTITIONER WELLNESS COMMITTEE

3.1 Initial Evaluation by the Practitioner Wellness Committee Chairperson. 5. The Practitioner Wellness Committee Chairperson shall perform an initial

review of all concerns referred to the Practitioner Wellness Committee to determine whether the information provided indicates an imminent danger to the health, safety or welfare of any individual. If so, the Practitioner Wellness Committee Chairperson will refer the concern to any individual with the authority to impose a summary suspension as set forth in the Medical Staff Bylaws. The Practitioner Wellness Committee Chairperson will ensure that the concern is properly documented in the appropriate section of the Review and Evaluation Record form, obtain additional information as necessary, and consult with the applicable Clinical Chairperson. If the Practitioner Wellness Committee Chairperson determines that the concern does not require review by the Practitioner Wellness Committee, the Practitioner Wellness Committee Chairperson will complete the appropriate section of the Review and Evaluation Record form and return it to the Quality Enhancement Manager (QEM). The QEM shall maintain a confidential record of all concerns that will not proceed through review by the Practitioner Wellness Committee or the Peer Review Committee. All such concerns shall be reviewed quarterly by the Peer Review Committee to determine whether there is a pattern of practice or conduct concerns that needs to be addressed by the Peer Review Committee.

3.2 Appointment of Primary Contact Person; Delivery of Notice of Evaluation Letter. 6. If the concern will proceed to review by the Practitioner Wellness Committee,

the Practitioner Wellness Committee Chairperson will complete the appropriate section of the Review and Evaluation Record form and assign a member of the Practitioner Wellness Committee to serve as the Staff Member’s primary contact person. The responsibilities of the primary contact person include: (a) facilitating communication between the Practitioner Wellness Committee and the Staff Member; (b) providing on-going availability and support to the Staff Member; and (c) working with the Staff Member to develop and coordinate a comprehensive recovery program, if necessary. The Practitioner Wellness Committee Chairperson, or his/her designee, shall deliver a “Notice of Evaluation” letter to the Staff Member, identifying the primary contact person and inviting the Staff Member to meet with the primary contact person and provide any relevant information that may assist in the evaluation process.

3.3 Evaluation and Report by Primary Contact Person. 7. The primary contact person will make a reasonable effort to obtain the relevant

facts by: (1) discussing the concern with the Staff Member, the initial reporter, and other individuals; (2) reviewing the Review and Evaluation Record form, relevant medical records, reports, and any other information deemed necessary or relevant by the primary contact person; and (3) consulting with internal or external specialists or resources as necessary. The Staff Member shall be invited to explain the activities and/or conduct involved and encouraged to submit a written explanation or response. Discussions with the Staff Member shall not constitute a formal hearing under the Medical Staff Bylaws, and need not be conducted as such. The primary contact person will generally conclude his or her evaluation within fourteen (14) days of receiving the concern, complete the appropriate section of the Review and Evaluation Record form, and forward the form to the Practitioner Wellness Committee Chairperson. The

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primary contact person will seek approval from the Practitioner Wellness Committee Chairperson in the event a longer time period is required.

3.4 Review by the Practitioner Wellness Committee. The Practitioner Wellness Committee Chairperson will distribute the Review and Evaluation Record form and other relevant information to Practitioner Wellness Committee members, arrange for Practitioner Wellness Committee review, and invite the Staff Member to meet with the Practitioner Wellness Committee and submit written materials. The Practitioner Wellness Committee shall meet and review the Review and Evaluation Record form and all supporting documents, including any materials submitted by the Staff Member. In addition, the Practitioner Wellness Committee will discuss the concern with the Staff Member (if he/she accepts the opportunity), the initial reporter, and other individuals. Discussions with the Staff Member shall not constitute a formal hearing under the Medical Staff Bylaws, and need not be conducted as such.

3.5 Recommendations; Treatment and Recovery Agreement. 8. Following its review, the Practitioner Wellness Committee shall describe its

findings and recommendations in the appropriate section of the Review and Evaluation Record form.

(a) No Further Action. If a majority of Practitioner Wellness Committee members conclude that no impairment exists, the Practitioner Wellness Committee Chairperson shall complete the appropriate section of the Review and Evaluation Form and forward the form to the QEM, who will ensure that all such documentation is maintained in the Staff Member’s Quality Assurance File. The Practitioner Wellness Committee Chairperson shall inform the Staff Member of the Practitioner Wellness Committee’s findings and recommendations.

(b) Further Action Required. If a majority of Practitioner Wellness Committee members conclude that an impairment exists, the Committee shall, depending on the nature and severity of the impairment:

i. Continued Monitoring. Continue informal evaluations and schedule additional meetings with the Staff Member and others, as appropriate, for purposes of further analysis and monitoring of the impairment and for providing advice to the Staff Member regarding treatment options, which may include referral of the Staff Member to appropriate professional internal and external resources for evaluation, diagnosis, and treatment of the impairment; and/or

ii. Treatment and Recovery Agreement. Reach a formal written agreement with the Staff Member regarding a program of treatment and recovery, a sample of which is attached as Exhibit A (“Treatment and Recovery Agreement”). The Staff Member shall be informed that failure to enter into a written Treatment and Recovery Agreement on a voluntary basis may necessitate referral of the Staff Member for appropriate corrective action under the Medical Staff Bylaws.

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(c) Corrective Action. If the Practitioner Wellness Committee determines corrective action is indicated, the Practitioner Wellness Committee will proceed in accordance with the corrective action process set forth in the Medical Staff Bylaws.

3.6 Documentation. All information acquired in connection with the review and evaluation of health care services provided by an individual Staff Member and any records of investigations, inquiries, proceedings and conclusions of such review or evaluation, including any materials submitted by the Staff Member, shall be included in the Staff Member’s confidential Quality Assurance File. Such information may be factored into the decision to permit the Staff Member to maintain existing Clinical Privilege(s), to modify the Staff Member’s existing Clinical Privilege(s), or to revoke the Staff Member’s existing Clinical Privilege(s) prior to or at the time of reappointment and renewal or modification of Clinical Privileges.

3.7 Tentative Time Period for Review. Unless the matter is submitted for corrective action, the review process will generally be completed within sixty (60) days of the date the matter was referred to the Practitioner Wellness Committee. This timeframe may be used as a general guide, but may also be extended on a case-by-case basis.

3.8 Need for Corrective Action; Breach of Treatment and Recovery Agreement. 9. If at any time during the diagnosis, treatment, or rehabilitation phase of the

process it is determined that a Staff Member is unable to safely perform the privileges he or she has been granted, the Practitioner Wellness Committee Chairperson shall forward the matter for appropriate corrective action in accordance with the Medical Staff Bylaws.

3.9 Confidentiality. 10. Medical Center leaders, Medical Staff leaders, and any involved committee

members shall comply with all applicable laws regarding the confidentiality of information related to the review of health care services.

3.10 Reporting. 11. The Wellness Committee shall meet as necessary and shall make reports to the

Administrator and Chief of Staff.

REFERENCES:

FORM(S):

Review and Evaluation Record


BOARD OF DIRECTORS APPROVAL: 04/17/2017 12.

of 2 MILW_9272712.5

TREATMENT AND RECOVERY AGREEMENT

This TREATMENT AND RECOVERY AGREEMENT (“Agreement”), is made and entered into effective as of the ___ day of _______, 20____, by and between ________________ (“Member”) and ___________________, Inc. (“Medical Center”).

RECITALS: WHEREAS, Member is on the Medical Staff of the Medical Center; and

WHEREAS, the Medical Center’s Practitioner Wellness Committee (the “Committee”) and Member desire to enter into an agreement regarding a program of treatment and recovery.

NOW, THEREFORE, in consideration of the mutual promises and covenants herein contained, it is agreed as follows:

1. Voluntariness. Member’s execution of this Agreement is voluntary and Member acknowledges and agrees that Member is not required to sign this Agreement.

2. Member Obligations. Member hereby understands and agrees that Member’s appointment to the Medical Staff of the Medical Center and the exercise of Member’s clinical privileges are hereby conditioned upon Member’s agreement with, and adherence to, the conditions described in the treatment plan, attached hereto and incorporated herein as Attachment A.

3. Release and Indemnification. Member hereby releases, indemnifies and holds harmless the Committee members, the Medical Center and the Medical Center’s officers, directors, members, Medical Staff members, employees, agents and representatives from any and all liability whatsoever as a result of any act or omission performed in good faith in connection with this Agreement.

4. Medical Center Obligations. Medical Center shall keep confidential any and all information it receives about Member pursuant to this Agreement unless disclosed: (1) to pursue corrective action in accordance with the Medical Center’s Medical Staff Bylaws; (2) to the extent necessary to enforce compliance with this Agreement and to facilitate treatment; (3) to the extent necessary to protect the health and safety of patients, including, without limitation, reporting to Medical Staff leadership instances in which Member is providing or has provided unsafe treatment; (4) to the extent required by ethical obligations; and/or; (5) as otherwise required or permitted by law.

5. Amendment. Member acknowledges and agrees that this Agreement shall be reevaluated and revised at such intervals as the Committee deems appropriate to keep the Agreement tailored to the current circumstances.

6. Termination. Member agrees that this Agreement shall remain in full force and effect until terminated by written notification to Member from the Committee that the special requirements imposed upon Member as a condition of Member’s appointment to the Medical Center’s Medical Staff or Advanced Practice Professional Staff have been terminated.

7. Failure to Comply. Member acknowledges and agrees that Member’s failure to comply with this Agreement will result in an immediate and automatic termination of Member’s Medical Staff or Advanced Practice Professional Staff membership, as applicable, and all

of 2 MILW_9272712.5

privileges at the Medical Center, and that in such event, Member hereby waives all hearing and appeal rights under the Medical Staff Bylaws.

IN WITNESS WHEREOF, the parties hereto have entered into this Agreement as of the date first written above.

Member Chairperson, Practitioner Wellness Committee Medical Center Administrator

Date Signed Date Signed Date Signed

Attachment A – Treatment Plan MILW_9272712.5

Attachment A

TREATMENT PLAN

Member understands and agrees that Member’s appointment to the Medical Staff or Advanced Practice Professional Staff, as applicable, of the Medical Center and the exercise of Member’s clinical privileges are hereby conditioned upon Member’s agreement with, and adherence to, the following conditions: (check all that apply)

___ 1. Abstinence. Member shall maintain total abstinence from all psychoactive and/or mood-altering substances, including but not limited to alcohol and herbal preparations, unless such substances are properly prescribed or recommended by Member’s treatment provider(s) and are used by Member in accordance with such prescriptions or recommendations. Prior to receiving a prescription or recommendation for any psychoactive or mood-altering substance, Member will:

1.1 Inform the treatment provider of this Treatment Plan and Member’s recovery status;

1.2 Provide the Committee with written documentation from the treatment provider that describes the Member’s diagnosis and states that the use of the substance shall not impair the Member’s ability to practice in a safe and effective manner and shall not interfere with the Member’s recovery program, provided the substance is used in accordance with the prescription or recommendation; and

1.3 Provide the Committee with a copy of the prescription or recommendation.

___ 2. Testing. Member shall provide observed biological samples and submit to alcohol breath analysis:

___ Random ___ Scheduled: _____________________________________

___ 3. Assessments; Evaluations. Member shall submit to additional assessments with ________________________, and such physicians or other treatment personnel as may from time to time be required and designated by the Committee. Member shall also participate in face-to-face conferences with the Committee at least _______________ for a period of ______________, or at such frequency and for such period of time as deemed appropriate by the Committee. Member is responsible for scheduling requested face-to-face conferences. Member’s failure to schedule or attend such conferences at the scheduled date/time without prior notice and an adequate reason for Member’s absence shall be deemed a breach of this Agreement;

___ 4. Notifications.

4.1 Member shall direct all treatment providers, counselors and programs to immediately notify the Committee in the event the treatment provider, counselor, or program has reason to suspect Member has failed to abstain from the possession and use of any substance not approved by Committee.

4.2 Member shall notify the Committee, as soon as possible, of any termination of Member’s relationship with Member’s treatment provider(s), counselor(s), or program(s) and the name(s) of any treatment provider(s), counselor(s), or program(s) assuming responsibility for Member’s treatment;

4.3 Member shall notify the Medical Center’s Administrator immediately in person or by telephone if the Member fails to maintain complete abstinence, refuses to participate in

Attachment A – Treatment Plan MILW_9272712.5

biological testing or breath analysis, and/or any biological testing or breath analysis reveals the presence of any unauthorized psychoactive, mood altering, or other substance. Member shall notify the Administrator within twenty-four (24) hours if Member fails to comply with any other term of this Agreement;

___ 5. Reports.

5.1 Member shall ensure that a formal written report is submitted to the Committee from Member and/or Member’s treatment providers, counselors and programs attesting to Member’s progress and treatment at least _________________ [insert weekly, monthly, quarterly] for a period of _______________; or at such frequency and for such period of time deemed appropriate by the Committee. Such reports shall include:

(a) A description of the Member’s progress with the Treatment Plan;

(b) An assessment of the Member’s abstinence from unauthorized substances (including but not limited to alcohol and herbal preparations);

(c) The dates and times of Member’s attendance at AA/NA meetings, verified by the signature of a group or meeting representative (as applicable);

(d) The dates and results of scheduled or random screening tests; and

(e) The signature of the Member and Member’s treatment provider, counselor, or program.

5.2 Member shall direct Member’s treatment providers, counselors and programs to submit copies of all assessments, progress notes, and reports to the Committee, ensure the all such documentation is sent by the relevant treatment providers, counselors and programs, and confirm that all such documentation is received by the Committee at least _________________ [insert weekly, monthly, quarterly] for a period of _______________; or at such frequency and for such period of time deemed appropriate by the Committee.

___ 6. Professional Practice; Monitoring and Restrictions. Member shall maintain a level of professional practice that is appropriate during the different stages of Member’s treatment and recovery as such is determined by the Committee, and to the Committee’s review and monitoring of the same and comply with any re-entry guidelines or conditions established by the Committee for Member’s return to professional practice at the Medical Center, if such is interrupted or curtailed;

___ 7. Authorizations. Member shall execute all applicable authorizations needed to permit the Committee and all practitioners and individuals involved in the treatment and assessment of the Member to disclose and/or receive confidential information, including without limitation, alcohol and/or drug abuse (AODA) treatment records, to or from each other regarding such Member’s condition and treatment, and all releases needed to facilitate the Member’s treatment and recovery, including the Release and Consent to Testing, in the form attached hereto as Attachment B;

___ 8. Costs. Member shall pay promptly when due all expenses in connection with Member’s recovery and performance under this Agreement including, but not limited to, medications, professional fees, laboratory fees and assessments with health care providers.

___ 9. Other. _____________________________________________________________________ _______________________________________________________________________________________________________________________________________________________.

POLICIES GOVERNING MEDICAL PRACTICES Confirmation of Identity

Page 3 of 80 Confirmation of Identity

Attachment B

RELEASE AND CONSENT TO TESTING I, ___________________, freely and voluntarily consent to the collection and testing of scheduled or random biological samples (including blood, hair and/or urine samples) for the presence of any substance as requested by the Committee, and to scheduled or random alcohol breath analysis from me, upon the request of and at the times designated by the Aurora Health Care Southern Lakes, Inc., doing business as Aurora Medical Center (“Medical Center”) Practitioner Wellness Committee (“Committee”), and to the release of test result from such samples. I hereby release, indemnify and hold harmless the Committee members, the Medical Center, and the Medical Center’s officers, directors, members, Medical Staff members, employees, agents, and representatives from any and all liability whatsoever as a result of laboratory examinations performed as requested by the Committee. I acknowledge that I am currently on the medications listed below: Medication Dosage Prescribed by Date Prescribed I have read and fully understand this Release and Consent To Testing. Signature Collection Witness Collector (if different than witness) Accession Number

Date and Time Date and Time Date and Time


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CONFLICT MANAGEMENT

POLICY STATEMENT

Conflict is a normal response to differing opinions about needs, values and interests. While not all conflict is harmful, ineffectively managed conflict may adversely affect patient safety and quality of care, particularly when leadership groups disagree about accountabilities, policies, practices, and procedures. The Medical Staff, in collaboration with the Medical Executive Committee, Administration and the Governing Body, developed the conflict management process set forth in this policy in order to: (1) promote productive, collaborative, and effective teamwork among and between all individuals and groups at the Medical Center, including leadership groups and committees; and (2) maximize patient safety and quality of care.38 All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

4. DEFINITIONS

“Conflict” means differences in beliefs, needs, interests, or values among leadership groups and/or other groups or individuals within the Medical Center.

“Dysfunctional Conflict” means an escalating Conflict that undermines productivity or organizational well-being, demoralizes teams and/or individuals, and/or jeopardizes patient safety and quality of care at the Medical Center.

“Conflict Management” means the process of identifying and handling Conflict in a manner that promotes patient safety, quality of care, and organizational well-being. Conflict management involves open, productive, and respectful communication that acknowledges the rights and responsibilities of stakeholder parties.

“Facilitator” means an individual skilled in Conflict management who can serve as a neutral facilitator.39

5. INFORMAL CONFLICT MANAGEMENT.

5.1 Generally. Most Conflicts can be informally resolved in a manner consistent with the Medical Center’s values and Code of Conduct Policy.

5.2 Informal Process. Individuals and/or groups involved in a Conflict and other stakeholders will participate in the informal Conflict management process by:

38 JCS LD.02.04.01, EP 1 and LD.01.03.01, EP 7 (Jul. 2015). 39 JCS LD.02.04.01, EP 3 (Jul. 2015).


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(a) acknowledging the Conflict and respectfully listening to and considering the positions of others;

(b) providing an opportunity for key stakeholders to openly discuss the situation at hand, ask questions of one another, and evaluate pertinent information;

(c) demonstrating acceptance and tolerance of different perspectives and a commitment to fundamental fairness;

(d) refraining from behaviors and/or language that would be inconsistent with the Medical Center’s Code of Conduct Policy and/or could potentially escalate the Conflict; and

(e) requesting the assistance of a competent Facilitator whenever necessary.

If the Conflict cannot be satisfactorily resolved through these informal means and/or the Conflict has escalated to the point of becoming a Dysfunctional Conflict, the participants shall communicate the general nature of the Conflict to the Medical Center’s senior leadership (see Section 3.2(a)).

6. FORMAL CONFLICT MANAGEMENT

6.1 Generally. Conflicts that cannot be resolved with informal Conflict management may need formal Conflict Management; however, involved parties must ensure a good faith effort has been expended to resolve the Conflict through informal means.

6.2 Formal Process. Formal Conflict Management is necessary when a Conflict becomes a Dysfunctional Conflict.40 If such a Dysfunctional Conflict occurs, the following process will be implemented:

(a) Notify Senior Leadership. If not already aware, senior leadership of the Medical Center (the Administrator, the Medical Executive Committee, or the Governing Body) shall be notified about the Conflict and the need for implementation of the formal Conflict Management process. Throughout and after the Conflict Management process, the senior leader(s) will implement all necessary actions to protect patient safety and quality of care.41

(b) Determine the Nature of the Conflict. The senior leader(s) will meet with the involved parties as soon as possible and identify the nature and extent of the Conflict. The senior leader(s) will also gather additional information as necessary.

(c) Identify Necessary Supportive Resources. The senior leader(s) will identify an appropriate internal or external Facilitator to assist with the Conflict Management. External facilitators (including mental health, legal, or human resource professionals)

40 JCS LD.02.04.01, EP 5 (Jul. 2015). 41 JCS LD.02.04.01, EP 4 (Jul. 2015).


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may be considered when the Conflict involves key organizational leaders, a particularly sensitive issue, and/or there are no unbiased internal resources.

(d) Conflict Management. The designated Facilitator will:

i. Expeditiously meet with the involved parties to define the issues associated with the Conflict and identify potential areas of common ground;42

ii. Gather pertinent information about the Conflict;

iii. Work with parties to manage, and when possible, resolve the Conflict; and

iv. Assure appropriate flow of information to Medical Center leadership regarding the Conflict Management process and, in particular, issues that could adversely affect patient safety or quality of care.

REFERENCES:

Joint Commission Standards JCS LD.02.04.01 (Jul. 2015) JCS LD.01.03.01 (Jul. 2015)

FORM(S): None



CONFIDENTIALITY OF MEDICAL STAFF RECORDS

42 JCS LD.02.04.01, EP 4 (Jul. 2015).


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POLICY STATEMENT

It is the policy of the Medical Center to maintain the confidentiality of documents relating to credentialing, peer review and quality improvement activities involving individual Staff members. Such Records shall be maintained and kept confidential in accordance with the Health Care Quality Improvement Act of 1986, Wisconsin Statutes § 146.38, and other applicable State and Federal laws. Records may be accessed or disclosed only as described in this policy and in accordance with applicable law. All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

7. DEFINITIONS

“Authorized Representative” includes the following representatives of the Medical Center:

Administrator/President

Chief of Staff

Chief of Staff Elect

Secretary/Treasurer

Clinical Chairpersons/Department Chair

Members of the following Medical Staff Committees: Medical Executive Committee Credentials Committee, Peer Review Committee, and Practitioner Wellness Committee

Medical Staff Services personnel

Medical Center’s Legal Counsel

“Consultant” means: (1) any person or entity engaged by the Medical Center to assist in peer review and quality assurance activities, or otherwise assist or provide counsel to the Medical Center, including without limitation external peer reviewers or experts; or (2) any authorized representative of a regulatory or accreditation agency acting within the scope of his/her authority.

“Disclose” “Disclosed” or “Disclosure” means to permit a person or entity to access and inspect Records, or to provide a person or entity with copies of Records.

“Records” means all individually identifiable documentation (including notes of discussions and deliberations) relating to focused and ongoing professional practice evaluations, credentialing, peer review and quality improvement activities maintained in a Staff Member’s credentials file and/or quality file.

“Records Subject” means the Medical Staff Member or Advanced Practice Professional Staff Member who is the subject of the Records.

“Third Party” means a person or entity who is not the Records Subject, an Authorized Representative, or a Consultant (e.g., another hospital).


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8. LOCATION AND SECURITY OF RECORDS

All Records shall be maintained under the care and custody of the Medical Center’s Authorized Representatives. The office where the Records are maintained shall be kept locked, unless an Authorized Representative is present. An Authorized Representative must supervise all access to and disclosure of the Records. Records stored electronically shall be protected by passwords.

9. REQUESTS FOR DISCLOSURE

9.1 Requests for Disclosure. All requests for Disclosure of Records to a person/entity other than the Records Subject or an Authorized Representative must be made in writing and presented to the Chief of Staff or his/her designee for approval. The written request must include the following:

(a) name and address of the person making the Disclosure request;

(b) name and address of the person or entity to whom the Records are to be Disclosed;

(c) specific information requested;

(d) purpose of the request; and

(e) if the person/entity to whom the Records are to be Disclosed is a Third Party, a written statement signed by the Records Subject and releasing the Medical Center and its representatives from liability for Disclosure of the Records. (If a form other than the Medical Center’s Authorization and Release Form is used, consult with legal counsel regarding the adequacy of release language, as appropriate.)

The Chief of Staff (or his/her designee), in consultation with Medical Staff Services, will determine whether the Disclosure will be permitted in accordance with Section 4 below.

9.2 Records of Requests and Permitted Disclosures. The Chief of Staff or his/her designee will maintain a record of all requests received, whether such requests were granted or denied, and, if granted, to whom Records were disclosed, and the date of the Disclosure.

10. PERMITTED ACCESS/DISCLOSURE

10.1 Access and Disclosure Generally. The original content of Records may not be altered or removed from the Medical Center under any circumstance. An individual permitted access to Records shall be afforded a reasonable opportunity to inspect the Records and to make notes regarding the requested Records. An Authorized Representative must be present at all times during the inspection of Records. Medical Staff Services personnel may make copies of Records to be Disclosed to an Authorized Representative, Consultant, the Records Subject, or a Third Party as set forth below.


Page 9 of 80

10.2 Authorized Representative. Medical Staff Services personnel may Disclose Records to an Authorized Representative as necessary for such Authorized Representative to fulfill his/her Medical Staff responsibilities.

10.3 Consultant. Medical Staff Services personnel may Disclose Records to a Consultant as necessary for such Consultant to fulfill his/her responsibilities, if such Disclosure is authorized by the Records Subject or the Chief of Staff (or his/her designee) in accordance with Section 3.1.

10.4 Records Subject. Medical Staff Services personnel may Disclose Records to the Records Subject if such Disclosure is requested by the Records Subject and authorized by the Chief of Staff (or his/her designee) in accordance with Section 3.1.

10.5 Third Party. Medical Staff Services personnel may Disclose Records to a Third Party if: (1) the Records Subject authorizes such Disclosure in an authorization and release document approved by the Medical Center, and (2) the Disclosure is authorized by the Chief of Staff (or his/her designee) in accordance with Section 3.1. Medical Staff Services personnel must confirm that an authorization and release form approved by the Medical Center and signed by the Records Subject is on file prior to disclosing Records to a Third Party. (If a form other than the Medical Center’s Authorization and Release Form is used, consult with the Medical Staff Legal Counsel regarding the adequacy of release language, as appropriate.)

10.6 Subpoenas. All subpoenas pertaining to Records shall immediately be referred to an Authorized Representative. Before responding to such a subpoena, an Authorized Representative shall consult, as necessary, with the Medical Center’s Legal Counsel regarding the appropriate response to the subpoena.

10.7 Costs. A Records Subject or Third Party may be charged an administrative fee to reimburse the Medical Center for costs incurred in producing and transmitting copies of Records.

REFERENCES:

Wisconsin Statutes >Wis. Stat § 146.38 (2015).

Federal Statutes >Health Care Quality Improvement Act of 1986

FORM(S):

Consent and Release from Liability Form

MEDICAL EXECUTIVE COMMITTEE APPROVAL: January 9, 2017

BOARD OF DIRECTORS APPROVAL: January 16, 2017

COMMUNICATION OF PRACTICE AND CONDUCT CONCERNS


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POLICY STATEMENT

The organized Medical Staff is accountable to the Governing Body for the quality of medical care provided to Medical Center’s patients, assists the Governing Body by serving as a professional review body, and monitors and evaluates the professional practice and conduct of individuals with Clinical Privileges in order to make recommendations regarding such individuals’ continued Staff Membership and Clinical Privileges. In order to fulfill these obligations and ensure that the professional practice and conduct of Staff Members are consistent with the highest standards of safety, quality and collegiality, the Medical Staff and the Medical Center strongly encourage all individuals who have concerns related to the practice or conduct of a Staff Member to promptly communicate such concerns. All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

1. IDENTIFICATION AND COMMUNICATION

1.1 Identification of Practice and Conduct Concerns. Individual practice or conduct concerns may arise from:

(a) Information obtained through the Ongoing Professional Practice Evaluation (OPPE) process;

(b) Information from other Staff Members, Medical Center staff, patients/families, and/or regulatory or other agencies related to specific incidents, complaints, grievances, or concerns relating to quality patient care;

(c) Recommendations from Risk Management or Utilization Review; and/or

(d) Other relevant information.

1.2 Communication of Practice and Conduct Concerns. The Medical Staff actively encourages any individual (including a Staff Member, Medical Center employee, patient, visitor, vendor or other person) who has or becomes aware of a question or concern related to the professional practice or conduct of any individual Staff Member, to promptly communicate such question or concern to any one or more of the following persons:

(a) Quality Enhancement Manager (QEM);

(b) Applicable Clinical/Department Chairperson;

(c) Chief of Staff;

(d) Administrator;

(e) Any member of the Practitioner Wellness Committee;

(f) Any member of the Peer Review Committee;

(g) Any member of the Credentials Committee;

(h) Any member of the Medical Executive Committee; or

(i) Any member of the Governing Body.


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A Medical Center employee may also communicate questions or concerns to his/her immediate supervisor and/or a representative from human resources. To the extent possible and appropriate, the identity of an individual who communicates his or her concerns shall be kept confidential.

2. PRELIMINARY EVALUATION AND REVIEW43

2.1 Preliminary Evaluation and Documentation. The individual who receives the concern shall consider whether the information provided indicates an imminent danger to the health, safety or welfare of any individual. If so, the individual who receives the concern shall immediately contact any individual with the authority to impose a summary suspension as set forth in the Medical Staff Bylaws (the individual may also, at any time, refer the matter to an individual with authority to submit a Request for Inquiry or Investigation under the Medical Staff Bylaws if he/she believes the concern warrants a different form of corrective action). If the concern does not indicate an imminent danger, the individual who receives the concern shall refer the matter to the Quality Enhancement Manager. The Quality Enhancement Manager will ensure that the concern is properly documented in the appropriate section of the Review and Evaluation Record form, obtain additional information as necessary, and consult with the applicable Clinical Chairperson.

2.2 Review by the Clinical/Department Chairperson and Quality Enhancement Manager. The Clinical Chairperson, in consultation with the Quality Enhancement Manager, shall evaluate the concern as described below, complete the appropriate section of the Review and Evaluation Record form, and obtain additional information as necessary.

(a) Imminent Danger. The Clinical Chairperson, in consultation with the Quality Enhancement Manager, shall consider whether the concern indicates an imminent danger to the health, safety or welfare of any individual. If so, the Clinical Chairperson shall immediately refer the concern to any individual with the authority to impose a summary suspension as set forth in the Medical Staff Bylaws.

(b) Impaired Practitioner. The Clinical Chairperson, in consultation with the Quality Enhancement Manager, shall consider whether the concern is related to a Staff Member who may be impaired. If so, the Clinical Chairperson will notify the Administrator and refer the concern to the Practitioner Wellness Committee, which shall address the concern in accordance with the Impaired Practitioner Policy.

(c) Allegations of Disruptive Conduct. The Clinical Chairperson, in consultation with the Quality Enhancement Manager, shall consider whether concern involves allegations of Disruptive Conduct (as defined in the Medical Staff’s Code of Conduct Policy). If so, the Clinical Chairperson will notify the Administrator and refer the concern to the Peer Review Committee Chairperson.

(d) Other Concerns. If the concern is not referred for further review as provided in subsections (a)-(c) above, the Clinical Chairperson, in consultation with the Quality Enhancement Manager, will determine whether the issue warrants further attention by

43 JCS LD.03.01.01, EP 5 (Jan. 2010).


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the Peer Review Committee. This determination is not intended to be a complete evaluation of the circumstances, but merely a determination whether additional inquiry or review is necessary.

i. Additional Review Required. If additional inquiry or review is necessary, the Clinical Chairperson shall forward the Review and Evaluation Record form and any other applicable documentation to the Peer Review Committee Chairperson.

ii. Additional Review Not Required. If additional inquiry or review is not necessary, the Clinical Chairperson shall seek the concurrence of the Administrator or Chief of Staff and forward the Review and Evaluation Record form to the Quality Enhancement Manager. The Quality Enhancement Manager shall maintain a confidential record of all concerns that are not referred for further review (i.e., concerns that are not referred for corrective action, to the Committee on Practitioner Wellness, or to the Peer Review Committee Chairperson). All such concerns shall be reviewed quarterly by the Peer Review Committee to determine whether there is a pattern of practice or conduct concerns that needs to be addressed by the Peer Review Committee in accordance with the Peer Review Policy.

(e) Possible Corrective Action. The Clinical Chairperson, or any other individual with the authority to submit a Request for Inquiry or Investigation as set forth in the Medical Staff Bylaws, may submit such request at any time. The performance or lack of performance of any step set forth in this Policy shall in no way affect concurrent or subsequent Corrective Action.

3. NO RETALIATION

Retaliatory behavior will not be tolerated. Any attempt to confront, intimidate, harass, discriminate, or otherwise retaliate against an individual who reports a concern, or cooperates or assists in the investigation of a concern, is a violation of this Policy. Any individual who engages such retaliatory behavior will be subject to corrective action in accordance with the procedures specified in the Medical Staff Bylaws.

4. IMMUNITY

The activities described in this Policy and conducted in good faith, and the individuals or groups that perform or assist in the performance of such activities, are protected by the civil immunity protections of Wisconsin Statute § 146.37 and the Health Care Quality Improvement Act.


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5. CONFIDENTIALITY

All activities shall be conducted in a manner consistent with applicable confidentiality laws. All OPPE and FPPE records and activities are confidential and shall not be disclosed except as permitted by law.

6. USE OF FORMS

Whenever this Policy specifies a form for a particular purpose, no subsequent action shall be deemed invalid merely because other documentation containing substantially similar or all essential information for the purpose is used.

REFERENCES:

Wisconsin Statutes Wis. Stat § 146.37 (2009). Joint Commission Standards JCS LD.03.01.01 (Jul. 2015).

FORM(S):

Review and Evaluation Record




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CONFIRMATION OF IDENTITY

POLICY STATEMENT

Consistent with the Medical Staff Bylaws and Joint Commission requirements, it is the policy of the Medical Center to verify that the Applicant applying for Staff Membership and/or Clinical Privileges is the same individual identified in the credentialing documents presented pursuant to such Application.44 All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

11. DEFINITIONS

“Aurora Affiliate” means any facility or entity owned, controlled, or managed by, or under common ownership, control or management with Aurora Health Care, Inc.

“Authorized Form of Identification” includes the following forms of identification:

A current picture hospital ID card; or

A valid picture ID issued by a State or federal agency (for example, a driver's license or passport)

“Confirmation of Identity Process” means the process of confirming an Applicant’s identity as specified in the Medical Staff Bylaws.

12. USE OF CONTRACTORS OR AURORA AFFILIATES FOR VERIFICATION

Medical Staff Services may delegate the Confirmation of Identity Process to an Aurora Affiliate, a Credentials Verification Organization, or a Telemedicine Service Organization (as defined in the Bylaws). In the event of such delegation, the entity performing the Confirmation of Identity Process must meet the requirements of the Bylaws, this Policy, and the Joint Commission requirements.

13. METHOD OF CONFIRMATION

Medical Staff Services (or its designee) may verify an Applicant is the same individual identified in the credentialing documents by using one of the following methods:

(a) comparing the Authorized Form of Identification against the Applicant either (1) in person or (2) via real-time electronic visual communication (for example, Skype or FaceTime), or

(b) having the Applicant complete and return the Identification Verification Form attached to this Policy. Please note the completed Identification Verification Form must be submitted via mail. Faxed copies will not be accepted.

44 JCS MS.06.01.03, EP 5 (January 2018)


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REFERENCES:

JCS MS.06.01.03, EP 5 (January 2018)




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FOR OFFICE USE ONLY

Please note the presence of notary seal must be verified prior to scanning the Identification Verification Form.

I verify and confirm that the appropriate notary seal was present on the Identification Verification Form submitted by (INSERT NAME OF APPLICANT).

___________________________ __________________

Name of person verifying Date

of 80 Confirmation of Identity

IDENTIFICATION VERIFICATION FORM

SECTION A.

SECTION B. APPLICANT ATTESTATION (Please check type of identification copied in Section A.)

Hospital ID Card Driver’s license Passport Other government issued I.D.: _________________________ I attest that I, _______________________________, am the person reflected in the above photograph, and I am applying for privileges/scope of practice at a medical center of Aurora Health Care. _________________________________________ __________________ Print name Date

_________________________________________ __________________ Signature Date

SECTION C. NOTARY ATTESTATION

Sworn to and subscribed before me this _________ day of __________________, 20_____ in the State of _________________ and County of _________________________. After presentation of the same identification copied above in Section A, the above statement was signed before

me by (applicant name) ____________________________________________. __________________________________________________ Notary Public’s printed name ______________ Notary Public’s signature ______________ My commission expires

SECTION A Place a copy of your

Authorized Form of Identification in this box

MUST BE LEGIBLE

NOTARY SEAL / STAMP


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CODE OF CONDUCT

POLICY STATEMENT

All individuals within Medical Center facilities shall be treated courteously, respectfully and with dignity. To that end, the Governing Body requires all individuals, including without limitation, Medical Staff Members, Advanced Practice Professional Staff Members, Medical Center employees, independent practitioners, volunteers, and vendors to conduct themselves in a professional and cooperative manner at all times. This Code of Conduct describes minimum expectations regarding the conduct of Staff Members and defines acceptable behavior and behaviors that undermine a culture of safety.45 The process, for evaluating and addressing concerns related to a Staff Member’s conduct is set forth in the Peer Review Policy. The processes for evaluating and addressing concerns related to a non-Staff Member’s conduct are set forth in other Medical Center or Aurora administrative policies. All capitalized terms not defined in this Policy shall have the meaning set forth in the Medical Staff Bylaws.

1. MINIMUM EXPECTATIONS

At a minimum, all Staff Members are expected to:

1.1 Treat all individuals with courtesy, dignity and respect;

1.2 Comply with all Aurora and Medical Center policies and the Medical Staff Policies Governing Medical Practices;

1.3 Address concerns about clinical and non-clinical judgments with fellow Staff Members directly and professionally;

1.4 Address dissatisfaction with Medical Center policies, the Medical Staff Policies Governing Medical Practices, or the services provided by Medical Center staff, vendors, and volunteers, through appropriate grievance channels;

1.5 Work together as a team;

1.6 Be fair and honest;

1.7 Cooperate with patients in their care and with colleagues at all levels, recognizing that we need one another to reach our goals;

1.8 Support an environment in which ideas and concerns may be expressed freely;

45 JCS LD.03.01.01, EP 4 (Jul. 2015).


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1.9 Value differences of opinion, and when conflicts occur, deal with them directly and constructively;

1.10 Offer criticism in a constructive manner and accept constructive criticism; and

1.11 Demonstrate behaviors that support the Aurora Service Commitment Standards.

2. UNACCEPTABLE CONDUCT

Unacceptable conduct includes, but is not limited to the following:

2.1 Any behavior that endangers the safety of anyone in the Medical Center, including patients, Staff Members and Aurora employees;

2.2 Any behavior that is inconsistent with applicable laws, regulations, or ethical standards;

2.3 Disruptive Conduct, including:

(a) Verbal, written or physical behavior that a reasonable person would consider intimidating, hostile, or otherwise unprofessional, whether directed at Staff Members, Medical Center/Aurora employees, patients, family members, visitors, or others encountered as a result of the Staff Member’s association with the Medical Center; and

(b) Any other conduct (including without limitation behavior that is inconsistent with the Medical Center’s policy on sexual harassment) that indicates the Staff Member is unable to work harmoniously with others in a manner that does not interfere with the orderly operation of the Medical Center.

2.4 Impertinent or inappropriate comments (or illustrations) made in a patient medical record or other official document;

2.5 Use of foul language (verbal or written) or non-constructive criticism that intimidates, undermines confidence, belittles or implies stupidity or incompetence;

2.6 Willful damage to or theft of Medical Center or Aurora property;

2.7 Willful disregard of Medical Center or Aurora policies or the Medical Staff Policies Governing Medical Practices;

2.8 Unauthorized use, possession, or ingestion of mood altering substances while providing services or during a period in which the Staff Member is on-call to provide services;

2.9 Threats, reprisals, or any other aggressive, intimidating, or discriminatory behavior that could be considered retaliatory, against individuals who express professional practice or conduct concerns; and


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2.10 Dishonesty in communications with peer reviewers, Medical Center/Aurora employees, personnel, patients, or family members of patients.

3. ADDRESSING PRACTICE AND CONDUCT CONCERNS

Questions or concerns regarding an individual Staff Member’s professional practice or conduct shall be addressed in accordance with the Communication of Practice and Conduct Concerns Policy, the Focused Professional Practice Evaluation process set forth in the Peer Review Policy, the Corrective Action process set forth in the Medical Staff Bylaws, and the Impaired Practitioner Policy (as applicable).46

REFERENCES:

Joint Commission Standards JCS LD.03.01.01 (Jul. 2015)

FORM(S): None

MEDICAL EXECUTIVE COMMITTEE APPROVAL: December 12, 2016

BOARD OF DIRECTORS APPROVAL: December 19, 2016

46 JCS LD.03.01.01, EP 5 (Jul. 2015).