Welcome to Aspirus Wausau Hospital Aspirus Wausau Hospital is a regional health resource for north central Wisconsin and the Upper Peninsula of Michigan. Aspirus Wausau Hospital is a Magnet facility licensed for 321 (with 263 available) beds and staffed by 350 physicians in 35 specialties. Best known for its world-class cardiovascular program, Aspirus Wausau Hospital also provides leading edge cancer, trauma, women’s health, and spine and neurological care.

Aspirus Wausau Hospital Mission & Vision Mission Statement Aspirus is an integrated, community-governed healthcare system, which leads by advancing initiatives dedicated to improving the health of all we serve. We work collaboratively with others who share our passion for excellence and compassion for people. Vision Statement Aspirus is the region’s health care system of choice. We deliver value, innovation, excellence and compassion. Passion for Excellence. Compassion for People

Aspirus Wausau Hospital Values Value Statements Compassion – We care for our patients above all. We exist to serve those who choose us. We strive to exceed expectations by showing utmost concern for their physical, emotional, and spiritual needs. Excellence – We create, innovate, and embrace change. We provide superior quality, showing measurable results. We always aim to improve. We provide a safe environment for all. Integrity – We honor our commitments. We treat everyone with dignity and respect, being consistent with the trust given to us. We are accountable for our actions. Collaboration – We work well together across the Aspirus system. We partner in service with people and organizations that share our vision. We value our workforce. We are active in the community. Fiscal Accountability – We prepare for the future of health care wisely. We effectively and efficiently manage resources, providing excellent and affordable services that ensure a strong future.

Orientation Guide This comprehensive orientation includes some key information for your review prior to practicing at Aspirus Wausau Hospital. Contents Introduction of Hospital Leaders/Services Medical Staff Information/Policies Communication Methods Hospital Department Specific Information HIM/CPOM CME Onsite Orientation – Provider Support Services Contact Information

Aspirus Wausau Hospital Services Aspirus Health Foundation Bariatrics Behavioral Health Services Birthing Center/Newborn ICU Cancer Center Cardiology Cardiopulmonary/Vascular Lab Diabetes Education Center Digestive Care/GI Genetic Counseling Heart & Vascular Institute Home Health Home Medical Equipment Hospice/Palliative Care Imaging (Radiology) Joint Replacement Center Kidney Care/Outpatient Dialysis Nephrology Pharmacy Services Pulmonary Medicine Reference Laboratory Regional Sleep Disorders Center Rehabilitation, Outpatient Services Respiratory Services Senior Health Spine & Neurosciences Surgical Services Trauma Center Women's Health Wound & Hyperbaric Center

Medical Staff Structure Dr. Rengel is President of the Medical Staff Dr. Hackworth is Vice President of the Medical Staff and chair of Bylaws/Credentials Comm Dr. Riveron is Medical Staff Secretary/Treasurer and chair of Quality Review Comm Board of Directors (Joint Commission Required) Bylaws/Credentials Committee Medical Executive Committee President, President Elect, Secretary/Treasurer Quality Review Committee DIVISIONS of the Medical Staff Hospital Based Chief and Vice Chief Surgeons & Interventionists Medicine Community Medicine Specialty Representatives are appointed from the following: Anesthesia Emergency Hospitalists Pathology Neonatology Radiology Cardiology Gastroenterology General Surgery Neurosurgery OB/GYN Oral/Maxillofacial Surgery Ophthalmology Orthopedics Otolaryngology Pain Medicine Plastic Surgery Thoracic Surgery Urology Family Medicine Infectious Disease Internal Medicine Medical Oncology Nephrology Neurology Pediatrics Physical Medicine Rehab Psychiatry Pulmonary/Critical Care Radiation Oncology Allergy Dentistry Dermatology Endocrinology Podiatry Psychology Rheumatology

Organized Medical Staff The Medical Staff Bylaws Outlines the following: Purposes and Responsibilities Medical Staff Membership Categories of the Medical Staff Allied Health Practitioners Procedures for Appointment and Reappointment Determination of Clinical Privileges Corrective Action Interviews, Hearing & Appellate Review Fair Hearing Plan Officers Refer to OnBase Policy #10379 Committees Divisions of the Medical Staff & Specialty Representation Medical Staff Meetings Privilege and Immunity/Confidentiality Rules, Regulations, Policies & Forms Conflict Resolution Dues and Assessments Histories and Physicals Bylaws Amendments/Revisions & Adoption

Medical Staff Officers/Meetings Officers President, President-Elect and Secretary/Treasurer are elected biannually via annual meeting or electronic voting in addition to Division Chiefs and Vice Chiefs. Specialty representatives are appointed every two years as well. Two years terms beginning in July. Meetings On going Medical Staff committees and specialty meetings are held on a regular basis. Please contact Provider Support Services at pss@aspirus.org for information regarding dates and times.

Provider Support Services (aka Medical Staff Services Office) Providers Support Services provides professional support to Aspirus Wausau Hospital Medical Staff and acts as a liaison between Administration and the Medical Staff. Please let us know if you need anything! Our group email is pss@aspirus.org. To contact us individually: Linda Hackbarth Director of Provider Support Services Ph. (715) 847-2268 email Linda.Hackbarth@aspirus.org Staci Rothamer Provider Support Assistant Ph. (715) 847-2276 email staci.rothamer@aspirus.org Chris McNutt Provider Support Specialist Ph. (715) 843-1104 email Christine.McNutt@aspirus.org

Medical Staff Communication Dr Know – weekly electronic newsletter Provide PSS a current and working email address (this address is kept confidential) Provider Website Communication boards in physician lounge Mailings Meetings (MEC, QRC, Specialty, Committee) Email

Medical Staff - Hospitalists These physicians provide care for patients during their hospitalized stay and transfer care back to the patients’ primary care physicians upon patient discharge. This hospital based care is available 24 hours a day, seven days a week. Practice Manager 715. 847.2989

Student Rotations/ Shadowing Please contact Physician Recruitment at 715 847-2996 or if interested in student rotations. Students are not allowed to be in the hospital without completing an approval process. Refer to Onbase Policy #7028

Credentialing & Privileging Initial Appointment Appointment is based on provider’s specialty, and limited to two years from appointment date. The appointment will include approved privileges. Reappointment Occurs every two years Paperwork sent to provider’s primary practice address. Return the reappointment application by the due date to avoid possibility of privileges expiring. Clinical Privileges granted by the Board Privileges are granted at Initial appointment and Reappointment after the Board of Directors has reviewed and approved your request. Please review your approved privileges and contact Provider Support Services if you desire to add or delete privileges. Any changes need to be approved by the Board. New procedures/services requires additional information such as the development of privilege criteria. Privileges for all AWH providers are available on the intranet at I Privileges – Search. Please refer to Onbase Policy #10379 section 6.2

Practitioner Background Checks It is the policy of Aspirus Wausau Hospital to comply with Wisconsin law pertaining to background checks.  The checks are intended to identify Practitioners who have been charged with or convicted of a serious crime, abused or neglected a patient or child or misappropriated patient property.  Background checks are conducted for newly appointed Practitioners and every four years thereafter.  Every Practitioner shall notify the President of the Medical Staff or Chief Executive Officer of Aspirus Wausau Hospital or their designees as soon as possible, but no later than the Practitioner’s next workday, when he or she has: Been convicted of any serious crime, act or offense. Been investigated by any governmental agency for any act, offense, or omission, including an investigation related to abuse or neglect of, or threat of abuse or neglect to a child. A pending charge against him or her for a serious crime, act or offense. A finding by a government agency or similar authority that he or she has abused or neglected a patient or misappropriated the property of a patient. A determination by a governmental agency or similar authority that he or she has abused or neglected a child. A license, authorization or certificate that is not current or that is limited so as to restrict him or her from providing adequate patient care. We appreciate your understanding and cooperation with this State requirement.

Medical Staff & Hospital Policies Access to all Policies and Procedures can be found on the AWH intranet. Click on the Policy & Procedures Link. Aspirus Wausau Hospital Policy & Procedures For questions on accessing policies please dial 0 and ask for the house supervisor.

Medical Staff Policies Peer Review Policy Aspirus Wausau Hospital and its Medical Staff are responsible for the quality of care provided to the patient population seen throughout the institution. Therefore it is the policy of Aspirus Wausau Hospital to support the Medical Staff peer review process. The peer review process is a non-biased, professional activity performed by the Medical Staff (with the assistance and involvement of hospital professional support personnel) to measure, assess, and where necessary, improve performance of both an individual and/or system processes. The results of peer review are communicated on an ongoing basis and are used as one factor in the bi-annual Medical Staff reappointment process. Ongoing Professional Practice Evaluation (“OPPE”) OPPE includes the routine monitoring of clinical cases, performance and outcomes data, or occurrences, to identify opportunities for improvement whether via process improvement or individual and group performance. OPPE is carried out by specialty peer review committees or select multi-specialty Medical Staff committee (MMC) Focused Professional Practice Evaluation (“FPPE”) FPPE consists of formal evaluation of the details of the performance of a particular member of the Medical Staff or AHP under certain circumstances such as: When a member or AHP with clinical privileges is new or when an existing member or AHP has been granted a new privilege; or When questions arise about whether a practitioner can continue to provide safe, high-quality care. Refer to On Base Policy #7311

Medical Staff Policies (cont’d) Medical Staff CODE OF PROFESSIONAL BEHAVIOR To create and maintain a culture of safety and quality, it is the policy of the organized Medical Staff of Aspirus Wausau Hospital (AWH) that all practitioners who are members of or affiliated with the Medical Staff conduct themselves in a professional, cooperative and appropriate manner while providing services as a practitioner at AWH. The Medical Staff Bylaws, of which this Code of Professional Behavior is attendant, shall be the exclusive means for review and disciplining Medical Staff members for inappropriate or disruptive behavior. Inappropriate and disruptive behavior interferes with the provision of quality patient care and the orderly administration of the hospital or its Medical Staff. Safety and quality thrive in a positive environment that supports teamwork and respect for others. Refer to OnBase Policy #12885 Medical Staff SUPPORT COMMITTEE POLICY PRACTITIONER HEALTH ISSUES The Medical Staff Support Committee (MSSC) is a peer review committee providing a forum for assistance, advocacy, monitoring, education, consultation, intervention, and recommendations of policies related to Medical Staff and Allied Health impairment and disruptive behavior. The Medical Staff Support Committee exists to ensure processes exist to identify and manage matters of individual health for ACI and AWH Medical Staff members and Allied Health Practitioners that is separate from actions taken for disciplinary purposes. MSSC’s goal is to improve the quality of care and promote the competence of the Medical Staff and Allied Health. Refer to OnBase Policy #6219

Medical Staff Policies - ALLIED HEALTH PRACTITIONERS An Allied Health Practitioner (AHP) is an individual other than a physician, oral and maxillofacial surgeon, dentist or podiatrist who is qualified by academic and/or clinical training and by prior and continuing experience and current competence in a discipline which the Board of Directors has determined to allow to practice in the Hospital and who either are to provide guidelines specific to Allied Health Practitioners associated with AWH Medical Staff. The three types of Allied Health Practitioners are: Licensed Independent Practitioners (LIP) –Psychologists and Certified Nurse Midwives. LIPs are granted clinical privileges but are not members of the Medical Staff. Advanced Dependent Practitioners (ADP) –. Currently approved disciplines include: Physician Assistants, Nurse Practitioners, and Certified Nurse Anesthetists. ADPs are granted clinical privileges but are not members of the Medical Staff. Dependent Allied Health Practitioner (Dependent AHP) – Provide care to patients in the hospital under the supervision of a member of the Medical Staff. Currently approved disciplines include: Surgical Assistants, Dental Assistants, Audiologists. Orthopedic Clinical Nurses, GI Procedure Assistants, and Physician Employed Research Personnel.

Medical Staff Policies - ALLIED HEALTH PRACTITIONERS (cont’d) AHPs meet as a group on a quarterly basis and have elected three (3 ) officer positions (President, President Elect & Secretary) to help lead and focus the committees goals. If you would like to contact one of the officers, please contact Provider Support Services pss@aspirus.org. AHPs are credentialed and authorized to practice at AWH through the Medical Staff and Board of Directors. Refer to OnBase Policy #4910

Medical Staff Policies – RESTRAINT ORDERS After all other options have been exhausted (i.e. Patient Sitters, family members), the use of restraint must be ordered by a Medical Staff member, licensed resident, advanced practice nurse, physician assistant or independent practitioner. Restraints must be ordered prior to application except in emergency situations, when the order can be obtained either during the application of restraint or immediately (within a few minutes) after the restraint has been applied. The order must also be time-limited up to a maximum of 24 hours as an order of shorter duration may be more appropriate for some. If the order is renewed for another 24 hour period, ordered or appropriate designee must conduct a face-to-face evaluation before writing the new order. Restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Refer to Onbase policy #6146

Medical Staff Policies - Preoperative Anesthesia Assessment Of Patients Guidelines for oral intake before elective procedures requiring anesthesia (general, regional, Monitored Anesthesia Care (MAC)) Blood work recommendations for patients Cardiac Clearance guidelines Chest x-ray guidelines EKG guidelines Before patients are brought into the OR for elective surgery or anesthesia, a complete history and physical examination (H&P) and pertinent physical findings must be recorded on the medical record. If an H&P has been obtained within 30 days prior to admission, updates to the patients condition since the assessments must be recorded at the time of admission. A licensed independent practitioner who has privileges to perform an H&P can do this update. Refer to Onbase policy #3138

Rapid Response Team (RRT) To prevent further deterioration, the RRT may be called to the bedside of any hospitalized patient, 18 years of age and older, experiencing a change in condition such as: Systolic blood pressure less than 85 mm/Hg or greater than 200 mmHg Heart rate less than 40 or greater than 130 SpO2 less than or equal to 90% with increasing 02 requirements Respiratory rate less than 8 or greater than 30 Respiratory distress/compromised airway Chest pain: new onset Altered level of consciousness Acute change in mental status, agitation, or restlessness Sudden loss of ability to speak New, repeated, or prolonged seizures Unexplained lethargy/difficulty waking Uncontrollable bleeding Loss of peripheral pulse or change in color of extremity Failure to respond to treatment for change of condition Uncontrollable pain Acute change in urine output less than 50 ml in 4 hours RN or family member concern for patient condition

To active RRT please dial 44. Rapid Response Team (cont’d) RRT CONSISTS OF: An Advanced Cardiac Life Support (ACLS) educated Medical/Surgical ICU RN, Cardiac Telemetry RN and Respiratory Therapist (RT). An Aspirus Hospitalist may be paged if additional assistance is identified. RESPONSIBILITIES OF Rapid Response Team: Perform assessment. Begin resuscitation to avoid further decline in condition. Quickly obtain data for physician Communicate clearly about patient condition with attending physician and/or hospitalist. Mentor non-critical care staff. Utilize appropriate equipment as needed The RRT is available in the hospital 24/7 To active RRT please dial 44. Refer to OnBase Policy #7222

Emergency Call Coverage Active Members of the Medical Staff of Aspirus Wausau Hospital shall be responsible for providing on call coverage for attached and unattached patients presenting in the Emergency Department of Aspirus Wausau Hospital in accord with this policy. The call schedule for a particular specialty shall include those physicians who are members of the Medical Staff and who are qualified to practice the core privileges within that specialty. Emergency Department unattached patient call coverage shall be provided equally by all members of the Aspirus Wausau Hospital Medical Staff within a given specialty. A physician on call should be available via telephone, pager or other mobile communication unit. A physician on call must be able to respond in person to the Emergency Department within thirty (30) minutes from initial contact if requested by the Emergency Department physician. Refer to OnBase policy #6740

Corporate Compliance Team Strong ethics policy & corporate culture that fosters ethical behavior Refer to OnBase Policy #2348 –Corporate Ethics-Conflict of Interest Policies & procedures to support a program Refer to OnBase Policy #7410 – Corporate Compliance Plan Monitoring & auditing systems Documentation Charging Coding Billing Reimbursement Accurate and clear orders Complete and legible notes Medical necessity for services Authentication of entries (sign & date) It is your Duty to report issues and your obligation to cooperate in compliance activities and investigations. Corporate Compliance Team Chief Compliance Officer - Cari Logemann 715-847-2166 or 800-450-2339 Physician Representative - Dr. Rick Reding Compliance Auditor/Privacy Officer - Sandy Lakey, 715-847-2181 Sandy.Lakey@aspirus.org

CORPORATE COMPLIANCE (cont’d) HIPAA Privacy Program - It’s everyone’s Responsibility It’s about Patients Rights Right to Privacy Notice Right to Disclosure Right to Access Right to Restrict Right to Amend Right to File a Complaint Your Responsibilities Respect the patient’s right to privacy Only access information needed to do your job Keep Information Confidential Curb human nature – curiosity – sharing experiences Disclosure of Personal Health Information violates the law Know Aspirus’ privacy policies Report Violations to the Compliance Hotline Compliance Hotline 715. 847.2166 or 800.450.2339 Refer to Onbase Policy #5133

Dr. Joseph F. Smith Medical Library Jan Kraus, MLS Photo: St Mary’s Hospital – Wausau – Medical Staff 1938

Resources Research & Publishing Teaching Technology UpToDate CME DynaMed Micromedex & Clinical Pharmacology MD Consult Prescriber’s Letter & Medical Letter OVID, online books, journals, etc. Research & Publishing Library staff will do research for you: Clinical questions, direct patient care Non-direct patient care, grants, white papers … Patients, family members Publishing Teaching Site visits to partner hospitals One-to-one or formal classes Evidence-based medicine Heath Literacy Vol. Community Faculty UW Madison Technology “Virtual Library” since 2001 Library, Health Literacy & Provider websites iPads, Podcasts, PowerPoint's, etc. 8 computer workstations eDocDelivery

Library’s collections Medical Nursing/Allied Health Management/Leadership Patient/Community Reference Please call the Library for passwords and access instructions to UpToDate CME, etc. Online Access Aspirus Intranet Select Resources/References Medical Library In Epic Click on the red EPIC button in the upper left corner Select Library Resources Library Staff Contact Information Website: www.aspiruslibrary.org Email: library@aspirus.org Phone: 715.847.2184 Fax: 715.847.2183

Medical Staff Resources - Bioethics Committee Whenever a clinical situation arises that presents a bioethical dilemma for a patient, his/her significant other(s) or any member of the health care team involved in the case the Bioethics Committee is available to address the issue. The Bioethics Committee does not mandate changes in care, but recommends options in regard to addressing the situation and implementing the most ethically acceptable decision. It is the responsibility of the physician and the nursing staff to advise the patient and his/her significant other(s) of their rights to access the Committee. The Bioethics Program may be accessed through the Bioethics Committee Chair or Provider Support Services at 847-2276 or 843-1104. After hours please dial 0 and ask for the House Supervisor. Refer to OnBase Policy #2498

Medical Staff Resource – Physician Connect Physician Connect line is 877.697.4324 or 715.847.2737. Aspirus Physician Connect Operator determines if the caller is looking for Advice for Treatment or Transfer of a Patient. They document the patient demographics and page the requested Aspirus provider using the On-Call Schedule. The operator call back number is followed by *888 indicating the page is for a consult or potential transfer and a physician is holding to talk to them. The Aspirus Provider, or their assistant, is expected to respond to the page within five minutes. If a response is not received within five minutes, the operator will either initiate a second page or contact an appropriate member of the Medical Staff. When the Aspirus Provider answers the page, the Physician Connect Operator conferences the call for the two providers. The Physician Connect Operator also remains conferenced in on the call to facilitate any other necessary connections and/or to contact MedEvac for transport. After the conversation is completed, the Aspirus Physician Connect Operator calls MedEvac for transport if required, connects the Aspirus Provider to Hospital Supervisor if appropriate, and documents the disposition of the call.

Medical Staff Resources - Laboratory Services Provided   Medical Staff Resources - Laboratory Services Provided Hours: 0630-1730 M-F, 0630-1200 Saturday and Sunday Location: West Lobby entrance behind Starbucks and next to Patient Registration. Appointments are preferred, but not necessary. Chemistry Blood Gas Analysis Cardiac Marker Analysis – Example: CKMB, CPK, Troponin T, NT-ProBNP Routine Chemical Analysis – Examples: Electrolytes, Total Protein, Glycosylated A1C, medical ETOH Therapeutic Drug Monitoring – Examples: TheopyLline, Vancomycin, Valproic Acid Thyroid Testing – Examples: TSH, FT4, T3 Tumor Marker Analysis – Examples: CA 1-25, CA 19-9, CEA, PSA, AFP(Tumor Marker) Body Fluid Chemical Analysis – Examples: Total Protein, Glucose, Albumin Other Immunochemistry testing – Examples: Follicle Stimulating Hormone, Estradiol, Progesterone, Luteinizing Hormone, Quantitative Human Chorionic Gonadotropin (HCG) Coagulation: Routine Coagulation testing (PT, PTT, Fibrinogen) Coagulation Factor Analysis Coagulation Abnormality Studies For Outpatient services (blood draws, urine and semen analysis collection*)

Medical Staff Resources - Laboratory Services Provided (cont’d) Hematology: Routine Hematology Testing Body Fluid Analysis – cell counts, and differential Special Stains for Hematologic Samples   Immunology: Antibody Analysis HIV testing Transfusion Services: Blood and Blood Product Compatibility Testing Urinalysis: Routine Urinalysis Testing Semen Analysis –fertility and Post Vasectomy Stool for Reducing and Non-Reducing Substances  Microbiology: Routine Culture and Sensitivity Testing Organism Identification Parisitology Molecular Testing: Factor V Leiden Mutation, Prothrombin Nucleotide 20210 G/A Gene Mutation (Factor II) Clostridium difficile, Chlamydia Gonorrhea Flow Cytometry: Immnuophenotyping of Blood, Bone Marrow and Tissue Helper/Suppressor Analysis

Medical Staff Resources - Laboratory Services Provided (cont’d) LAB RESULTS/REPORTS Computer – Lab results are available in Epic as soon as tests are completed. If patient had work done as an outpatient (ER, pre-op, etc.) this is also available in Epic. The results of tests referred to Aspirus Reference Laboratory by Aspirus entities also appear in the Epic medical record. Paper Reports – only upon request.   LAB SPECIMEN COLLECTION Collection time – routine AM collection is from 0400-0500 for critical care units and 0400-0600 for all other care units. Lab does routine collection rounds every hour. Tests ordered as routine will be collected during the next hourly rounds. Use of routine priority when ordering tests facilitates combining draws so patient doesn’t get multiple venipunctures.  Nursing staff collects specimens from patient lines and ports, Respiratory Therapy does arterial sample collection on critical care patients, and lab collects all other blood samples. Whenever possible lab will use specimens already in lab rather than having patient receive another venipuncture when test is ordered with Routine or STAT priority. Improperly identified or labeled specimens will be recollected unless specimen is irretrievable. LAB RESULT AVAILABILITY Test Completion Time – Goal is to have general chemistry, hematology, and coagulation testing complete by 0700 M-F.  QUESTIONABLE RESULTS/REPEAT TEST REQUESTS Lab staff will validate questionable results before they are reported Lab will repeat tests at no charge to confirm results when requested by physician Reference Lab Associated Regional University Pathologists (ARUP) is the primary reference lab used by Aspirus. ARUP is one of the largest reference labs in the US and is widely used by hospitals because of their excellent reputation for quality and value. Samples we send to them go by air to their main lab. Results electronically download into our computer system and are reported as tests are completed.  For a complete test listing please see our online Reference Manual – available on the Aspirus Intranet – Resources and References page. You may also access the manual from the Aspirus Public website located under Reference Laboratory on the Our Services Page – www.aspirus.org/ourServices.

Medical Staff Resources Blood Supply & Ordering Information The Aspirus Wausau Hospital Transfusion Service (x72127) receives blood components through the Blood Center of Northcentral Wisconsin (BCNW), 211 South Forest Street, Wausau.  The following components are available in our hospital: Prestorage leukocyte-reduced red blood cells (300 cc) Fresh frozen plasma (~200 cc) Random donor platelet packs (50 cc) Pooled Cryoprecipitated AHF (120 cc) Platelet Pheresis (~260 cc) Other products including - albumin, immune globulin, Rh Immune Globulin (300mg/dose) are available through Pharmacy. Packed red blood cells (Prestorage leukocyte-reduced red blood cells are transfused for all red blood cell transfusions. Irradiated products (red blood cells and platelets) are prepared on site for individuals at risk for transfusion-associated graft-vs-host disease. CMV seronegative cellular components are available through the BCNW. Autologous and Directed-donor units may be drawn at BCNW. A physician order is required for donation. Autologous units should be made 3-5 days before needed to assure completion of all processing tests. A surcharge for autologous and directed units is billed to the patient. Blood donated by blood relatives to be used as a directed donation requires irradiation before transfusion.

Medical Staff Resources - Pathology Associates in Pathology, S.C. offers comprehensive, CAP certified Histology and Cytology laboratories processing approximately 18,000 surgical cases and 20,000 cytology cases, annually.   Personalized, local pathology consultation including frozen section interpretation is provided 24/7.  Routine results are usually available within 24 hours after receipt of the specimen. Normal hours of operation are 7:30am – 5:00pm, Monday – Friday (excluding major holidays) On-call pathologist available 24/7 During normal operating hours, call 847-2130 Outside normal operating hours, call Aspirus Wausau Hospital operator (847-2000) and request to page the Pathologist on call To see a listing of AIP Pathologists, click here.  Main office: (ph) 715-847-0075 or 1-888-228-3375 (fax) 715-847-0065  Hospital Office: (ph) 715-847-2130 (fax) 715-847-2133   Histology Lab: (ph) 715-847-2000 x53126 (fax) 715-847-2133 Secretary 715-847-2130   Cytology: (ph) 715-847-2000 x50075 Billing Inquiries: 715-847-0075 or view our FAQ’s on the web www.aipathology.com General inquiries: info@aipathology.com

Safety – Aspirus Wausau Hospital Codes

Safety – Aspirus Wausau Hospital Codes (cont’d)

Safety – Aspirus Wausau Hospital Codes (cont’d)

Medical Staff Resources - Medical Imaging The Medical Imaging department consists of seven subspecialties of diagnostic radiology: Diagnostic X-ray 24hr/7 days Computerized Tomography CT 24 hrs/7days Ultrasound (US) 24hrs/7days Intervention/Angio IR Magnetic Resonance MR Nuclear Medicine Women’s Imaging Center Ph. 715.847.2283 or x72283

Medical Staff Resources - Nutrition Services All patients are screened by nursing for nutrition risk on admission Patients with positive nutrition screens, specific lab levels or diagnosis, and physician consults will have in depth nutrition assessments Patient education is provided by physician consult All patients on tube feeding and parenteral nutrition will be assessed Patients will receive meals by Room Service while at AWH – they can order between 6:30am and 6:30pm daily Nutrition Supplements are provided by physician order or as ordered by Clinical Nutrition Staff Orders for Diet as Tolerated are not accepted. Instead please write for an end diet: i.e. Advance diet as tolerated to General or to Consistent Carbohydrate The Clinical Nutrition Staff is on site 7 days a week, 8:00am to 4:30pm. Dial 0 and have the nutritional staff paged

Medical Staff Resources - Pharmacy Following services are Monday – Friday by Clinical Pharmacists Parenternal Nutrition consults Hyperemesis Gravidarum Consults Follow up initial pharmacokinetic consults Consults that require lengthy research Pain Management Following Services are 24/7 basis: Drug information Pharmacokinectic Dosing Renal Dosing Adjustment Therapeutic Interchange BBMC Anticoagulation clinic Referrals Patient Teaching Medication Reconciliation Pharmacy Number Hyperglyceia Management Policy – Pharmacy to dose Pharmacy Phone number is 847-2871. Office Fax 847-0005

Medical Staff Resources – Surgical Services SCHEDULING GUIDELINES Standing specialty and scheduling release times assigned to all allocated blocks are as follows : Cardiac Surgery 0 days Dental 10 days Dermatology 10 days ENT 5 days Eye 5 days General Surgery 2 days GI Procedures 5 days GU Surgery 3 days GYN Surgery 2 days Neurosurgery 2 days Orthopedic Surgery 2 days Plastic Surgery 2 days PV/Vascular Surgery 2 days For the complete policy and bump schedule please refer to Onbase policy #10138

Medical Staff Resources – Interpreter Services DO YOU NEED AN INTERPRETER? DO NOT USE FAMILY MEMBERS OR FRIENDS! Accurate Translations provides interpreter services to Aspirus, Inc., for the Deaf & Hard of Hearing, Spanish, Arabic and several other languages 24/7 via video on-demand. For Aspirus Wausau Hospital campus locations, iPads will be housed in the Aspirus Security Department and available for checkout when a patient need arises. For offsite Clinic locations, please contact Human Resources for available options. Hmong and Laotian - Video on-demand translation will initially be available Monday-Friday, 9:00am-5:00pm only. For Hmong and Laotian translation needed outside of these hours, use of the telephone translation option is preferred. However, onsite interpreter services are also available. As interpreter services needs warrant for Hmong and Laotian languages, availability via video on-demand may be extended. Remember to have all patients who require an interpreter sign a Patient Determination Form, whether they elect to utilize an interpreter, or decline the service.

Quality – Patient Safety When you have concerns about patient safety or quality of care you should…. Use your chain of command: First, always notify and discuss your concern with the Department Director and/or House Supervisor You can also report your concerns to your Administrator and or the President of the Medical Staff. It is the policy of AWH that no employee or physician will be disciplined for reporting in good faith any concern about patient safety or quality of care.

Quality – Patient Safety Event and Unanticipated Outcomes Organization-wide paperless electronic reporting via Aspirus Intranet of: Any unusual event that is inconsistent with the normal routine operation of the health care entity, or any unexpected outcome that has caused some harm, or has the potential to cause some injury to a person. These capture potential as well as actual: Patient safety events, Medication Events/ ADRs Equipment/product failures Patient Complaints Once reported, incident will be investigated, disclosed, and documented which is a Joint Commission requirement. Refer to OnBase Policy #3289

Just Culture What is a Just Culture ? A Just Culture is NOT: A Just Culture manages risk by promoting an open and fair environment in which we learn from our (and others’!) mistakes and are accountable for our behavioral choices. We recognize that none of us is perfect and no systems are perfect, but we can work together to design safer systems and make better choices. A Just Culture is NOT: Blame Free Guilt Free Without consequences Black and white Easier Faster

Investigation is Key……….. The Three Behaviors Human Error At-Risk Behavior Reckless Behavior Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment A Choice: Risk Believed Insignificant or Justified Manage through: Removing incentives for at-risk behaviors Creating incentives for health behaviors Increasing situational awareness Conscious Disregard of Substantial and Unjustifiable Risk Remedial action Punitive action Console Coach Punish Investigation is Key……….. What happened? What normally happens? What does procedure require? Why did it happen? How was the organization managing risk?

Just Culture Continued… The Basics To err is human To drift is human Risk is everywhere We must manage in support of our values We are all accountable The Goals All are accountable & feel safe to “raise their hand’ and report errors/near-misses. We do not base our responses on the severity of an outcome. We see increased peer-to-peer coaching that curbs at-risk behaviors, therefore improving safety & bettering outcomes.

Quality – Discharge Planning

Quality – Discharge Planning

INFECTION CONTROL -TB CONTROL PROGRAM Medical Staff are required to have a PPD skin test at the time of appointment to the Medical Staff and annually thereafter. Provider Support Services will send notification of annual PPD skin testing. Providers may have the skin test performed through Aspirus Wausau Hospital Employee Health Service or at a healthcare facility of their choice. Providers with a history of a positive PPD skin test should have that result on file in the Provider Support Services and will exempt from further skin test requirements. A signs and symptoms questionnaire is completed annually. RESPIRATORY PROTECTION PROGRAM – RESPIRATOR FIT TESTING Any provider who sees patients who requires respiratory-AFB isolation because of suspected or confirmed active pulmonary tuberculosis must be fitted for a N95 respirator before entering the room. Contact Employee Health at 715-847-2785 to schedule the medical evaluation fit testing .

THE "BOTTOM LINE" - REQUIRED OF ALL CLINICAL STAFF Infection Control - Hand Hygiene When to wash with soap and water: Wash with soap and water when hands are visibly dirty or soiled with blood or body fluids Wash hands with soap and water before eating and after using the restroom If hands are not visibly soiled use an alcohol based hand disinfectants decontaminate hands: When to Decontaminate Hands with Alcohol Hand Rubs: Before having direct contact with patients Before inserting Foley catheters, IV catheters or other invasive devices After contact with a patient’s intact skin (taking pulse, blood pressure,) After contact with body fluids, excretions, mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled If moving from a contaminated body site to a clean one during patient care When to Decontaminate Hands with Alcohol Hand Rubs (cont’d): After contact with objects (including equipment) in the immediate vicinity of the patient After removing gloves (gloves do not provide complete protection against acquisition of microorganisms - bacteria from patients are recovered from up to 30% of healthcare workers hands after they remove intact glove Technique for Use of Alcohol Based Hand Antiseptics Apply enough to cover the entire surface of hands and fingers Rub the antiseptic on to your hands until it is dry – if your hands feel dry after rubbing for only 10 – 15 seconds, you didn’t use enough Do not wipe excess antiseptic off your hands Wash your hands with soap and water when they are visibly dirty or contaminated with blood, body fluids Do not use if exposure to C. difficile spores is anticipated – use soap and water THE "BOTTOM LINE" - REQUIRED OF ALL CLINICAL STAFF GOOD HAND HYGIENE: HAND DISINFECTION WITH AN ALCOHOL HAND RUB (OR HANDWASHING WITH SOAP AND WATER IF HANDS ARE DIRTY) MUST BE DONE PRIOR TO ENTERING AND UPON LEAVING ANY PATIENT'S ROOM

Infection Control - OSHA’S Blood Borne Pathogens Standard Methods of Compliance Standard Precautions Barrier precautions used to prevent contact with all patients blood, body fluids, mucous membranes, excretions, secretions, non-intact skin Personal protective equipment (gowns gloves masks, face shields, goggles) available in patient care areas Use safety needles/sharps available in all patient care areas Do not eat, drink, apply cosmetics or lip balm, or handle contact lenses in areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials Follow indications for hand hygiene Dispose of medical waste in red bags Dispose of used needles in sharps containers Specimens of blood or other potentially infectious materials are placed in a container that prevents leakage All contaminated surfaces/equipment will be decontaminated with a hospital approved disinfectant Significant exposure One of the following occurs: Needle stick injury or cut with a sharp object contaminated with blood, bloody body fluids or potentially infectious material Splash into mucous membranes (eyes, mouth) Blood, bloody body fluid or potentially infectious material on non-intact skin These should be reported immediately to Employee Health at ext. 72785 during regular business hours or to the Hospital Supervisor after hours for follow up. Refer to OnBase policy #129

Pain Management AWH utilizes a verbal pain scale from 0 to 10 where 0 represents “no pain” and 10 represents “worse pain”. Pain is assessed and documented on patient admission, every 4 hours, with change of caregiver and with each new report of pain.

Clinical Documentation Abbreviations for Medical Staff All abbreviations, acronyms, symbols and dose designations in the reference Stedman’s Abbreviations, Acronyms & Symbols are approved for use with the exception of dangerous abbreviations (see next slide) Approved abbreviations apply to both electronic and handwritten documentation. All final diagnoses, complications, operative procedures, medications and consents shall be recorded without the use of symbols or abbreviations. Dangerous abbreviations with list on “ Do not abbreviate patient safety” card are not be used in both electronic and/or handwritten documentation. References: Abbreviations Approved for Charting Policy # 7464 Dangerous Abbreviations for Clinical Documentation Policy #7465 Do not abbreviate Patient Safety card #PHARM-052

Clinical Documentation Program Aspirus Wausau Hospital has had a Clinical Documentation Improvement Program since 2010. The Clinical Documentation Specialist (CDS) communicates with providers regarding missing, unclear, or conflicting medical record documentation in an effort to clarify and obtain the documentation that will support the appropriate severity of illness, expected risk of mortality and complexity of care.

Documentation Query Process The CDS reviews most inpatient charts When clarification in the documentation is needed, the CDS will place a Documentation Query in the patient’s chart. You are asked to provide the requested clarification within the progress note and DC summary.  

Medical Staff Clinical Documentation (cont’d) Banned Abbreviation Potential Problem Preferred Term U (for unit) Mistaken as zero, four or cc Write “unit” IU (for international unit) Mistaken as IV (intravenous) or 10 (ten) Write “international unit” QD (for daily) QOD (for every other day) Mistaken for each other, use of a period after Q can be mistaken for an “I” and the O can be mistaken for “I” so understood as QID instead of QD or QOD Write “daily” or “every other day” Trailing zero (X.0 mg) Lack of leading zero (.X mg) Decimal point is missed creating a 10-fold overdose Never write a zero by itself after a decimal point (X mg) and always use a zero before a decimal point (0.X mg) MS, MSO4, MgSO4 Confused for one another can mean morphine sulfate or magnesium sulfate Write “morphine” or “magnesium sulfate”

Medical Record Completion Attending practitioner responsible for completeness of the medical record. H & Ps required to be placed in the chart within 24 hours of admission Note*  H&P Updates require the following documentation: That the H&P was reviewed That the patient was examined Note any relevant changes or no changes Operative Report must be dictated within 24 hours of procedure. Inpatient telephone & verbal orders must be signed, dated & timed within 48 hours (Note: Another Medical Staff member may sign, date & time these). Medical Records/Reports must be complete within 30 days. A cautionary notification will be sent from HIM within 20 days; A phone call and notice of possible suspension will occur on the 30th day; Suspension will occur if the practitioner does not complete his/her deficient chart within 35 days.

Dictation Process Please click on the following attachment for step by step instructions on using the dictation equipment at Aspirus. MedQuist Manual

CPOM/EPIC You will need to schedule your CPOM/EPIC training. This is typically done by the clinic or practice manager when scheduling your orientation. You will receive user names and passwords to access the electronic medical record once membership and privileges are approved by the Board. If you need to have your passwords reset, please contact IT at 715.847.2300. Privileges may not be exercised until CPOM/EPIC training has been successfully completed. Please contact Leslie Sedivy our EPIC trainer if you prefer to do some on-line training prior to your orientation. Leslie.Sedivy@aspirus.org

On-site AWH Orientation Orientation Scheduled on Mondays from 11am – 12pm in Provider Support Services. Expectation is that providers complete the online orientation prior to the on site orientation. Issuing of ID badge, Parking Stickers, and Hand Scan will be done during On-site orientation. CPOM training will be scheduled Monday afternoon and Tuesday morning. Please remember to access the on-line learning modules at (link)? Double check on this info

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