DHS 118.03  Definitions. In this chapter:


 (1) "Ambulance service provider" has the meaning specified in s. 256.01 (3), Stats., namely, a person engaged in the business of transporting sick, disabled or injured individuals by ambulance to or from facilities or institutions providing health services.
 (2) "ACS" means the American college of surgeons.
 (3) "Assessment and classification criteria" means the required trauma care services and capabilities for a hospital to be classified as a Level III or IV trauma care facility.
 (4) "Audit" means a close examination of a situation or event in a multidisciplinary peer review.
 (5) "Bypass" means to forego delivery of a patient to the nearest hospital for a hospital whose resources are more appropriate for the patient's injury pursuant to direction given to a pre-hospital emergency medical service by on-line medical direction or predetermined triage criteria.
 (6) "Classification" means the process whereby a hospital identifies its service level as a trauma care facility and the department reviews and approves the hospital as a provider of a level of trauma care services to meet the needs of the severely injured patient.
 (7) "Coordinating facility" means an ACS verified level I or II hospital that has a collaborative relationship with the regional trauma advisory council and the department as specified under s. DHS 118.06 (3) (c).
 (8) "Definitive care" means comprehensive care for the full spectrum of injuries beyond the initial assessment and resuscitation phase.
 (9) "Department" means the department of health services.
 (10) "Dispatch" means identifying and coordinating the emergency resources needed to respond to a specific traumatic injury or illness.
 (11) "Emergency medical technician" or "EMT" means an individual licensed by the department under ch. DHS 110 as an EMT-basic, EMT-basic IV, EMT-intermediate, or EMT-paramedic.
 (12) "Executive council" means the RTAC leadership body, which is composed of professionals from each region who reflect trauma care expertise, leadership and diversity within each trauma care region.
 (13) "First responder" means a person who is certified under ch. DHS 110 and who provides emergency care to a sick, disabled, or injured individual prior to the arrival of an ambulance as a condition of employment or as a member of a first responder service.
 (14) "First responder service" means a group of persons licensed by the department as a first responder group under s. 256.15 (8), Stats., who are employed or organized to provide emergency care to sick, disabled, or injured individuals as a response for aid requested through a public service access point in conjunction with the dispatch of an ambulance, but who do not provide ambulance transportation of a patient.
 (15) "Fiscal agent" means the person or organization responsible for transactions of RTAC funds.
 (16) "Health care provider" means a medical professional who or organization that is involved in either the detection, prevention, or care of an injured person and includes all of the following:
     (a) A nurse licensed under ch. 441, Stats.
     (b) A dentist licensed under ch. 447, Stats.
     (c) A physician or physician assistant licensed under subch. II of ch. 448, Stats.
     (d) A rural medical center, as defined in s. 50.50 (11), Stats.
     (e) A hospital.
     (f) An ambulance service provider.
     (g) An emergency medical technician.
     (h) A first responder.
     (i) A doctor of podiatric medicine and surgery licensed under subch. IV of ch. 448, Stats.
 (17) "Hospital" means entities approved under subch. II of ch. 50, Stats., and ch. DHS 124, including critical access hospitals, that routinely provide trauma care, excluding hospitals whose principal purpose is to treat persons with a mental illness.
 (18) "Indicator review" means the RTAC's assessment of trauma system performance based on desired trauma system measurements and used by the RTAC in the performance improvement process.
 (19) "Lead agency" means an organization or agency that serves as the focal point for program development on the local, regional and state level. In this chapter, the department serves as the lead agency.
 (20) "Level I" means a class of trauma care facility that is characterized by the hospital's capability of providing leadership and total care for every aspect of traumatic injury from prevention through rehabilitation, including research.
 (21) "Level II" means a class of trauma care facility that is characterized by the hospital's ability to provide initial definitive trauma care regardless of the severity of injury, but may not be able to provide the same comprehensive care as a level I trauma center.
 (22) "Level III" means a class of trauma care facility that is characterized by the hospital's ability to:
     (a) Provide assessment, resuscitation and stabilization.
     (b) Provide emergency surgery and arrange, when necessary, transfer to a level I or II trauma facility for definitive surgical and intensive trauma care.
 (23) "Level IV" means a class of trauma care facility that is characterized by the hospital's ability to stabilize and provide advanced trauma life support prior to patient transfer.
 (24) "Loop-closure" means the process whereby an RTAC has identified a quality improvement problem, completed an evaluation, developed an action plan and notified appropriate health care providers of the results.
 (25) "Medical director" means the physician who is designated in an EMT operational plan to be responsible for all of the following off-line medical direction activities:
     (a) Controlling, directing and supervising all phases of the emergency medical services program operated under the plan and the EMT's performing under the plan.
     (b) Establishing standard operating protocols for EMTs performing under the plan.
     (c) Coordinating and supervising evaluation activities carried out under the plan.
     (d) Designating on-line medical control physicians, if the physicians are to be used in implementing the emergency medical services program.
 (26) "Needs assessment" means a written report prepared by an RTAC identifying and documenting trauma care and injury prevention resources and deficiencies within a defined area of the trauma system and which serves as the basis for developing a regional trauma plan.
 (27) "Nurse anesthetist" means a professional nurse licensed under ch. 441, Stats., who has obtained, through additional education and successful completion of a national examination, a certification as an anesthesia nursing specialist.
 (28) "Off-line medical direction" means medical direction that does not involve voice communication provided to EMTs and first responders providing direct patient care.
 (29) "On-line medical direction" means medical direction of the activities of an EMT that involves voice communication provided to the EMTs by the medical director or by a physician designated by the medical director.
 (30) "On-line medical control physician" means a physician who is designated by the medical director to provide voice communicated medical direction to emergency medical technician and first responder personnel and to assume responsibility for the care provided by emergency medical technician and first responder personnel in response to that direction.
 (31) "Out-of-hospital" means care provided to sick or injured persons before or during transportation to a medical facility, including any necessary stabilization of the sick or injured person.
 (32) "Pediatric trauma center" means a hospital that is dedicated to providing for the trauma needs of a pediatric patient population and meets the resource requirements outlined by the ACS in chapter 10 of the publication Resources for Optimal Care of the Injured Patient: 1999" for verification as a pediatric trauma center. The trauma center may be freestanding or a separate administrative unit in a larger hospital.
     Note: The publication, Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons (1998), is on file in the Department's Division of Public Health, the Legislative Reference Bureau and the Secretary of State's Office, and is available for purchase from the American College of Surgery, 633 W. Saint Clair St., Chicago, Illinois 60611-3211. Chapter 10 is titled "Pediatric Trauma Care."
 (33) "Performance improvement" means a method of evaluating and improving processes of trauma patient care that emphasizes a multidisciplinary approach to problem solving.
 (34) "Physician" means a person licensed under ch. 448, Stats., to practice medicine and surgery.
 (35) "Protocol" means a written statement approved by the department and signed and dated by the medical director that lists and describes the steps any out-of-hospital care provider is to follow in assessing and treating a patient.
 (36) "Regional trauma advisory council" or "RTAC" means an organized group of healthcare entities and other concerned individuals who have an interest in organizing and improving trauma care within a specified geographic region approved by the department.
 (37) "Regional trauma plan" means a written report prepared by an RTAC that meets all of the following criteria:
     (a) Identifies the region's current trauma care development strengths and weaknesses.
     (b) Describes specific goals for future growth and activities in the region.
     (c) Is based on the RTAC's needs assessment.
 (38) "Resource hospital" means a hospital in Wisconsin or a bordering state that makes a written commitment to assist the level III coordinating facility of an RTAC to meet the needs required for the development, implementation, maintenance and evaluation of the regional trauma system.
 (39) "Rural" means outside a metropolitan statistical area specified under 42 CFR 412.62 (ii) (A) or in a city, village or town with a population of less than 14,000.
 (40) "Statewide trauma advisory council" or "STAC" means the entity established by the department to advise the department on a variety of issues pertaining to the establishment and operation of the statewide trauma care system.
 (41) "Trauma care system" means a comprehensive and organized approach to facilitating and coordinating a multidisciplinary system response to traumatically injured patients and includes the continuum of care from initial injury detection through definitive care, rehabilitation and injury control.
 (42) "Trauma care facility" means a hospital that the department has approved as having the services and capabilities of a level I, II, III or IV trauma care facility.
 (43) "Traumatic injury" means major or severe injuries to more than one system of a person's body or major injury to a single system of the body that has the potential of causing death or major disability.
 (44) "Trauma registry" means a system for collecting data from hospitals for which the department manages and analyzes the data and disseminates the results.
 (45) "Triage" means classifying patients according to the severity of their medical conditions at the scene of an injury or onset of illness and subsequently providing care first to those patients with the greatest medical needs and who are likely to benefit from that care.
 (46) "Unclassified hospital" means a hospital that either has chosen not to be a part of Wisconsin's trauma care system, or a hospital that the department has not approved as a level I, II, III or IV trauma care facility.
 (47) "Urban" means an area within a metropolitan statistical area specified under 42 CFR 412.62 (ii) (A) or in a city, village or town with a population of 14,000 or more.
 (48) "Verification" means the process specified by the ACS whereby a hospital desiring recognition as a level I, II, III or IV trauma care facility is designated as that level by the ACS.

     History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; corrections in (1), (9), (11), (13), (14) and (17) made under s. 13.92 (4) (b) 6. and 7., Stats., Register January 2009 No. 637; correction in (11) made under s. 13.92 (4) (b) 7., Stats., Register July 2011 No. 667; correction in (13) made under s. 13.92 (4) (b) 7., Stats., Register March 2014 No. 699

Attachment 5:  Wisconsin DHS 118:  WI Trauma Admin. Rule

DATA/PERFORMANCE IMPROVEMENT


Suggestions for initial objectives of the PI Component;

  1. Determine process for reviewing data filters and specific occurrences as they arise (peer review)- have clearly stated goals and objectives
  2. Develop feedback loop to all regional stakeholders
  3. Improve communication, education, and quality of care for all trauma patients
  4. Improve quality of care for the trauma patients in the RTAC

STRENGTHS:  STEMI/ CVA programs; WARDS/State
WEAKNESS:  HIPAA; Follow up contacts; Access to data; quality of data
OPPORTUNITIES: After care follow up; RTAC coordinator requesting access to WARDS and State Registry; EMS office with Chuck; RTAC chart reviews
THREATHS:  Turnover of the trauma Registers

Wisconsin's Trauma Care System is located in the Bureau of Communicable Disease and Emergency Response (BCDER) in the Division of Public Health, Department of Health Services. Chapter 118 (PDF, 65 KB) provides the authority for the Department of Health Services to develop and implement a statewide trauma care system. The departmental lead for the program is the State Trauma Coordinator.

In July of 2009, the Department of Health Services (DHS) restructured several program areas in an effort to improve the coordination and communication across program areas with common interests or populations. Placement of these program areas within the same bureau facilitates integrated grant funding and planning. It is designed to promote synergy with program integration and collaboration related to the daily management of injured patients, disaster, mass casualty, and surge capacity planning.


As a result of the reorganization, the Trauma Care System, Emergency Medical Services (EMS), Emergency Medical Services for Children (EMSC) and Public and Hospital Preparedness programs were strategically located within the Department of Health Services (DHS), Division of Public Health (DPH), in the Bureau of Communicable Disease and Emergency Response (BCDER). 

EDUCATION 


Suggestions for initial objectives of the Education Component;

  1. Determine educational offerings to pre-hospital agencies and hospitals for the year
  2. Develop a tool to evaluate effectiveness of educational offerings
  3. Explore options for lay public educational offerings regarding the trauma system

STRENGTHS:  Regional programs (Active Shooter, WITrac, Falls)
WEAKNESS: Funding source
OPPORTUNITIES: Agencies that do not participate.
THREATHS: none

NEWRTAC MISSION STATEMENT


The North East Wisconsin RTAC is dedicated to designing, implementing, and evaluating a regional trauma system that is data-based, confidential, and sensitive to the needs, limitations, and resources of this area. Our focus is on injury prevention, reducing the severity of injuries, and decreasing the number of deaths. Our objective is to optimize the quality of care and outcomes for all trauma patients. The patient is the focus of this organization. We also believe that education of trauma providers on all levels is essential

Subchapter II — Statewide Organization for Trauma Car

5. RTAC maintains/supports injury prevention related education and training in the region (may include hospitals and other organizations).


This objective is intended to demonstrate compliance with the Administrative Rule for the Trauma Care System DHS 118.06 (3)(k).

  • Injury prevention offerings and information is discussed at RTAC meetings.


RTAC minutes provide the supporting documentation of the presence of information sharing related to injury prevention activities in the region. Target for contract completion is 100% compliance. 


6. RTAC participates in the regional Healthcare Coalition RTAC and HCC minutes provide documentation of RTAC participation in HCC activities.

1. Maintain RTAC infrastructure in a manner that supports participation by all representative members and is consistent with DHS 118.06. 


This objective is intended to demonstrate compliance with the Administrative Rule for the Trauma Care System related to the structure of the RTAC.

  • Meetings are held at least 4 times per year.  There is an Executive Council, a fiscal agent, a coordinating facility, etc. Agendas and minutes are communicated in a timely manner (ie, posted on RTAC web site, or by email, etc). An archived copy is maintained by the RTAC.


RTAC minutes provide the supporting documentation of the presence of an Executive Council, regular meetings (a minimum of 4 per fiscal year/contract) and that the membership is consistent with DHS 118.06. Target for contract completion is 100% compliance.

3. RTAC has a functional Performance Improvement Program.


This objective is intended to demonstrate the effort to meet the intent for compliance with the Administrative Rules for the Trauma Care System found in DHS 118.06 and 118.10. The objective is to work through the PI process on a trauma related issue/concern and working towards loop closure.

  • RTAC minutes or subcommittee minutes provide documentation related to a performance improvement process/activity for at least one specific issue or process within the region.   Project accomplishments will be presented in a report to the region. Target for contract completion is 100% compliance.

A Regional Trauma Advisory Council is an organized group of healthcare entities and other concerned individuals who have an interest in organizing and improving trauma care within a specified region. It serves as the unifying foundation to bring together all local, county, regional, state, federal and other agencies, for the planning, education, training and prevention efforts needed to assure the exemplary care needed pre, acute and post injury. The primary purpose of an RTAC is to design, implement and evaluate a trauma system within a region that is data-based, confidential and sensitive to the needs and limitations of each regional area.

The purpose of a Regional Trauma Advisory Council is to develop, implement, monitor and improve the regional trauma system. The functions and responsibility of the RTAC are delineated in DHS 118.06. RTAC programming efforts are funded through state tax dollars (GPR) by the State Trauma Program through Appropriation 101.  This document also serves as Exhibit I to the 2016-2017 RTAC Contract.

2. RTAC reviews regional trauma registry data collected under DHS 118.09.


This objective is intended to demonstrate the intent for compliance with the Administrative Rules for the Trauma Care System found in DHS 118.06 and 118.10.

  • Hospitals in the RTAC review and submit data to the Trauma Registry.


Evidence that Regional data is being reviewed and used will be demonstrated through identified process improvement and injury prevention projects.  This will be documented in the RTAC minutes.        Target for contract completion is 100% compliance.

4. Develop and Revise Regional Trauma Plan


This objective is intended to demonstrate compliance with the Administrative Rule for the Trauma Care System DHS 118.06 (3)(L)2.

  • RTAC minutes provide the supporting documentation of the discussion or revision of the Regional Trauma Plan.  The Plan will be filed with the state and updated annually. Target for contract completion is 100% compliance.
DHS 118.04  Lead agency.

 (1)  Designation. The department shall be the lead agency for the development, implementation and monitoring of the statewide trauma care system.
 (2) Lead agency duties. The lead agency shall do all of the following:
     (a) General duties. Develop and revise guidelines and administrative rules for the statewide trauma care system.
     (b) Organize and structure RTACs.
            1. Approve the designation of all trauma care geographic regions based on consideration of what represents the best care of the trauma patient.
            Note: Wisconsin is divided into 9 trauma care geographic regions. Each region has an RTAC. A trauma care region is defined by the location of the health care providers that have selected a particular RTAC for primary membership and in which the majority of each provider's trauma care and prevention occurs.
          2. Review the geographic distribution and organization of regional trauma advisory councils and ensure executive councils that promote the optimal operation of the statewide trauma care system.
          3. Approve regional trauma advisory councils under sub. (6) (c).
          4. Approve coordinating facilities, fiscal agents, executive councils and resource hospitals under sub. (6) (c).
    (c) Classify trauma care facilities.
          1. Establish and revise the assessment and classification criteria for characterizing a hospital as a trauma facility.
          2. Review and approve hospital applications to be a trauma care facility in accordance with standards and guidance given by the American college of surgeons in the publication Resources for Optimal Care of the Injured Patient: 1999 and the criteria in appendix A and according to the process under sub. (6) (a).
          Notes:   

                        1. The publication, Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons (1998), is on file in the Department's Division of Public Health and the Legislative Reference Bureau, and is available for purchase from the American College of Surgery, 633 W. Saint Clair St., Chicago, Illinois 60611-3211.
                        2. Hospitals are verified by the American College of Surgeons as level I or II trauma care facilities based on conformance with the standards and guidelines contained in the publication, Resources for Optimal Care of the Injured Patient: 1999. The Department bases its classification of hospitals as level III or IV trauma care facilities on appendix A of this chapter.
                        3. Review and approve a hospital's selection of an RTAC with which the hospital will participate under s. DHS 118.08 (1).
      (d) Guide RTAC plan development.
          1. With the advice of the STAC, establish the guidelines for RTAC needs assessments and trauma plans developed pursuant to s. DHS 118.06 (3) (L) and triage and transport protocols developed pursuant to s. DHS 118.06 (3) (o).
          2. Review and approve regional trauma needs assessments, triage and transport protocols and plans under sub. (6) (c).
     (e) Develop and operate state trauma registry.
          1. Develop, implement and maintain the state trauma registry under s. DHS 118.09.
          2. Develop and prepare standard reports on Wisconsin's trauma system using the state trauma registry as described in s. DHS 118.09 (4).
     (f) Guide improvement of regional trauma care performance.
          1. Provide all of the following reports to RTACs:
                    a. Quarterly standard reports of trauma registry results for the region.
                    b. Other reports as requested by RTACs.
          2. Develop guidelines for a regional performance improvement program under s. DHS 118.10 that includes all of the following:
                    a. The purpose and principles of the program.
                    b. How to establish and maintain the program.
                    c. The requirements for membership of the regional performance improvement committee.
                    d. The authority and responsibilities of the performance improvement committee.
     (g) Maintain statewide trauma care system.
          1. Resolve conflicts concerning trauma care and prevention issues between the RTAC and trauma care providers and any other entity within the RTAC's geographic region according to the process specified under sub. (3).
          2. Maintain awareness of national trends in trauma care and periodically report on those trends to RTACs and trauma care system participants.
          3. Encourage public and private support of the statewide trauma care system.
          4. Assist the RTACs with developing injury prevention, training and education programs.
          5. Seek the advice of the statewide trauma advisory council in developing and implementing the statewide trauma care system.
                    (h) Enforce chapter requirements.
                              1. Regulate and monitor trauma care facilities.
                              2. Investigate complaints and alleged violations of this chapter.
                              3. Enforce the requirements of this chapter.

 (3) Complaint and dispute resolution.
          (a)

                    1. Upon receipt of a complaint about the trauma system, the department shall either investigate the complaint or request one or more RTACs to initially investigate and respond to the complaint. The department shall monitor how the RTAC or RTACs are addressing and responding to the complaint. When the RTAC has completed its investigation and has prepared its response, the RTAC shall communicate its response to the department.

                    2. Regardless of whether the department has requested one or more RTACs to investigate and respond to the complaint, the department may initiate an investigation of and response to a complaint within 2 business days following the department's receipt of the complaint.
                              Note: The time within which the Department resolves a complaint depends on the nature of the complaint and the resources required to investigate and resolve the complaint.
          (b)
                    1. The department shall maintain a record of every complaint and how each complaint was addressed and resolved.
                    2. Within the constraints imposed by laws protecting patient confidentiality, the department shall make available its complaint record under subd. 1. to any person requesting to review it.
                              Note: To request review of the Department's complaint record, contact the Statewide Trauma Care Coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
 (4) Investigations.
          (a) An authorized employee or agent of the department, upon presentation of identification, shall be permitted to examine equipment or vehicles or enter the offices of an RTAC, a hospital seeking or having department recognition as a trauma care facility or an ambulance service provider during business hours with 24 hour advance notice or at any other reasonable prearranged time. The authorized employee or agent of the department shall be permitted to inspect and review all equipment and vehicles and inspect, review and reproduce records of the trauma care facility, ambulance service provider or RTAC pertinent to the nature of the complaint, including, but not limited to, administrative records, personnel records, training records and vehicle records. The right to inspect, review and reproduce records applies regardless of whether the records are maintained in written, electronic or other form.
          (b) If, based on the department's investigation, the department determines that corrective action by the trauma care facility is necessary, the trauma care facility shall make the corrective actions. The department may subsequently conduct a final investigation following corrective action and notify the trauma facility of the results.
 (5) Waivers. The department may waive any nonstatutory requirement under this chapter, upon written request, if the department finds that strict enforcement of the requirement will create an unreasonable hardship for the provider in meeting the emergency medical service needs of an area and that waiver of the requirement will not adversely affect the health, safety or welfare of patients or the general public. The department's denial of a request for a waiver shall constitute the final decision of the department and is not subject to a hearing under sub. (7).
          Note: To request a waiver from a nonstatutory requirement under this chapter, contact the statewide trauma care coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
 (6) Department review process.
          (a) Department review of and decision on hospital trauma care facility applications.
                    1. A hospital requesting department approval to act or advertise as a trauma care facility shall submit an application to the department on a form provided by the department.
                              Note: For a copy of the Department's assessment and classification criteria application form for approval as a trauma care facility, write to the Wisconsin Trauma Care System Coordinator, Division of Public Health, P.O. Box 2659, Madison WI 53701–2659 or download the form from the DHS website at:http://www.dhs.wisconsin.gov/forms/F4/F47479.doc.
                    2. The department shall review each hospital application submitted pursuant to s. DHS 118.08 (2).
                    3. The department may require a hospital to document the basis for the hospital's professed level of trauma care facility.
                    4. The department may perform a site visit of a level III or IV trauma facility to determine compliance with the trauma facility assessment and classification criteria in accordance with all of the following conditions:
                              a. The department shall select the site visit team.
                    Note: The Department recommends that a trauma surgeon, emergency room physician and a trauma coordinator, all from a Level I or II verified trauma care facility, minimally comprise the site visit team.
                              b. The department's site visit shall be to determine whether the facility meets the assessment and classification criteria in appendix A.
                              c. The site visit team shall submit their findings to the department within 30 calendar days of completing the site visit.
                    5.
                              a. Except as provided under subd. 5. b., within 60 business days of receiving a complete application for department approval to be a trauma care facility, the department shall either approve or deny the application and notify the applicant hospital in writing. In this subdivision paragraph, "complete application" means a completed application form and the documentation necessary to establish that the hospital is a level I, II, III or IV trauma care facility.
                              b. If the department determines a need to conduct a site visit of the applicant hospital, the department shall notify the applicant hospital of its level of trauma care within 10 business days following the department's receipt of the site visit findings under subd. 4. c.
                              c. If the department does not approve the applicant hospital's application, the department shall give the applicant reasons, in writing, for the denial and shall inform the applicant of the right to appeal the department's decision under sub. (7).
                              d. In the absence of other evidence of receipt, receipt of the department's notice under this subdivision is presumed on the 5th day following the date the department mails the notice.
                    6. If the department determines the applicant hospital's trauma care capabilities do not warrant the hospital being approved as a trauma care facility, the department shall consider the hospital to be an unclassified hospital.
          (b) Department review of and decision on a hospital's selection of an RTAC for primary membership.
                    1. The department shall review each hospital selection of an RTAC for primary membership pursuant to s. DHS 118.08 (1) (a) 2.
                    2. If the department does not notify the hospital of its approval or disapproval within 30 calendar days of receiving a hospital RTAC selection for department approval, the hospital may consider their selection approved by the department.
                    3. If the department does not approve the hospital's selection of an RTAC, the department shall give the applicant reasons, in writing, for the denial and shall inform the applicant of the right to appeal the department's decision under sub. (7).
                    4. In the absence of other evidence of receipt, receipt of the department's notice under this subdivision is presumed on the 5th day following the date the department mails the notice.
          (c) Department review of and decision on RTAC applications, selections, needs assessments, triage and transport protocols and plans.
                    1. An RTAC requesting department approval of any of the following shall submit it to the department:
                              a. An application under s. DHS 118.06 (3) (a).
                              b. A selection of an executive council, coordinating facility, fiscal agent and resource hospital under s. DHS 118.06 (3) (c), (d), (e) and (f).
                              c. A needs assessment of its trauma region under s. DHS 118.06 (3) (L), and a triage and transport protocol or plan under s. DHS 118.06 (3) (o).
                              2. The department shall review each RTAC submission made under subd. 1.
                              3.
                                        a. Within 90 business days of receiving an RTAC submission under subd. 1., the department shall either approve or deny the RTAC submission and notify the RTAC in writing.
                                        b. If the department does not approve an RTAC's submission, the department shall give the RTAC reasons, in writing, for the denial. The department shall also inform the applicant of the right to appeal the department's decision under sub. (7).
                                        c. In the absence of other evidence of receipt, receipt of the department's notice under this subdivision is presumed on the 5th day following the date the department mails the notice.
                              4. In response to the department's non-approval under subd. 3., the RTAC may modify its submission and submit the revision to the department for subsequent department review or appeal the department's decision pursuant to sub. (7).
          (d) Department withdrawal of RTAC approval.
                              1. The department may withdraw its approval of an RTAC's operations if the department makes a finding of any of the following:
                                        a. The RTAC does not meet the eligibility requirements established in s. 256.15, Stats., and this chapter.
                                        b. The department approval was obtained through error or fraud.
                                        c. The RTAC violated any provision or timeline of s. 256.15, Stats., or this chapter.
                              2. The department shall send written notice of the department's proposed action and of the right to request a hearing under sub. (7) to the RTAC within 48 hours after the withdrawal takes place. In the absence of other evidence of receipt, receipt of the department's notice is presumed on the 5th day following the date the department mails the notice.
 (7) Appeals of department decisions.
          (a) If under sub. (6), the department does not approve a hospital's application under sub. (6) (a) or selection under sub. (6) (b), or an RTAC's submission under sub. (6) (c) or the department withdraws its approval of an RTAC under sub. (6) (d), the hospital or RTAC may request a hearing under s. 227.42, Stats. The request for a hearing shall be submitted in writing to and received by the department of administration's division of hearings and appeals within 30 days after the date of the notice required under sub. (6). A request is considered filed when received by the division of hearings and appeals.
          (b) The division of hearings and appeals shall hold the hearing no later than 30 days after receiving the request for the hearing unless both parties agree to a later date and shall provide at least 10 days prior notification of the date, time and place for the hearing.
          (c) The hearing examiner shall issue a proposed or final decision within 30 days after the hearing. The department decision shall remain in effect until a final decision is rendered.
                    Note: A hearing request should be addressed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707. Hearing requests may be delivered in person to that office at 5005 University Ave., Room 201, Madison, WI or submitted by facsimile to 608-264-9885.
                    History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; corrections in (6) (d) 1. a. and c. made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637.


DHS 118.05  Statewide trauma advisory council. The statewide trauma advisory council shall be responsible for all of the following:

 (1) Advising the department on issues related to the development, implementation and evaluation of the statewide trauma care system.
 (2) Reviewing and approving the department's proposed format and content of RTAC trauma plans.
 (3) Reviewing and recommending components of the department's trauma data submission manual under s. DHS 118.09 (2) (a) and the use of trauma registry data under s. DHS 118.09 (4) (a).
          History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.


DHS 118.06  Regional trauma advisory councils.

 (1)  Purpose. The purpose of a regional trauma advisory council is to develop, implement, monitor and improve the regional trauma system.
 (2) Participation in RTAC activities. A regional trauma advisory council may include facilities or organizations located in a neighboring state that provide trauma care to Wisconsin residents.
 (3) Regional trauma advisory council responsibilities. A regional trauma advisory council shall do all of the following:
          (a) Submit an application to the department for approval as an RTAC pursuant to s. DHS 118.04 (2) (b) 3.
                    Note: To obtain an application, contact the statewide trauma care coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
          (b)
                    1. Establish an executive council that has all of the following characteristics:
                              a. Reflects professional representation from out-of-hospital trauma care providers, trauma care facilities, education and injury prevention.
                                        Note: Out-of-hospital trauma care providers include EMTs, first responders or air medical personnel.
                              b. May have representation of an out-of-state hospital or ambulance service provider if the hospital or ambulance service provider regularly provides care for persons injured in Wisconsin.
                              c. Includes representation from both urban and rural areas.
                              d. Does not have more than 50 percent of its representation from any single organization. In this subdivision paragraph, "organization" means corporate affiliation, entity or ownership.
                              e. Is responsive to the input of its primary membership and participants.
                              f. Has officers who either live or work in Wisconsin.
                              g. Has representatives who serve only on that single executive council.
                                        Note: The Department believes that limiting primary service to the executive council of one RTAC will promote a representative's focus on and allegiance to that RTAC. Any person, however, may participate in the activities of more than one RTAC.
                    2. Submit the names and affiliations of council members to the department for review and approval pursuant to s. DHS 118.04(2)(b)4.

          (c)

                    1. Select a coordinating facility. The coordinating facility shall be or do all of the following:
                              a. Work in collaboration with the department and the regional trauma advisory council to meet the needs required for the development, implementation, maintenance and evaluation of the regional trauma system.
                              b. Except as provided in subd. 1. c. and d., be a Wisconsin-based ACS-verified level I or II trauma facility.
                              c. If a regional trauma advisory council area contains no ACS-verified level I or II trauma facility, the coordinating facility may be an entity that provides written commitment to the department that the entity will become an ACS-verified level I or II trauma facility within 3 years of that assurance.

                              d. If a regional trauma advisory council area contains no ACS-verified level I or II trauma facility, and no entity can provide the department the assurance under subd. 1. c., the coordinating facility may be an entity that assures the department in writing that the entity will obtain the department's recognition as a level III trauma facility within the time frame specified in the RTAC application.
                              e. Have an ACS-verified level I or II hospital, or an equivalent hospital from an adjoining state, serving as its resource hospital if a level III hospital is serving as the coordinating facility.
                              f. If 2 facilities agree to serve as co-coordinating facilities, one of the facilities shall be an ACS-verified level I or II trauma facility.
                    2. Submit the name of the facility selected under subd. 1. to the department for review and approval pursuant to s. DHS 118.04(2)(b)4.
                    3. Notify the department and the RTAC executive council at least 30 days before relinquishing the title of coordinating facility if the coordinating facility is unable to fulfill the duties required by the regional trauma advisory council.
          (d)
                    1. Select a Wisconsin fiscal agent and submit the name of the fiscal agent to the department for review and approval pursuant to s. DHS 118.04 (2) (b) 4.
                    2. Ensure that the fiscal agent holds and distributes funds only for the purpose of RTAC activities by not commingling RTAC funds with other funds or using RTAC funds for personal purposes.
                    3. Ensure that the fiscal agent notifies the department and the executive council at least 30 days before relinquishing the title of fiscal agent if the fiscal agent is unable to fulfill the duties required by the regional trauma advisory council.
          (e) Select a resource hospital and submit the name of the hospital to the department for review and approval pursuant to s. DHS 118.04 (2) (b) 4.

          (f) Transmit all pertinent materials to all regional trauma advisory council members in a timely manner.
          (g) Develop a format for meetings, agendas and minutes, and provide the department with all RTAC meeting times, agendas and minutes.
          (h) Designate a liaison with the department.
          (i) Analyze local and regional trauma registry data collected under s. DHS 118.09.
          (j) Create a local and regional performance improvement process that is consistent with that specified in s. DHS 118.10.
          (k) Develop and implement injury prevention and education strategies based on performance improvement findings.
          (L)
                    1. Develop and submit to the department by June 1, 2006, a regional trauma plan based on a needs assessment and with the structure specified by the department.
                    2. Update the regional trauma plan specified under subd. 1. and submit the plan to the department every 2 years beginning June 1, 2008 following the submittal of the of the initial plan on June 1, 2006.
                    3. Beginning June 1, 2005, submit a yearly progress report to the department, in the format specified by the department, that contains a description of the progress being made towards achieving the actions specified under the most recent regional trauma plan.
          (m) Resolve conflicts concerning trauma care and injury prevention within the region through a process having the following characteristics:
                    1. Conflicts needing resolution by the RTAC shall be addressed by the executive council.
                    2. If the executive council is unable to resolve a contested issue, the executive council chair shall submit the issue to the department for resolution.
          (n) Notify the department within 30 days of any changes in leadership, bylaw revisions or other substantive revisions to the RTAC policies or operations.
          (o) Develop regional triage and transport protocols.
                    History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.


DHS 118.07  EMS services.

(1)  Responsibility to affiliate with one RTAC.
          (a) All ambulance service providers and first responder services shall select one regional trauma advisory council for primary membership by July 30, 2005.
          (b) Notwithstanding par. (a), an EMT, first responder or ambulance service provider may participate in any regional trauma advisory council.
          (c) An ambulance service provider or first responder service shall notify the department if the service changes membership in an RTAC.
 (2) Effect of non-participation. The department and the pertinent RTAC may not recognize as a trauma system participant an ambulance service provider that does not participate in the activities of its chosen RTAC pursuant to sub. (1) (a), or submit data to the department under s. DHS 118.09 (3).
          Note: Pursuant to s. DHS 110.34 (11), an ambulance service provider must specify in its operational plan the name of the regional trauma advisory council that it has chosen for its primary membership.
          History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.


DHS 118.08  Hospitals.

(1)  Hospital responsibility to affiliate with an RTAC.
          (a)

                    1. All hospitals shall select one regional trauma advisory council for primary membership by July 30, 2005.
                    2. Pursuant to s. DHS 118.04 (2) (c) 3., the hospital shall submit its selection under subd. 1. to the department for approval.
          (b) Notwithstanding par. (a), a hospital may participate in the activities of any regional trauma advisory council.
          (c) A hospital shall notify the department if the hospital changes membership in an RTAC.
 (2) Classification of hospitals.
          (a) Initial hospital selection of trauma care level.
                    1. `All hospitals.'
                              a. All hospitals shall declare their current trauma care capabilities to the department within 180 days of January 1, 2005, according to the criteria specified in this section.
                              b. A hospital desiring level I or II classification and verification shall be responsible for expenses associated with the verification process under s. DHS 118.04 (2) (c) 2. and (6) (a).
                              c. A hospital desiring level III or IV classification may be responsible for expenses associated with the classification process under s. DHS 118.04 (2) (c) 2. and (6) (a).
                    2. `Level I and II trauma care facilities.'
                              a. A hospital declaring itself as a level I or II trauma care facility shall have been verified at that level by the American college of surgeons in accordance with the publication Resources for Optimal Care of the Injured Patient.
                              Note: The publication, Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons (1998), is on file in the Department's Division of Public Health and the Legislative Reference Bureau, and is available for purchase from the American College of Surgery, 633 W. Saint Clair St., Chicago, Illinois 60611-3211.
                              b. A hospital desiring department approval as a level I or II trauma care facility, but which has not received ACS verification at that level, may only be approved as a level III or IV trauma care facility.
                    3. `Level III and IV trauma care facilities.'
                              a. A hospital desiring department approval as a level III or IV trauma care facility shall either submit documentation to the department that it has received ACS verification at level III or IV or complete the department's assessment and classification criteria application form.

                                        Note: For a copy of the Department's assessment and classification criteria application form for approval as a trauma care facility, please write to the Wisconsin Trauma Care System Coordinator, Division of Public Health, P.O. Box 2659, Madison WI 53701–2659 or download the form from the DHS website at:http://www.dhs.wisconsin.gov/forms/F4/F47479.doc.
                              b. The department shall review the information in the hospital's application and base its approval or disapproval of the application on the conformance of the facility with the criteria in appendix A.
                    4. `Pediatric trauma center.' A hospital may not refer to itself as a pediatric trauma center unless it has received ACS verification as a pediatric trauma center.
                    5. `Unclassified hospital.' A hospital that chooses not to participate in the Wisconsin trauma care system or that has not been approved by the department as a level I, II, III or IV trauma care facility shall be considered an unclassified hospital.
                              Note: To obtain a form for selection of trauma care level and application for Department approval of the chosen level, contact the Statewide Trauma Care Coordinator by phone at 608-266-0601 or by writing to the Statewide Trauma Care System Coordinator, Department of Health Services, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson, Madison, WI 53701 or by sending a fax to 608-261-6392.
          (b) Trauma care facility change in capability.
                    1. `Level I or II trauma care facility.' If a hospital loses its ACS verification as a level I or II trauma care facility, the following shall occur:
                              a. The hospital shall notify the department of that change within 30 calendar days.
                              b. The department may no longer recognize the hospital as having the level of trauma care that the ACS previously verified the hospital as having.
                              c. The hospital may complete and submit to the department a new application form under par. (a) or choose to be an unclassified hospital.
                    2. `Level III or IV trauma care facility.'
                              a. A level III or IV trauma care facility shall notify the department of the facility's intent to change its level of trauma care. If the trauma care facility meets the department's trauma care assessment and classification criteria under sub. (1), or has been verified by the ACS as being another level trauma care facility, the department shall recognize the facility at the level desired.
                              b. The department may revoke its approval of a level III or IV trauma care facility if the department determines the facility does not meet the criteria associated with the facility's existing classification.
                              c. The department may perform a site visit of a level III or IV trauma facility to determine compliance with the evaluation criteria in accordance with s. DHS 118.04 (6) (a) 4.
                              d. If a level III or IV trauma care facility is unable to continue functioning at its current level of trauma care, the facility shall notify the department no more than 30 calendar days after the facility no longer continues to function as a level III or IV trauma care facility.
          (c) Renewal of a hospital's level III or IV classification.
                    1. At least once every 3 years after initial classification, the department shall provide all level III and IV trauma care facilities an assessment and classification criteria form.
                    2. The trauma care facility shall declare to the department the facility's level of trauma care capability on the assessment and classification form.
                    3. The trauma care facility shall submit the assessment and classification criteria form to the department at least 6 months before the expiration of the department's approval of facility's existing level of trauma care capability.
                    4. A level III or IV trauma care facility's existing classification shall continue until the department makes a final decision on the renewal request, unless the department determines a compromise in patient care exists, at which time the department may immediately revoke the facility's classification.
                    5. A level III or IV trauma facility that does not renew its classification within the time specified under this paragraph shall automatically lose its department approval as its existing level of trauma care facility and shall be considered an unclassified hospital.
                              (d) Restricted use of term "trauma care facility" or "trauma facility".
                                        1. A hospital may not advertise in any manner or otherwise represent itself as either a trauma care facility or trauma facility unless the hospital has been classified as a level I, II, III or IV trauma care facility by the department in accordance with this chapter.
                                        2. A hospital's advertisement or public representation of its classification as a trauma care facility shall include its level.
 (3) Complaints.
          (a) A trauma care facility may submit a complaint to the department regarding a department action.
          (b) The department shall respond to the complaint pursuant to s. DHS 118.04 (3).
                    History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.

NEWRTAC REGIONAL TRAUMA PLAN (2016/2017 FISCAL YEAR)


OVERVIEW OF WISCONSIN TRAUMA SYSTEM


Subchapter III — Trauma Care Improvement


DHS 118.09  Trauma registry.

(1)  Purpose. The purpose of the trauma registry is to collect and analyze trauma system data to evaluate the delivery of adult and pediatric trauma care, develop injury prevention strategies for all ages, and provide resources for research and education.
 (2) Department coordination of data collected by trauma care facilities, ambulance service providers and first responder services. The department shall do all of the following:
     (a) Develop and publish a data submission manual that specifies all of the following:
          1. Data elements and definitions.
          2. Definitions of what constitutes a reportable trauma case.
          3. Method of submitting data to the department.
          4. Timetables for data submission.
          5. Electronic record format.
          6. Protections for individual record confidentiality.
     (b) Notify trauma care facilities, ambulance service providers and first responder services of the required registry data sets and update the facilities and providers, as necessary, when the registry data set changes.
     (c) Specify both the process and timelines for hospital and ambulance service provider submission of data to the department.
 (3) Submission of data. All hospitals, ambulance service providers and first responder services shall submit to the department on a quarterly basis trauma data determined by the department to be required for the department's operation of the state trauma registry. The department shall prescribe all of the following:
     (a) Standard application and report forms to be used by all applicants and trauma care facilities.
     (b) The form and content of records to be kept and the information to be reported to the department.
 (4) Registry use.
     (a) The department and RTACs shall use the trauma registry data to identify and evaluate patient care and to prepare standard quarterly and annual reports and other reports and analyses as requested by RTACs.
     (b) The department shall use injury data collected under s. 256.25 (2), Stats., for confidential review relating to performance improvement in the trauma care system. The department may use the confidential injury data for no other purpose.
          History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; correction in (4) (b) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637.


DHS 118.10  Performance improvement.

 (1)  Purpose. Each RTAC shall use the trauma registry data collected under s. DHS 118.09 to improve trauma care, reduce death and disability and correct local and regional injury problems.
     Note: The RTAC should include in its performance improvement activities for all patient ages a surgeon involved in trauma care, an emergency department physician, an EMS representative, an EMS medical director, a person who coordinates the trauma program or the performance improvement process in a trauma facility, and other trauma care and prevention professionals the RTAC determines appropriate.
 (2) Data confidentiality. Each RTAC shall observe the confidentiality provisions of the Health Insurance Portability and Accountability Act under 45 CFR 164.
 (3) Process. The performance improvement process shall include all of the following for both pediatrics and adults:
     (a) Data collection and analysis.
     (b) Adult and pediatric-specific quality indicators for evaluating the trauma system and its components.
     (c) A system for case referral.
     (d) A process for indicator review and audit.
     (e) A mechanism for loop-closure.
     (f) A mechanism for feedback to executive council.
     (g) An evaluation of system performance.
     (h) A procedure for ensuring that all parties having access to information associated with individuals and entities with respect to a trauma care system problem or issue keep the information confidential throughout the performance improvement process.
          History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.

COMMUNICATION


Suggestions for initial Objectives of the Communications Component:

  1. Review dispatch procedures, dispatch training, response time and communication devices used in each county
  2. List the communication devices, operating frequencies, and the effective range of each device used by EMS services and facilities
  3. List how two-way communication occurs between each EMS service and each receiving facility in the region
  4. List all EMS, Aeromedical and First Responder services’ frequencies, helicopter transport services and hospitals within the RTAC
  5. Identify dispatch call priority policies

STRENGTHS:  MABAS system; WITRAC (Hospital/EMS); NEW RTAC
WEAKNESS:  Radio changes; Hospital/EMS communication (follow-up, WARDS)
OPPORTUNITIES:  Equipment become uniform; EMR/Pt. tracking; Dispatch EMD; after case follow-up (HIPAA)
THREATHS: Radio changes; equipment funding

MEDICAL OVERSIGHT


Suggestions for initial objectives of the Medical oversight Component:

  1. Identify all EMS Medical Directors in the region with addresses, phone numbers and the agencies they provide services for in the RTAC
  2. Review and/or develop regional protocols in use throughout the region
  3. Review and/or develop regional protocols for alerting and activating helicopters in the region.

Currently not utilized at RTAC level.  Completed at the County EMS level with EMS Councils. HERC and RTAC coordinators attend regularly. 

SYSTEM ACCESS


Suggestions for initial Objectives of System Access Component:

  1. Identify all EMS and First Responders in each county
  2. Identify what areas each EMS and First Responder agency provides services for
  3. Identify mutual aid agreement that EMS may have with other areas
  4. Identify backup or emergency systems
  5. Consider public education regarding resources and accessing help

STRENGTHS:  County EMS Meetings, RTAC (EMS/Hospital relations; Regional Coordination; NWTC (Educational facility), NEW HERC

WEAKNESSES:  First responder system; Cost of programs; Funding Source

OPPORTUNITIES: NEW HERC, Grants

THREATS: Funding-State/Federal; Aging workforce; Volunteerism

2016-2017 Statewide RTAC Objectives/Strategies


The purpose of a Regional Trauma Advisory Council is to develop, implement, monitor and improve the regional trauma system. The functions and responsibility of the RTAC are delineated in DHS 118.06. RTAC programming efforts are funded through state tax dollars (GPR) by the State Trauma Program through Appropriation 101.  This document also serves as Exhibit I to the 2016-2017 RTAC Contract.  

Objective/Strategy            Supporting Documentation        Measure(s) of Success      Contract Completion 

Regional Trauma Plan

Chapter DHS 118


TRAUMA CARE


Subchapter I — General Provisions

DHS 118.01   Authority and purpose.
DHS 118.02   Applicability.
DHS 118.03   Definitions.


Subchapter II — Statewide Organization for Trauma Care

DHS 118.04   Lead agency.
DHS 118.05   Statewide trauma advisory council.
DHS 118.06   Regional trauma advisory councils.
DHS 118.07   EMS services.
DHS 118.08   Hospitals.


Subchapter III — Trauma Care Improvement

DHS 118.09   Trauma registry.
DHS 118.10   Performance improvement.
Note: Chapter HFS 118 was renumbered chapter DHS 118 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7, Stats., Register January 2009 No. 637.

INJURY PREVENTION


Suggestions for initial Objectives of the Injury Prevention Component:

  1. Determine Injury Prevention programs within the RTAC for the year
    1. Address the burden of falls in the region.
    2. Offer Stepping On Course and closely collaborate with the EMS Providers within the county
  2. Develop a tool to evaluate the effectiveness of Injury Prevention offerings
    1. Stepping On is an evidence based course so it has been proven to be effective
    2. In terms of evaluating the effectiveness of program and collaboration with EMS Providers and education, this will be done using data collection through DHS as well as regional trauma registry.

Injury Prevention
STRENGTHS:  ADRC (Brown County); Safe Kids (Car seat, Adolescent program)
WEAKNESS: ADRC communication between counties; Minimal involvement from hospitals in the Safe Kids program
OPPORTUNITIES:  ADRC other counties involvement

THREATHS:  Funding Source

Subchapter I — General Provisions


DHS 118.01  Authority and purpose. 

This chapter is promulgated under the authority of s. 256.25 (2), Stats., to develop and implement a statewide trauma care system. The purpose of the statewide trauma care system is to reduce death and disability resulting from traumatic injury by decreasing the incidence of trauma, providing optimal care of trauma victims and their families, and collecting and analyzing trauma-related data.
          History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; correction made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637.


DHS 118.02  Applicability. 

This chapter applies to all of the following:

(1) The department.

(2) All persons who are any of the following:
   (a) An EMT – basic or EMT – basic IV.
   (b) An EMT – intermediate.
   (c) An EMT – paramedic.
   (d) A medical director.
   (e) A first responder.

(3) A hospital approved under subch. II of ch. 50, Stats., and ch. DHS 124, excluding hospitals whose principal purpose is to treat persons with a mental illness.
(4) An ambulance service provider licensed under s. 256.15, Stats., and ch. DHS 110.
(5) A regional trauma advisory council developed by the department pursuant to s. 256.25 (1r), Stats.
(6) Any health care provider involved in the detection, prevention or care of an injured person and is a member of a Wisconsin RTAC.
(7) A Wisconsin law enforcement agency that is a member of a Wisconsin RTAC.

     History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; corrections in (3), (4) and (5) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register July 2011 No. 667.