PERIODIC REVIEW PROCESS
Clinical policies will be reviewed and updated by the policy author at least every 3 years. Additional changes may be requested outside of periodic review. The policy author will be notified of the requests and if changes are made, the clinical policy will then need to go through the formal approval process.
NEW Policy DEVELOPMENT PROCESS
Clinical policies may be developed by any discipline. Clinical policies must have sufficient content and guidance to provide appropriate patient care when implemented by a diverse practitioner group to create consistent patient outcomes. Clinical policies should be developed in consultation with CCKM. CCKM shall ensure that all clinical policies are evidence based, have undergone multidisciplinary review, and are formatted properly before they are submitted for approval.
Clinical Policy Approval process
All UW Health clinical policies must be approved by the UW Health Clinical Policy Committee. Clinical policies that contain content that affects physician practice must be approved by the Medical Board. Clinical policies approved by the UW Health Clinical Policy Committee (and Medical Board if necessary) will proceed for final approval by the UW Health Chief Medical Officer.
UW Health Clinical Policy Committee
The UW Health Clinical Policy Committee provides oversight for UW Health clinical policies to promote consistent consolidated clinical policies that will guide care across the entities of the UW Health system (University of Wisconsin Hospitals and Clinics (UWHC), University of Wisconsin Medical Foundation (UWMF), the University of Wisconsin Department of Family Medicine and Community Health (UWDFMCH), and the University of Wisconsin School of Medicine and Public Health (UWSMPH)).
- Committee Chair: J. Scott McMurray, MD
- Committee Vice Chair: Brian Arndt, MD
- Representation for UW Health and UWSMPH Legal Services
- Risk Management director (or designee)
- Representation from various specialties (Clinical Laboratory, Infection Control, Nutrition, Pharmacy, Radiology, Respiratory Therapy)
- Medical Staff members from the 17 departments of the UWSMPH
- Adult and Pediatric Nursing Representation from Ambulatory and Inpatient Settings
- Advanced Practice Provider Representation
- Surgical Services Representation
- UW Health at The American Center Representation
- House Staff Representation
- Senior Management Representation (Senior Vice President Patient Care Service and Chief Nursing Officer designee, Senior Vice President and Chief Operating Officer designee, Chief Ambulatory Administrative Officer designee)
- Director of Quality, Safety, and Innovation
- Director of the Center for Clinical Knowledge Management
- Information Services Representation
- Graduate Medical Education Representation
- Ad Hoc Compliance Representation
What is the difference between a clinical and non-clinical policy?
Clinical policy: mandatory instructional writings that directly affect patient care and are subject to discipline if not followed. They describe how UW Health staff and providers (including students, externs, interns, etc.) interact, touch, and communicate with patients and their families and involve areas in which clinicians are considered experts.
Non-clinical policy: mandatory instructional writings that direct safety of personnel and property, describe interface with equipment and technology, and set employee expectations.
The best way to determine if a policy is clinical or non-clinical is to consult with the Chair of the UW Health Clinical Policy Committee and/or the Administrative Policy and Procedure Committee.
When is something considered a guideline versus a policy?
Although clinical practice guidelines and clinical policies both guide patient care, one important distinction is disciplinary action. Clinical practice guidelines contain recommendations for best practices and allow a clinician to exercise their professional judgment, whereas noncompliance of a policy may lead to disciplinary action (including termination of employment).
What is the difference between UW Health-wide and Departmental policies?
There are two types of clinical policies: (a) UW Health-wide clinical policies are mandatory policies that apply to all entities of UW Health regardless of facility or program, and (b) Departmental clinical policies that are also mandatory policies, but they may be developed separately from UW Health-wide clinical policies by a specific department. Therefore these policies will only apply to members within that department. The clinical policy shall state the population it applies to. UW Health-wide policies take precedent over departmental policies if they speak to same or similar topics.
Do UW Health clinical policies apply to Clinical Joint Ventures?
Clinical policies are not applicable to Clinical Joint Ventures.
UW Health Clinical Policies
UW Health Clinical Policies 1.1.1
UW Health Clinical Policy Committee Charter
Center for Clinical Knowledge Management (CCKM)
Clinical Knowledge Management Council
UW Health Intellectual Property
Other Content Trackers
Best Practice Alerts (BPA)
Clinical Practice Guidelines
Preventive Health Care and Health Maintenance