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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of
University of Wisconsin Hospital and Clinics and University of Wisconsin Medical Foundation.
Policy Title: UW Health Administrative (Non-clinical) Policies -
Development, Revision, Retiring and Approval
Policy Number: 1.10
Effective Date: August 10, 2017
To specify the action steps for developing, deleting, revising and maintaining the UW Health
Administrative (Non-Clinical) Policies.
“Policy” will be defined as: an instructional writing which describes expected practice. UW Health staff
may be subject to discipline and/or other appropriate action if a policy is not followed. Policies differ
from guidelines, which are considered recommendations or advisory instructional writings.
“Non-clinical” or “Administrative” policy pertains only to administrative non-clinical matters, meaning
the substance does not contain any clinical content. This involves anything from interfacing with
technology or equipment to reacting to events such as weather, and does not require clinical expertise.
(Clinical Policies are managed by the UW Health Clinical Policy Committee)
(See UW Health Clinical Policy 1.1.1).
III. POLICY ELEMENTS
All UW Health Administrative Non-clinical Policies are developed, reviewed and approved by the UW
Health Administrative Policy and Procedure Committee which consists of a multidisciplinary team that
provides a broad institutional perspective. Final approval is by the UW Health CEO or his/her designee.
A. The Chair of the Committee, and/or his/her respective staff, support and coordinate the review of
all UW Health Administrative Policies. Each Administrative Policy will be reviewed at least once
in a five-year period.
B. Each policy will have a designated Sr. Management Sponsor and a designated author. Initial
policy reviews and revisions are completed by the appropriate author, departments and/or
committees designated by the UW Health Administrative Policy and Procedure Committee in
accordance with the UWHC Authority bylaws.
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C. The UW Health VP of Business Integrity will provide oversight to ensure that the committee
performs its function as required by this policy.
D. Criteria for UW Health Administrative Policies.
1. The policy directly affects the operation of UW Health integrated enterprise.
2. The policy affects the safety of UW Health, its patients, its personnel or its property.
3. The policy affects the legal position of UW Health or its position as an accredited provider
of health services.
4. The policy affects more than one department and/or holds system-wide implications.
E. UW Health departments may develop departmental policies specific to their own functions. These
policies will only apply to employees within that specific department.
1. Departmental policies must be structured and formatted using the organizational policy
2. Departmental policies will be maintained on a regular, not less than tri-annual review cycle.
3. Departmental policies will be housed on U-Connect as directed by UW Health’s E-Health
4. Administrative Policies take precedence over departmental policies when they speak to the
same or similar topics. Employees are required to follow all Administrative Policies.
IV. PROCEDURE FOR DEVELOPMENT OF NEW POLICIES
A. Sources of Policies and Procedures
Management, committee chairperson(s), or medical staff members may submit topics for
consideration to the chair of UW Health Administrative Policy and Procedure Committee.
B. Content Requirements
1. Proposed policies will be submitted to the committee in draft format using the
organizational policy template found on the UW Health Intranet site.
2. All proposed policies will include the following information:
a. Policy Title
b. Proposed effective date
c. Purpose statement
d. Definitions (if applicable)
e. Policy Elements
g. Forms (if applicable)
h. References (if applicable)
i. Policy coordination information to include:
i. Title of Senior management sponsor
ii. Title of policy author
iii. Other required committee(s) review/approval (i.e. UW Health Environment of
Care Safety Committee; Medical Board etc.)
C. Format and Style
1. Policy statements should be concise and written in clear prose, using technical language
and abbreviations only where specifically required. Statements should indicate the general
intent regarding the goals of the policy.
2. Headings and subheadings should be outlined in a consistent and logical order, consistent
with templates as provided by and as otherwise counseled by committee staff.
3. Spell out acronyms and other abbreviations prior to using elsewhere in the policy.
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4. Charts and graphs must be included as an attachment or addendum and cannot be used in
the body of the policy.
D. Review Procedure
1. Policy drafts are reviewed in the following order:
b. Representatives from other departments impacted by the policy
c. The Senior management sponsor
d. Other committee(s), (e.g., UW Health Environment of Care Safety Committee,
Infection Control Committee, Pharmacy & Therapeutics Committee etc.)
e. UW Health Administrative Policy and Procedure Committee
f. Medical Board, if required
g. Chief Administrative Officer
2. Once final approval is obtained, the policy will be made available on the UW Health
Intranet site. Additionally, The Chair of the Committee, and/or his/her respective staff, will
communicate to all UW Health Senior Vice Presidents, Vice Presidents, Managers and
Directors a list and summary of new policies.
3. Department Managers and Directors will be responsible for communicating and in-
servicing staff regarding applicable new policies.
V. PROCEDURE FOR PERIODIC REVIEW OF ADMINISTRATIVE POLICIES AND
A. The Chair of the Committee, and/or his/her respective staff, will ensure that all policies and
procedures will be reviewed and revised, at least once in a five-year period by the appropriate
author, department and/or committees. In addition, policies are revised when warranted based on
changes in the state of UW Health, current knowledge, current technology, changes in laws or
regulations, or other factors.
1. The policy author is responsible for identifying proposed policy revisions and making
changes to the electronic copy of the current policy. The author must use the "Track
Changes" function in Microsoft Word so that comparisons can be made by the reviewing
committee/department and assigned approval committees. The highlighting feature may not
be used to show changes.
2. The Author of the policy must prepare a brief summary of proposed policy changes and
rationale, and include it with the revision.
3. If there are no revisions to a policy, or if the policy is to be retired from the manual, this
must be noted and the policy will be presented to the committee for approval.
4. The UW Health Administrative Policy and Procedure Committee will review and approve
policy revisions. Authors or their designee will attend the committee meeting to provide
relevant background information about content changes in the policy.
5. Changes to policies designated for Medical Board review shall be submitted to the Medical
Board for review and approval, unless the changes are minor and do not have an impact on
physician practice and the changes have been approved by a policy and procedure
committee. The Medical Board shall be given a report listing any policies designated for
Medical Board review that are not submitted for formal Medical Board review and, if any
member of the Medical Board requests review, the Medical Board shall review the policy.
6. After a policy has been recommended for approval by the committee, the policy will be
submitted to the UW Health Chief Administrative Officer for final approval.
7. Once final approval is obtained, policies will be made available on the UW Health Intranet
site. Additionally, The Chair of the Committee, and/or his/her respective staff, will
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communicate to Senior Vice Presidents, Vice Presidents, Managers and Directors, a list of
retired policies, approved policies and a summary describing the rationale for the revisions.
8. Department Managers and Directors will be responsible for communicating and in-
servicing staff regarding applicable new or revised policies.
9. Old versions of policies will be archived for 10 years.
Sr. Management Sponsor: SVP, Chief Legal Officer & General Counsel
Author: UW Health VP of Business Integrity
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer