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UWHC,UWMF,

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Administrator On-Call and Incident Response (1.12)

Administrator On-Call and Incident Response (1.12) - Policies, Administrative, UW Health Administrative, Administration

1.12

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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 (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Administrator On-Call and Incident Response
Policy Number: 1.12
Effective Date: July 1, 2016
Chapter: Administration
Version: Revision
I. PURPOSE

The purpose of this policy is to communicate the process for designating the UW Health Corporate
Administrator On-Call (AOC) and to set forth the proper notification processes and the responsibilities of
the AOC.

II. POLICY ELEMENTS

The Corporate Administrator On-Call (AOC) will be notified of situations in which safety may be
jeopardized, in which facilities operations are disrupted, and when there is any unusual occurrence in
which administrative action is required. Additionally, the Local and the Corporate AOC serves as a
resource for the Nursing Coordinators, Attending Physicians, Public Affairs, and other UWHC staff
requiring clarification of hospital policies and procedures.

III. DEFINITIONS

Corporate Administrator On-Call (AOC) - The AOC is the highest functional administrative authority for
all of the facilities within UW Health while on call. It is assumed that the AOC will consult with
appropriate health system leadership as needed for all issues requiring their involvement.

Local Administrator On-Call (AOC) - The AOC is the highest functional administrative authority for each
building site. There are three Local AOC pools: (1) University Hospital/American Family Children’s
Hospital/Business, (2) UW Health at The American Center and (3) Ambulatory.

Facility Manager On-Call – The person with the highest administrative authority for the individual
building site or department. Title may be different from Facility Manager, such as Department Manager,
General Manager or Building Manager, for example.

IV. RESOURCES

Incident Response Algorithm
AOC Hand-off Form




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V. PROCEDURE
A. AOC Scheduling
1. The Chief Administrative Officer (CAO) will designate weekly, Monday through
Sunday, an administrator who will act as Corporate AOC.
2. The CAO, or his/her designee, will distribute the administrator on-call list covering a
period of not less than three months. This list will include the appropriate telephone
numbers of the administrators and will be sent to the following:
a. Administrators on call
b. UWHC Paging and Message Center
c. Public Affairs
d. Nursing Coordinator's Office
e. Director of Safety
f. Director of Security
g. Director of Facilities and Engineering
3. The administrator assigned on-call responsibility must secure administrator coverage in
the event he/she is unable to keep the original schedule. The administrator, additionally,
is responsible for notifying the schedule coordinator of any changes, as well as UWHC
Paging and Message Center in the event a change is implemented after business hours.
4. Local AOCs will be scheduled by designated senior leadership within each group per
policy or executive structure. The schedules will be posted to the Paging Page under the
appropriate on-call group.
B. Contacting an AOC (See Incident Response Algorithm)
1. The Nursing Coordinator on duty during non-business hours at each hospital is
responsible for handling all routine occurrences throughout the Hospital and should be
contacted by Hospital staff prior to contacting the AOC.
2. The Facility Manager on duty during non-business hours at each site is responsible for
handling all routine occurrences throughout the facility and should be contacted by staff
prior to contacting the Local or Corporate AOC. The Local AOC may be reached via the
web paging intranet site under the appropriate on-call group or the UWHC Paging and
Message Center at 262-2122. The administrator will maintain paging access at all times
while on-call.
3. The Corporate AOC may be reached via the web paging intranet site (administrator-
hospital) or the UWHC Paging and Message Center at 262-2122. The administrator will
maintain paging access at all times while on-call.
C. AOC Responsibilities
1. The AOC is authorized to act on behalf of the UW Health CEO, for the immediate
resolution of problems or incidents. He/she is responsible for the proper application of
policy and correct administrative actions indicated by policy and circumstances, with
appropriate consultation of other UW Health leaders.
2. The AOC should be able to respond by phone within10 minutes of an emergency request
(page or phone call) or in person within 60 minutes.
3. The administrator on-call must notify the Public Affairs on-call representative of events
that may result in media coverage.
4. The AOC will document any calls that they receive as well as actions taken to allow for
systematic review and systems quality improvement of trending situations/conditions.
(See AOC Handoff Form)
5. The AOC will assume the incident command role from any authorized activator in a code
triage situation as requested or based on need.
6. Handoff Communication (AOC to oncoming AOC):

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a. Any incidents or any pertinent information requiring further follow-up should be
communicated by the administrator to the incoming administrator on-call.
b. Handoff can occur verbally for no events during the call period.
c. For call periods involving situations or events which required AOC involvement,
the AOC Hand Off form should be used.
7. The administrator on-call will be notified and triage an unannounced surveyor or survey
team per the Unannounced Survey Plan.
D. Event notification
1. The Facility Manager shall be notified of specific events or concerns in their facility,
including but not limited to:
a. Emergencies which have potential actual impact to patients, visitors, faculty,
staff, students, or volunteers (fire alarms, flooding situations, security related
events, hazardous materials events or spills, IT or Utilities outages, etc.)
b. Events which could impact medical center operations including privacy, legal,
regulatory or brand/reputation impacts (i.e. public figure admissions, IT or
Privacy breach, policy or procedural violations, etc.)
c. Events which may result in negative or sensational media coverage, this includes
sentinel events which could involve active violent intruders and infant/child
abduction.
2. Notification to the Local AOC will be made by the Facility Manager or others in
authority (such as Safety, Security and/or Facilities and Engineering staff) for specific
events.
3. The Local AOC shall be notified of specific events or concerns at a UW Health facility,
including but not limited to:
a. Emergencies which have actual impact to patients, visitors, faculty, staff,
students, or volunteers (a fire, a flood, security related events, hazardous
materials events, IT or Utilities outages, prisoner elopement from the hospital,
etc.)
b. Events which could impact medical center operations including privacy, legal,
regulatory or brand/reputation impacts (i.e. public figure admissions, IT or
Privacy breach, policy or procedural violations, etc.)
c. Events which may result in negative or sensational media coverage, this includes
sentinel events which could involve bed availability/capacity, ICU/ER restriction
and/or infant/child abduction.
d. Lawyer or law enforcement demands for immediate release of patient
information outside the normal course of hospital procedures.
e. Distraught patients or families who are requesting to speak with Hospital
Administration.
f. Situations which impact patient throughput or flow to multiple patients or
individual patients unresolved by normal escalation paths (i.e. high census alerts,
financial clearance issues, discharge concerns, special medical or ancillary
support service referrals, etc.)
g. Disruptive behavior or challenging Human Resource situations which need
immediate attention.
4. The UW Health AOC shall be notified of specific events or concerns at a UW Health
facility, including but not limited to:
a. Events which may result in negative or sensational media coverage, this includes
sentinel events which could involve bed availability/capacity, ICU/ER restriction
and/or infant/child abduction.
b. Situations which cause a change in patient care ability, such as potential closing
of a service line or department.

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c. Emergencies which have caused structural damage preventing partial occupancy.
d. There is an estimated repair cost greater than $500,000.
e. Situations which have the potential to trigger a survey or inspection.
f. Situations which have an immediate threat to life or health of any occupants of a
UW Health facility.
IV. COORDINATION

Sr. Management Sponsor: Chief Administrative Officer
Author: Director, Safety
Reviewer (s): Director, Security: Director, Facilities & Engineering Services; VP, Facilities and Support
Services

Approval Committee: UW Health Administrative Policy and Procedure Committee

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer


Revision Detail:

Previous revision: 062013
Next revision: 072019