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Policies,Administrative,UW Health Administrative,Human Resources

Training and Competency Verification for RNs Engaged in Clinical Research at UW Health Who are Not Employed by UW Health (9.85)

Training and Competency Verification for RNs Engaged in Clinical Research at UW Health Who are Not Employed by UW Health (9.85) - Policies, Administrative, UW Health Administrative, Human Resources

9.85

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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: Training and Competency Verification for RNs Engaged in Clinical
Research at UW Health Who are Not Employed by UW Health
Policy Number: 9.85
Effective Date: January 1, 2017
Chapter: Human Resources
Version: Original
I. PURPOSE

To define the training, competency requirements, and the process for approval to practice by Registered
Nurses (RNs) engaged in clinical research at UW Health who are not employed by UW Health.

II. POLICY ELEMENTS

A. All RNs engaged in clinical research must submit attached application to be approved by the RN
Research Practice Committee (RN RPC) on both an initial and annual basis.
B. RNs who are also credentialed providers within UW Health are exempt from this policy.
C. RNs are approved for independent activities within their RN scope of practice at UW Health once
the Education Plan is completed and they’ve received notification of approval to practice from the
RN RPC.
D. RN Research Coordinator Health Link access will be granted once the RN has completed all
applicable compliance, Health Link training, and authorization requirements, including approval
from the RN RPC.
E. The RN employee is responsible to notify the RN RPC prior to making any changes to their
practice activities (see section III-C).
F. The RN employee is responsible to maintain current license, immunization, basic life support
(BLS) certification, and other applicable research training as required.

III. PROCEDURE
A. Initial Approval
1. The following criteria are required for initial approval:
a. *License verification
b. Caregiver background check
c. Immunization and health status according to Administrative Policy 9.21-
Non-Employee Health Screening
d. UW HIPAA training
e. **Current BLS certification for healthcare providers

* Individuals licensed to practice as an RN, but not hired into a position where
they will be practicing as an RN, only need to submit license verification.

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**Individuals who will not be providing direct patient care (e.g. only consenting,
conducting interviews, and signing orders) are not required to maintain current
BLS certification as per Administrative Clinical Policy 9.35-Certification
Cardiopulmonary Resuscitation & Other Life Saving Interventions.
2. RN & RN’s supervisor completes and submits the application form to the RN RPC Chair.
3. RN RPC Chair will forward the application form to the RN’s employer HR Department
(e.g. UW SMPH HR).
4. HR Department to verify initial requirements (listed under III-A-1) and forward the
application to the RN RPC.
5. RN RPC representative to verify all initial requirements (listed under III-A-1) have been
met according to their respective HR Department, reviews self-identified practice
activities, and fills out the Education Plan according to the predefined template. If
practice activities fall outside of the predefined template, the RN RPC will be consulted.
6. The Education Plan is to be completed within 3 months unless otherwise approved by the
RN RPC.
7. Once the Education Plan has been completed, RN to submit documentation to the RN
RPC designee.
8. The RN RPC designee to then submit the Education Plan to the Director of NED (or
NED designee) who will verify completion and email a signed copy back to the RN RPC
designee.
9. The RN RPC designee will send the completed Education Plan and notify the following
of the Research RN’s approval to practice at UW Health:
a. RN
b. RN’s supervisor
c. RN’s UW campus HR representative
d. UW Health Information Services Sr. Security Consultant (as applicable)
10. The RN RPC will maintain a copy of the completed application, Education Plan,
competencies, and any pertinent communication on the RN RPC Workspace on U-
Connect.
B. Annual approval
1. The following criteria are required for annual re-approval:
a. *License verification
b. Flu & TB immunization (as a reminder, Flu & TB are due by December 1st each
year)
c. UW HIPAA training
d. **Current BLS certification for healthcare providers
2. The RN RPC will notify the RN and their supervisor of the need to re-submit the
application to begin the process for annual re-approval. This communication will be
emailed no later than December 15th.
3. RN & RN’s supervisor completes and submits the application form to the RN RPC Chair.
4. RN RPC Chair will forward to the RN’s employer HR Department (e.g. UW SMPH HR).
5. HR Department to verify annual requirements (listed under III-B-1) and forward the
application to the RN RPC.
6. RN RPC representative to verify all annual requirements (listed under III-B-1) have been
met according to their respective HR Department, reviews self-identified practice
activities, and fills out the Education Plan according to the predefined template. If
practice activities fall outside of the predefined template, the RN RPC will be consulted.
7. The Education Plan is to be completed by March 1st.
8. Once the Education Plan has been completed, RN to submit documentation to the RN
RPC designee.
9. The RN RPC designee to then submit the Education Plan to the Director of NED (or

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NED designee) will verify completion and email a signed copy back to the RN RPC
designee.
10. The RN RPC designee will send the completed Education Plan and notify the following
of the RN’s approval to practice at UW Health:
a. RN
b. RN’s supervisor
c. RN’s UW campus HR representative
11. The RN RPC will maintain a copy of the completed application, Education Plan,
competencies, and any pertinent communication on the RN RPC Workspace on U-
Connect.
12. For RNs who did not complete this process by March 1st, the RN RPC will notify:
a. UW Health Information Services Sr. Security Consultant to request their RN
Health Link access be removed
b. RN and RN’s supervisor of their non-compliance and that they are no longer
approved for independent activities within their RN scope of practice at UW
Health until their completed application is submitted and approved.
c. Research RNs on leave during the annual approval process will be addressed on a
case-by-case basis.
C. Practice activity change
The RN employee is responsible to notify the RN RPC prior to making any changes to their
practice activities
1. The RN & RN’s supervisor completes and submits the application addendum to the RN
RPC Chair.
2. RN RPC representative reviews self-identified practice activities and fills out the
Education Plan according to the predefined template. If practice activities fall outside of
the predefined template, RN RPC will be consulted.
3. Process will continue as outlined above in section III, A, 6-10.

IV. COORDINATION

Sr. Management Sponsor: SVP, Patient Care Services, Chief Nursing Officer
Author: Director, Nursing Practice & Innovation, Evidence Based Practice
Reviewer(s): Director, Education and Development for Nursing and Patient Care Services; Nursing
Administrative Policy & Procedure Committee; RN Research Practice Committee ; UW Health VP
Specialty Clinics (UWMF); Director of Clinical Research, UWHC & UWSMPH

Approval: UW Health Administrative Policy Committee

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer


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