Page 1 of 2
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
Policy Title: Safety Committee Authority & Function
Policy Number: 12.26
Effective Date: July 1, 2016
Chapter: Safety/Emergency Management
The purpose of the committee is to carry out analysis of and to seek resolution of Environment of Care,
Life Safety and Emergency Management issues which fall under the seven management plans of The
Joint Commission. The committee is charged with the responsibility for maintaining a comprehensive
safety program through appropriate policies and procedures, and for conducting ongoing monitoring and
evaluation of all aspects of the program.
II. POLICY ELEMENTS
The UW Health Environment Of Care Safety Committee is a multi-disciplinary committee appointed by
the UW Health Chief Administrative Officer (CAO). Members include individuals qualified by training
and/or experience. The committee makes recommendations to the Safety Department for monitoring and
evaluation of applicable laws, regulations, accepted practices, and operational activities and the
effectiveness of these changes.
The Environment of Care Safety Committee purview includes, but is not limited to, general safety,
security, hazardous material and waste management, emergency management, life safety, medical
equipment management, and utility system management. The Program is monitored through a set of
defined performance measures selected by the Environment of Care Safety Committee.
1. The Director of Safety, chairperson of the UW Health EOC Safety Committee, will have
the authority to intervene whenever conditions pose an immediate threat to life, health or
threaten damage to equipment or buildings.
2. The Chairperson is responsible for keeping the committee informed of potential and
actual regulatory violations and practice/process improvement opportunities for
continued process improvement of the Safety Program.
B. The UW Health EOC Safety Committee meets at least every other month to address environment
of care issues. Meetings held more or less frequently than every other month are acceptable when
supported by current hospital experience and UW Health EOC Safety committee approval.
Page 2 of 2
Ongoing justification of meeting frequency is dependent on a satisfactory annual evaluation of
performance. Safety issues are analyzed in a timely manner.
C. The UW Health EOC Safety Committee has responsibility for the following:
1. Development of written institution wide policies and procedures designed to enhance
safety within UW Health facilities;
2. Review departmental and corporate safety policies, practices and safety programs;
3. Review Accident Summary Reports and recommend corrective action;
4. Maintain a working liaison relationship with UW Radiation Safety Committee and UW
Chemical Safety Committee;
5. Review results of the hospital-wide hazard surveillance program;
6. Review employee safety orientations and other training programs;
7. Review applicable laws, regulations, accepted practices and operational activities to
8. Evaluate effectiveness of UW Health EOC Safety Program and make recommendations
for improvement to the Administration.
9. Review any reports of incidents or events brought forward to the Committee.
10. Safety issues are communicated to individuals responsible for performance improvement
activities, department managers, Executive leadership, and governing councils, as
D. Committee membership is composed of representatives from administration, clinical services, and
support services as outlined in the Safety Management Plan.
Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Safety
Approval Committee(s): Environment of Care Safety Committee; UW Health Administrative Policy and
UW Health, Chief Administrative Officer
Previous revision: 042013
Next revision: 072019