/policies/,/policies/administrative/,/policies/administrative/uw-health-administrative/,/policies/administrative/uw-health-administrative/safetyemergency-management/,

/policies/administrative/uw-health-administrative/safetyemergency-management/1257.policy

201611335

page

100

UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Safety/Emergency Management

Key Control (12.57)

Key Control (12.57) - Policies, Administrative, UW Health Administrative, Safety/Emergency Management

12.57

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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: Key Control
Policy Number: 12.57
Effective Date: December 1, 2016
Chapter: Safety/Emergency Management
Version: Revision
I. PURPOSE

To provide guidelines for an effective key and access control program; to facilitate timely access in case
of emergency; to enhance personal safety for all patients, visitors and staff; and to secure assets to UW
Health facilities.

II. POLICY ELEMENTS

Administrative responsibility for key and access control, which includes all locks and locking hardware,
is the combined responsibility of the Director of Security Services and Director of Facilities and
Engineering Services.
A. Hierarchy of Keys
1. This policy addresses how door keys are organized, distributed, managed and returned.
This includes all keys from a single door key to a master key. The greater the access
rights, the higher the level of approval for obtaining keys.
2. The issuance of UW Health keys will always follow a plan that issues: (1) the lowest
level of key in the system hierarchy that is necessary to provide access required by the
individual's position and responsibilities and (2) the least number of keys. Below is an
overview of the types of keys available and the approval process for obtaining keys.
3. Key and lock request for file cabinets, desks, and storage cabinets should be approved by
department managers or supervisors according to the same procedure used to approve
door keys.
Key Hierarchy and Approval Requirements
COVERAGE AREA KEY TYPE APPROVAL LEVEL
Hospital/Ambulatory/Business
Facilities
Great Grand Master
Key
Approved by: VP of Facilities and Security Director

Grand Master Key VP Level and Security Director

Building Master Key VP Level and Security Director


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“UT” Grand Master
Key
Director of Facilities and Engineering Services and
Security Director



Module Master Key Director Level of controlled space and Security
Director

Room/Door Key Manager/Supervisor Level of controlled space

File Cabinets, Desks,
Storage Cabinets
Manager/Supervisor Level of controlled space

III. PROCEDURE
A. How to Obtain a Key
1. Any employee/student/medical staff member may obtain a key as long as they have a
completed and properly approved "Key Request" form.
B. The "Key Request" form can be found on U-Connect under the department web pages of
Facilities and Engineering Services and Security Services. This form requires the signature of the
person making the request and the manager of the area the key grants access to, as well as any
additional approvals noted in the above table.
C. The signed and properly approved "Key Request" form may be faxed (265-7278), scanned, sent
via e-mail (uwhcsecurity@uwhealth.org) or delivered in person to the Security Office located at
E6/206 at University Hospital (UH).
1. When a key is ready to be picked up the person getting the key or their authorized
designee must go to the Security Office E6/206 show proper UW Health, Medical
School, or UW Campus ID and then sign for the key.
2. Designee's must have prior approval to pick up keys.
3. Security Department staff will review requests for keys to access UW Health managed
doors. Designated department staff are authorized to approve requests, after verifying that
the appropriate approvals have been obtained.
D. Master Keys
1. The issuance of any key with a "master" designation will be closely scrutinized and if
there are other alternatives they will be considered before a master key is issued.
2. Any key that has a "great grand master" designation requires approval by the Security
Director and VP of Facilities, with no exceptions.
3. All "master" level keys must be picked up and signed for by the person the key is issued
to at the Security Office E6/206 at UH.
4. Security Department and Key Shop personnel will keep an active file of all issued and
stored "great grand master" keys.
5. Security Director will conduct an annual inventory of all great grand masters and all
master keys. The Director will retrieve master keys from managers and staff members
when the possession of a master key is not deemed essential or required.
E. Keys are Non-transferable
1. Keys are issued to one person, and the name should correspond to the name on the key
request form.
2. Keys may not be transferred from one employee to another for any reason.

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3. Keys are not the property of the office, department or supervision; they belong to UW
Health Administration.
4. Unless otherwise authorized and except where properly managed there will be no shared
keys. There may be approved exceptions to this rule in departments like Environmental
Services and Security Services where multiple shifts share keys specifically assigned to
an area. In these cases, department leadership must be able to show that they have a
reliable key control program in place to manage the process.
F. Lost Keys
1. The loss of individual door keys should immediately be reported to the employee’s
manager who will notify Security to evaluate the risk.
2. The loss of a "master" key should immediately be reported to the Security Director (890-
5555). Security will complete appropriate documentation and discuss follow-up with the
Security Director and department leadership in the area accessed by the lost master key.
G. Security Sensitive Areas
1. Security will evaluate all areas designated "security sensitive" and make appropriate
key/lock/card reader recommendations.
2. Some "security sensitive" areas may require re-keying from time to time. These situations
will be reviewed by the Security Director and appropriate leadership.
H. Contractor Issued Keys
1. There are times when contractors will be issued keys to work in specific areas. Issuance
of these keys is controlled by Facilities and Engineering Services.
2. Keys will be issued only to contractors who have obtained required UW Health photo
identification.
3. Issuance of keys to contractors is specifically addressed in Facilities and Engineering
Services Department policy number 2.10.01.
4. Return of keys issued to contractors is the responsibility Facilities and Engineering
Services.
I. Keys OFF the Great Grand Master
1. Occasionally, there may be cause for a door or an area to be keyed off the great grand
master. All requests of this nature must be explained in detail and approved by both the
Director of Facilities and Engineering Services and the Director of Security.
J. Keypad Lock
1. The adding of keypad locks should be done with review and approval by the Security
Director and Key Shop.
2. The Key Shop should retain records of all the doors with keypads.
K. Key Return
1. Department managers are responsible for retrieving UW Health keys from terminated
employees or when the individual no longer has a business reason for possession of the
key. Keys should be returned to the Security Office at UH for deactivation and disposal.
2. If an employee is unable to return their keys to Security (E6/206) the responsibility for
returning keys falls to that employee's manager.










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IV. COORDINATION

Sr. Management Sponsor: VP, Facilities and Support Services
Author(s): Director, Security Services; Director, Facilities and Engineering Services

Approval Committee: UW Health Administrative Policy and Procedure Committee

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer



Revision Detail

Previous revision: 122013
Next revision: 122019