4.03 Security Management Plan – Non-CSC Locations
Category: UWHC Departmental Policy
Policy Number: 4.03
Effective Date: October 22, 2014
To provide and promote the safest possible physical environment at non-CSC locations that is free of hazards.
Everyone can help prevent theft, vandalism and assaults. These offenses are often committed by strangers or
unauthorized people posing as patients, staff or visitors. By staying alert you can keep a watchful eye on your
possessions and the hospital’s property.
A. Crime Prevention: All employees are responsible to help prevent theft, vandalism and assaults.
1. Securing Personal Property
a. Keep all personal valuables IN YOUR OFFICE, LOCKED IN DESK OR FILE DRAWER. Do
not leave purses, billfolds, money, etc. in a visible, open space.
b. If you find personal property has been stolen: Notify your supervisor or director;
immediately report the theft to UW Hospital Security at 890-5555; and complete an
incident report using Patient Safety Net.
2. Securing Patient's Property
a. Have the patient take their valuables with them, wherever they go (i.e. from exam room
to testing room). Make sure the patient's personal property is in their sight at all times.
b. If a patient has valuables stolen, report the theft to the department supervisor or
manager who will:
i. Report the theft to UW Hospital Security at 890-5555.
ii. Communicate follow-up with patient;
iii. Complete an incident report using Patient Safety Net; and
iv. Refer the patient to Patient Relations (Patient Relations and Risk Management
will be responsible for determining whether or not UWHC will reimburse the
patient for an item reported lost or stolen).
3. Employee Safety in Workplace
a. If you feel threatened or harassed in any manner, call out and get to a safe place.
b. If alone, call 911 and give name, location, and your concerns.
c. If you are feeling uncomfortable about a situation, call UW Hospital Security & UW Police
at 262-2957 or speak with your supervisor or manager.
d. Wear your UWHC issued photo ID badge when at work, as required by UWHC Policy
e. Ask for ID when you see someone in your area working without an ID badge.
f. Be aware of your surroundings. If you see someone in your clinic or building that you
don’t recognize, take a moment and verify who they are and their purpose in the
area. If you are not satisfied in the response or the person becomes uncooperative,
contact your manager and call Hospital Security at 890-5555 immediately.
4. Handling Disruptive/Combative Patients
a. If the front desk staff observes the disruptive behavior, it should be reported to the
department supervisor or manager. The department supervisor or manager will
determine if the patient is to be seen. If the patient is to be seen, the patient should be
registered and every effort made to reduce waiting time. The physician should be
notified and the patient should be seen as soon as possible.
b. Call/page the Behavior Response Team for those buildings that have Behavior Response
Teams (refer to Ambulatory Policy 4.70 – Behavior Response Team – Non-CSC
c. If the patient begins to act out in a combative manner, the staff should determine the
need for UW Police and call 911, if appropriate. The police will take control of the
situation and consult with medical staff to determine a resolution.
d. If the individual has a weapon, follow Code Yellow/Active Shooter Non-CSC facilities,
UWHC Administrative Policy 12.62, as appropriate. The Out strategies should be followed
Get Out, Call Out, Hide Out, Take Out. The decision to evacuate the premises or to take
shelter within the building may be determined by staff without intervention of a
supervisor or manager. The department supervisor and/or the Building Manager or
delegate will intervene as time allows. Do not attempt to argue or talk to an individual
with a weapon.
e. In case of an assault by a combative patient, dial 911. The staff should intervene,
without putting themselves in harms way.
f. If the assaulted individual(s) is another patient, the patient should be examined by a
staff physician if the assault occurs during normal, clinic hours, and appropriate medical
attention given. If the assault occurs outside of normal, clinic hours, staff should try to
make the individual comfortable until Emergency Medical Services arrive. An incident
report should be completed using Patient Safety Net by at least one person who is
involved or made aware of the incident.
g. If the assaulted individual is a staff member, he/she will:
i. Be examined by UWHC Employee Health or the Emergency Department; and
ii. Fill out an Occupational Accident and Illness Report on line, this will route to the
B. Key Control: UWHC Administrative Policy 12.57 on key control should be followed. Administrative
responsibility for key and access control, which includes all locks and locking hardware, is the combined
responsibility of the Security Director and Director of Plant Engineering. Requests for keys should be done
through the online key request form.
C. After Hours Building Access: If there are areas within the building that can be utilized by outside
businesses and organizations after the facility closes, the Building Manager or delegate is responsible for
staffing and securing these functions. He/she should follow these procedures:
1. Lock doors leading to clinics, if possible, or limit floor access.
2. Have staff person man front desk until all persons have arrived, unless other arrangements have
3. Lock front door entrance (rear should already be locked).
4. Limit use to utilized area only.
5. Check utilized area after event is completed and secure the area and building.
6. UWHC Security should be notified when the event conflicts with the arming and disarming of the
security intrusion alarm system. This will assist with false alarms.
D. Research Park: The front Registration desk will be staffed when the facility is open. A minimum of two
staff members will open and close the building. Closing and securing the facility should be done together.
If there are locking issues with the exterior doors, staff should call UWHC Security at 890-5555. Staff
members should walk together to their cards.
UWHC Administrative Policy 12.02 - Security Management Plan
Ambulatory Policy 4.70 – Behavior Response Team - Non-CSC Locations
UWHC Administrative Policy 12.62 - Code Yellow/Active Shooter Non-CSC Facilities
V. WRITTEN BY
Director of Orthopedics
VI. REVIEWED AND APPROVED BY
Safety Program Manger
Offsite Clinics Building Facilitators
Ambulatory Policy and Procedure Committee
Karen Leimkuehler, RN, MS, Clinic Operations Director