X Other: Information Services
Policy #: SE-
Title: UW Health IS Problem Review
Policy (this policy is used by UWHC and
The purpose of this policy is to provide a mechanism to review and assess adverse
events or unplanned system outages (downtime) with the goal of identifying root causes
to prevent a similar problem from occurring in the future.
Problem: Any issue or event for which a root cause is unknown.
Unplanned or Unscheduled Downtime (Outages): A system is not accessible or non-
operational for a period of time that was not previously scheduled and communicated to
the system users.
Planned or Scheduled Downtime: A system is not accessible or non-operational for a
period of time that was planned, scheduled, and communicated to the system users.
A. Documentation and Review of Problems
All problems that meet one of the following criteria and/or are declared problems by
the IS Help Desk or IS management are documented and reviewed utilizing a formal
standardized method as outlined in the referenced Procedure document.
Criteria That May Result in a Problem:
1. Significant Impact: The unplanned or unscheduled downtime, system
outage, or reduction in service has a substantial impact. For example:
a) Patient Care: Situations that impact Patient Care / Patient Safety
b) Infrastructure / System-wide: Situations that are system wide affecting
several areas of the hospital, clinics, or business administration
c) Department / Group: Situations that impair a department or group
from performing their daily job, requiring department downtime
d) Services provided to affiliated partners.
2. Exceeds Planned Downtime by 10%: A planned downtime has taken more
than 10% longer than specified.
3. A Data Breach has occurred
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1. Problem Creation: It is the responsibility of the Help Desk or IS
ξ Create a problem record.
ξ Relate incoming incidents to the problem record.
ξ Generate notification banners, if necessary.
2. Problem Investigation and Resolution: It is the responsibility of the
assigned IS team to investigate, resolve, and document the problem. The
assigned team may delegate responsibilities to other IS teams via sub-tasks
in ServiceNow. When the problem is resolved, the IS team has the option to
resolve all problems relating to the problem. The customer(s) is/are notified
when the problems are resolved.
3. Problem Review: It is the responsibility of the management of the assigned
team to review all problems in a timely manner and pursue any follow up
actions. If necessary, the assigned team calls a meeting of all teams,
management, and operational stakeholders involved in the problem to
prevent the problem from recurring in future.
UW Health IS Problem Review Procedure (SE-PRO-003)
UW Health is not a legal entity. UW Health is comprised of three separate entities. This
policy applies to facilities and programs operated by the University of Wisconsin
Hospitals and Clinics Authority and the University of Wisconsin Medical Foundation, Inc.
Each entity is responsible for enforcement of this policy in relation to the facilities and
programs that it operates.
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The details of Coordination of UWHC and UWMF are shown below. Approval and
coordination of this policy by those entities occurs per their individual processes.
UWHC Sr. Management Sponsor: UW Health IS CIO
UWHC Author: UW Health IS Project Management Office
UWHC Reviewers: UW Health IS Directors
UWHC Approval committee(s): UW Health IS Directors
UWMF Sr. Management Sponsor: UW Health IS CIO
UWMF Author: UW Health IS Director – Systems Security
UWMF Reviewers: UW Health IS Directors
UWMF Approval: UW Health IS Directors
V. SIGNED BY
Jocelyn DeWitt, UW Health CIO
Peter Christman, UWMF COO
VI. REVISION HISTORY
Effective Date Next Review Summary of Changes Change Authors
Revised for compliance
with ServiceNow S. Juedes, J. Leonard
1/23/2014 1/23/2015 Original release. D. Jaworski, E. Gerke, S. Schroeder