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Nursing Patient Care Procedures Committee (2.36)

Nursing Patient Care Procedures Committee (2.36) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Committees, Department of Nursing

2.36


UW HEALTH NURSING ADMINISTRATIVE POLICY

Policy Title: Nursing Patient Care Policy & Procedure Committee
Policy Number: 2.36
Effective Date: October 24, 2017

1


As of October 5, 2017 this administrative policy applies to the operations and staff of legacy UWHC. Effective
July 1, 2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of
Wisconsin Hospitals and Clinics Authority (UWHCA). All administrative policies are being transitioned to apply
UWHCA-wide, but until future revision to this policy #2.36, it applies only to the operations and staff of legacy
UWHC.


I. PURPOSE

A. The Nursing Patient Care Policy and Procedure Committee collaborate with subject matter experts (SMEs) or
appropriate department leaders or designees to write and/or revise policies and procedures for nursing care. The
policies and procedures:
i. Are evidence-based
ii. Cite the course of action or processes in a step-by-step method
iii. Identify crucial points in the nursing processes
iv. Accurately depict and communicate Nursing and Patient Care Service's philosophy of patient care.
B. When applicable, nursing patient care policies and procedures may be forwarded to other relevant decision-making
bodies (i.e., UWHC Medical Board Committee on Patient Care and Procedures) for further review and
recommendations.

II. ACCOUNTABILITY

A. Nursing Executive Council
B. Senior Vice President Patient Care Services, Chief Nurse Executive directs the Nursing Patient Care Policy and
Procedure Committee to develop, revise and approve clinical policies and procedures.
C. Nursing Practice Council

III. MEMBERSHIP
A. The committee will be chaired by the Director of Nursing Practice Innovation or designee.
B. Members will be selected to achieve representation of major nursing specialty areas.
C. Interested members may apply to join the Nursing Patient Care Policy and Procedure Committee at the beginning of
each fiscal year.
D. Members are appointed by the Committee Chair for a one-year term.

IV. RESPONSIBILITIES

A. At least every three years, review and revise all Nursing Patient Care policies and procedures.
B. Identify and develop policies and procedures that need to be added.
C. Identify resources to supplement such as standard references for clinical nurses.
D. Ensure that procedures are theoretically and technically accurate, practical and cost-effective in application.
E. Coordinate actions of this committee with other committees and departments when policy or procedure changes may
affect them.
F. Determine effective methods for communicating and implementing policy and procedure revisions to the nursing
group.

V. MEETINGS

A. Monthly or more frequently as needed.

VI. COORDINATION

Author: Director, Nursing Practice Innovation
Reviewers: Nursing and Patient Care Policy & Procedure Committee, May 2017
Approval committees: Nursing Administrative Policy and Procedure Committee, October 2017


UW HEALTH NURSING ADMINISTRATIVE POLICY

Policy Title: Nursing Patient Care Policy & Procedure Committee
Policy Number: 2.36
Effective Date: October 24, 2017

2


UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities. This
policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics and the
University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs administered by the
University of Wisconsin School of Medicine and Public Health. Each entity is responsible for enforcement of this
policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive


VIII. REVIEW DETAILS

Version: Revision
Last Full Review: September 18, 2017
Next Revision Due: September 2020