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Policies,Administrative,UWHC,Department Specific,Transplant,Transplant - Solid Organ

Policy Development and Maintenance (3.01)

Policy Development and Maintenance (3.01) - Policies, Administrative, UWHC, Department Specific, Transplant, Transplant - Solid Organ

3.01



POLICY & PROCEDURE
Effective Date: May 2011
Revised Date: June 2015 Title: Policy Development and Maintenance Policy Number: 3.01

Page 1 of 3
I. PURPOSE
A. The purpose of this policy is to establish guidelines for development of policies and procedures for
inclusion into the University of Wisconsin Hospital and Clinics (“UWHC”) Transplant Policies and
Procedures available on U-Connect (UWHC intranet site) to all hospital providers and staff.
B. To establish guidelines for periodic review and management of existing policies contained in the
Transplant Policies and Procedures.

II. POLICY
A. It is the policy of the UW Transplant program to adhere to the University of Wisconsin Hospital and
Clinics (UWHC) standards of patient care, as well as the standards determined by regulatory and
accrediting agencies, such as The Joint Commission, the Organ Procurement and Transplantation
Network (“OPTN”) and the United Network of Organ Sharing (“UNOS”) and the Centers for
Medicare and Medicaid Services (“CMS”), and any State and Federal laws.
B. The UWHC Transplant program directors, managers, transplant coordinators, physician leaders and
other multidisciplinary team members provide a broad perspective on the organ procurement and
transplantation operations and regulations. These individuals will identify the need for
departmental policies and coordinate the development and approval of new policies to be added to
the Transplant Policies and Procedures. The Service Line Director, division chairs, and Managers will
be responsible for reviewing and approving all policies.
C. The UWHC Transplant team will review all policies at least once every three years. Policy changes
implemented by regulatory agencies (e.g., UNOS, CMS, The Joint Commission etc.) will be
monitored by the Operations Director, and transplant managers. Revisions will be made to UWHC
Transplant policies appropriately made to ensure compliance.
III. PROCEDURE
A. Review of Existing Policies
1. All policies will be on a schedule for review every third year by the UWHC Transplant team.
2. If during the review the team determines that a policy requires revisions, the manager will
appoint an author.
3. The author will revise the policy and circulate it to all team members and necessary
stakeholders for review.
4. Once the team has reviewed and the manager has approved any changes, the author will
revise the policy, and the policy will be presented to the Service Line Director and Division
Chair for review and approval.



POLICY & PROCEDURE
Effective Date: May 2011
Revised Date: June 2015 Title: Policy Development and Maintenance Policy Number: 3.01

Page 2 of 3
5. The author will request that the revised policy be added to the next UWHC Transplant staff
meeting agenda to be communicated and discussed with the team or routed via email.
6. Signed policies will be placed on the UWHC intranet site (U-Connect), and in the electronic
policy and procedure shared drive for access by all employees.
B. Development of New Policies
1. If a new policy is required, an author will be appointed by the manager.
2. The author will be responsible for drafting the new policy.
3. The author will circulate the new policy to the UWHC Transplant team for review.
4. Once the team has reviewed, the author will make the necessary changes and present the
policy.
5. The author requests that the policy be added to the next UWHC Transplant staff meeting
agenda to be communicated and discussed with the staff.
6. Signed policies will be placed on the UWHC intranet site (U-Connect) for access by all
employees.
C. Monitoring of Compliance
1. Internal audits will be performed regularly to ensure compliance with all program
policies. Audits will be prioritized based upon any deficiencies found by regulatory agencies
such as UNOS and CMS.
2. A summary of internal audit findings will be shared with the UWHC Regulatory and
Compliance Committee and other stakeholders as necessary.
IV. COORDINATION

University of Wisconsin Transplant Program

V. REVIEWED AND APPROVED BY

Kidney Transplant Manager
Liver Transplant Manager
Heart and Lung Transplant Manager
Operations Director









POLICY & PROCEDURE
Effective Date: May 2011
Revised Date: June 2015 Title: Policy Development and Maintenance Policy Number: 3.01

Page 3 of 3
VI. SIGNED BY

________________________________ _________________________________
Jill Ellefson, MBA Dixon Kaufman, M.D., PhD
Director, Organ Donation and Transplant Service Line Chair, UW Transplant Program