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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC, UWMF and UWSMPH (shared)
Policy Title: UW Health Non-Physician Observer Policy
Policy Number: 1.48
Effective Date: July 1, 2015
The UW Health entities (UWHC, UWMF and UWSMPH) are committed to providing educational
services to the community, and for that reason welcome many non-employees (referred to herein as
“Participants”) to visit UW Health facilities to learn about the care provided at UW Health and about
careers in health care in general. This policy provides clear and consistent requirements for and rules to
govern the activities of Participants, in order to maximize the value of their experiences with UW Health
while maintaining a safe and healthy environment for UW Health patients, employees, and other visitors
to UW Health facilities.
All physicians who are not faculty members of UWSMPH and visit UW Health facilities must coordinate
their visits through UWHC Medical Staff Affairs in accordance with UWHC Administrative Policy 1.45
(“UWHC Visiting Physicians Observing Privileged UWHC Medical Staff”) and the Department
Administrator of the UWSMPH clinical department coordinating such visit.
The various types of experiences allowed at UW Health are distinguished from one another on the basis
of the nature and duration of the experience. Based upon the type of experience sought by an individual,
age limits and on-boarding requirements differ as described below.
Note 1: This policy does not apply to individuals covered under existing or future educational affiliation
agreements between various academic units and UW Health entities. Individuals covered under affiliation
agreements are on-boarded via procedures outlined in each affiliation agreement.
Note 2: The policy does not apply to individuals who are employed by any UW Health entity. It is
presumed that interns and other trainees who are employed have position descriptions that specify the
tasks that can and cannot be performed and the level of supervision required. For those employees under
age 18, the restrictions placed on participation in patient care activities must be followed. Active
employees who participate in experiences outside their area of employment would be required to follow
the conditions set forth in this policy.
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Note 3: In the context of this policy, “patient care” includes not only clinical care being provided to a
patient, but also includes any direct interactions with patients and/or identifiable medical records where
protected health information may be seen by a Participant.
Note 4: All physicians, including those licensed in the US and those from outside the US, who wish to
take part in observation experiences are on-boarded by the Medical Staff Affairs Office, per UWHC
Tours Providing individuals not employed by a
UW Health entity an opportunity to visit
a UW Health facility for purpose of
observing facilities and non-patient care
activities. Includes tours, health career
exploration events, Take Your Child to
Work Day, etc. Individuals on tours
have no more than incidental contact
with patients similar to the type of
contact any visitor might have with
patients in hallways, lounges, or cafeteria
than 2 hours, but
not more than 8
by Human Resources
Providing individuals not employed by a
UW Health entity an opportunity to visit
a UW Health facility for purpose of
observing facilities, non-patient care
activities, and (if age restrictions are met)
Not more than 8
place in one day.
Vendor Liaison Office
as outlined in Section
Training individuals not employed by a
UW Health entity in a systematic
manner, for purpose of observing
facilities, non-patient care activities, and
(if age restrictions are met) patient-care
Greater than 8
often occurs full-
time, over long
periods of time
(several weeks, up
Vendor Liaison Office
as outlined in Section
Preparing under-represented youth or
college students, who are not employed
by a UW Health entity, for careers in
health care. These experiences are
offered by UW Health in collaboration
with strategically-chosen external
Experiences are a
minimum of four
Human Resources as
outlined in Section
following existing HR
Volunteer Providing individuals who are not
employed by a UW Health entity an
opportunity to provide voluntary service
to UW Health.
Greater than 8
several hours per
day, several days
per week, over
long periods of
Volunteer Services as
outlined in Section
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A. It is a privilege to participate in these experiences at UW Health. Participants must adhere to a
number of requirements, as outlined below. Participants who are under 18 years of age must
comply with additional requirements, also outlined below. All experiences are approved based
upon availability of operational resources necessary to accommodate Participants, and individual
departments have the right to refuse to offer experiences if resources are unavailable.
B. Age Restrictions
1. Based on the table of definitions in Section II above, and the graphic below, various types
of experiences exist, each with its own restrictions with respect to the age of Participants.
2. Age restrictions do not exist for participation in tours, but organizers are expected to
exercise prudent judgment with respect to inclusion of young Participants.
3. For all other types of experiences, Participants must have completed the 8th grade to take
part in experiences in non-patient care areas or in direct patient care.
4. Individuals who wish to observe direct patient care must be at least 16 years of age for
experiences in adult patient care areas, or 18 years of age in pediatric patient care
areas. These restrictions include any direct interactions with patients and/or identifiable
medical records where protected health information may be seen by a Participant. In those
settings where both pediatric and adult patients are cared for, those under 18 should be
restricted to observation of the care of adults only.
5. In all cases, experiences within Operating Rooms (Surgical Services) are limited to
individuals who are at least 18 years of age.
C. On-Boarding Requirements Applicable to Tours
1. No specific on-boarding requirements exist for Participants taking tours. Tour leaders
should exercise prudent judgment when selecting which areas are visited, especially to
minimize unnecessary incidental contact with particularly vulnerable patient populations.
D. On-Boarding Requirements Applicable to Short-and Long-Term Observation in Patient Care
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1. These requirements apply to all individuals applying for a Short-Term or Long-Term
Observation, regardless of participant age. Additional requirements for all participants under
18 years of age who are observing patient care are found in Section III(G) below.
2. As defined in Section II, Short-and Long-Term Observation experiences are coordinated by
the Vendor Liaison Office (VLO). Participants may be referred to the VLO to answer
questions regarding the application and on-boarding process.
3. Short-or Long-Term Observation Participants may not begin their experience until all on-
boarding requirements are met.
4. All visiting Short-or Long-Term Observation Participants must pay a small on-boarding fee
(determined annually in consultation with UW Health leadership). The funds collected are
used to defray the cost of administering these programs.
a. Exceptions to the on-boarding fee requirement will be considered on a case-by-case
basis, as approved by the Director of the Center for Clinical Knowledge
b. Participants who are actively pursued and invited to observe by UW Health faculty
or staff (e.g., as part of employment and/or volunteer recruitment efforts) will
receive a fee waiver without requiring the approval of the Director of CCKM. The
sponsor must tell the VLO that the Participant was recruited for the experience, and
the fee will be automatically waived.
c. Participants from strategic partners including, but not limited to, Epic, McKesson,
and GE Healthcare, will be exempt from paying the fee, but must comply with all
other requirements outlined in this policy, and must apply in the same manner as
any other Participant.
5. During the application process, all required documentation must be submitted to the VLO
by Participants at least 2 weeks prior to their requested experiences.
6. The on-boarding of potential Short-and Long-Term Observation Participants follows a
process of approval stages:
a. The potential Participant initiates contact with UW Health.
b. Requests for experience must first be approved by a manager or department
head. The approving manager or department head will serve as the Participant’s
“host” during the Short-or Long-Term Observation experiences.
c. The approving manager or department head will complete the Sponsorship
Agreement Form on U-Connect, sending their approval to the VLO.
d. The VLO will then contact the Participant, providing instruction on the application
process, all application materials, and coordinating all further on-boarding steps.
e. All Participants interested in observing in an Operating Room setting must also
complete an online evaluation tool prior to approval. Those approved must comply
with the Operating Room (OR) Observer Guidelines which will be provided by the
VLO, if approved.
7. The Participant will return paperwork to the VLO for approval. All required documentation
must be presented in English or with certified translations. Required documentation
a. UW Health Sponsorship Agreement electronically signed by the sponsor (UW
Health manager or department head).
b. UW Health Short-or Long-Term Observation Experience Application.
c. UW Health Confidentiality Agreement and Release of Liability.
d. UW Health Short-or Long-Term Observation Health Assessment, including
i. Current TB testing status
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iii. Varicella Zoster (Chickenpox)
iv. Influenza Vaccination (October- March)
v. UW Health TB Screening Questionnaire
vi. UW Health Latex Allergy Screening Questionnaire
vii. UW Health Safety and Infection Control Questionnaire.
8. Incomplete applications will be denied, and the VLO will send notification of denial to both
the potential Participant and the approving manager or department head.
9. Participants who satisfy the requirements will be approved, and the VLO will notify the
Participant and the approving manager or department head.
10. Following approval, the Participant must schedule an appointment with the VLO to secure a
name badge. If the experience is taking place at a remote location, all application steps can
be completed electronically, and the name badge will be sent to the Participant by mail.
11. At the conclusion of the experience, the name badge must be returned to the VLO.
E. On-Boarding Requirements Applicable to Short-and Long-Term Observation in Non-Patient Care
1. Those Participants that are not entering patient care areas (including those Participants
under 16 years of age) are excluded from the Health Assessment outlined in III.D.7.d.
2. All other requirements listed in III.D.1-11 remain the same.
3. Hosts should exercise prudent judgment when selecting which non-patient care areas are
visited, especially to minimize unnecessary incidental contact with patient populations.
4. To protect patient confidentiality and to avoid disruptions in patient care, non-patient care
Participants are prohibited from all patient care areas or from areas where there is access
to patient information. Direct patient care areas include any area where direct patient care
occurs such as inpatient hospital rooms, procedure room (i.e. OR, Cath/EP Lab,
Imaging), hospital nursing stations, outpatient clinic examination rooms and the
emergency room. They may travel through these areas en route to scheduled meetings,
but are prohibited from conducting business in or lingering in these areas.
5. Examples of non-patient care areas would include conference rooms, offices, and
facilities with no patient care activity (AOB, UCB, UBD, etc).
6. Sponsors will identify that the Participant’s experience is in a non-patient care area on the
Sponsorship Agreement Form.
F. On-Boarding Requirements Applicable to Workplace Readiness Internship Program
1. These requirements apply to all individuals applying for the Workplace Readiness
Internship Program, regardless of age. Additional requirements for all Participants under 18
years of age who are observing patient care are found in Section III(G) below.
2. As defined in Section II, the Workplace Readiness Internship Program is coordinated by
Human Resources, using the same on-boarding procedures followed for on-boarding of new
employees (including processing as un-paid appointments in PeopleSoft, issuing staff ID
3. Workplace Readiness Internship Program Participants may not begin their experience until
all on-boarding requirements are met.
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G. On-Boarding Requirements Applicable to Volunteers
1. These requirements apply to all individuals applying as a Volunteer, regardless of
age. Additional requirements for all Participants under 18 years of age who are observing
patient care are found in Section III(G) below.
2. As defined in Section II, Volunteer on-boarding is coordinated by Volunteer
Services. Individuals may be referred to Volunteer Services to answer questions regarding
the application and on-boarding process
3. Volunteers may not begin their experience until all on-boarding requirements are met.
H. Additional On-Boarding Requirements and Restrictions Applicable to Experience Participants
Under 18 Years of Age Who Are Observing Patient Care
1. Participants under 18 years of age are prohibited from entering the Operating Room.
2. Participants under 18 years of age who meet the requirements set forth in Section III(B)
above and who wish to observe direct patient care must be sponsored by a UW Faculty
Physician, or if observing the practice of another health care provider, by a licensed health
care professional employed by a UW Health entity, who must complete and sign the
Sponsor Acknowledgement Form.
3. Participants under 18 years of age who are observing direct patient care must be supervised,
at all times during interactions with patients, by their sponsoring physician or other licensed
health care provider. Participants less than 18 years of age not observing direct patient care
may be supervised by other UW Health faculty or staff who are not physicians or licensed
health care providers.
4. A custodial parent or guardian of Participants under 18 years of age must sign a form
consenting to the Participant’s experience, accepting liability for the Participant’s actions
during the experience, and releasing UW Health entities from liability in connection with
the Experience. This form must also be signed by the Participant.
5. A custodial parent or guardian of Participants under 18 years of age must also provide a
signed privacy and confidentiality agreement on behalf of the Participant. This form must
also be signed by the Participant.
6. No participant under 18 years of age will be allowed to observe patients under the influence
of anesthesia or who are sedated for their medical procedures (or are otherwise unable to
give permission for the observation), or procedures where patients are disrobed, or genitals
or breasts are exposed.
I. Behavior of Experience Participants
1. Participants must be sponsored by an employee of a UW Health entity. Participants may not
be sponsored by members of their immediate family.
2. Participants must be supervised at all times by a designated employee of a UW Health entity
who is responsible for ensuring that the Participant complies with all policies and
procedures relevant to the area they are visiting or observing.
3. Participants must recognize that they are observers or volunteers only. They must not
participate in patient care while observing. This restriction includes, but is not limited to the
a. Participants must not communicate with patients and/or their families with regard to
b. Participants must not examine or touch patients.
c. Participants must not document in patient medical records.
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d. Participants must not retrieve or interpret diagnostic tests.
e. Participants must not scrub in or assist in the operating room or outpatient
f. Participants must not touch medical equipment.
g. Participants must not prescribe or administer drugs.
4. Participants who become concerned about anything they see in the clinical setting (such as
threats to patient safety or unethical behavior), should share those concerns with their
supervising host immediately.
5. Participants must comply with UW Health Dress Code and Appearance Policy.
6. Participants must wear the UW Health-issued name badge (provided by the VLO, or
through HR or Volunteer Services), at all times in UW Health facilities.
7. Participants are prohibited from having cellular phones, tablets, or any other electronic
devices in their possession during their experience. Use of UW Health electronic devices
and computers may be allowed for volunteers or participants in workplace readiness
programs only to the extent authorized and required for the experience. Such use shall be
strictly limited by the supervising UW Health employee. Participants under 18 years of age
who are observing patient care must relinquish all electronic devices (cellular phones, iPods,
iPads, cameras, computers, etc.) to their sponsoring physician for the duration of the
experience. Electronic devices will be returned at the conclusion of the experience.
8. Participants who are approved to visit operating rooms must abide by the UWHC Surgical
Services Departmental Policy 1.24-Visitors in Surgical Services/OR: Students, Observers,
J. Photographers Overseen by UW Health Marketing and Public Affairs
1. Photographers may be invited to observe and take still and video images of patients during
care delivery. These situations are overseen by UW Health Marketing and Public Affairs,
who ensure that all policies related to patient confidentiality and consent are followed.
2. Photographers hired by any UW Health entity, or working under contract with any UW
Health entity, must follow all requirements outlined above for on-boarding prior to being
allowed to enter patient care areas. In these situations, any applicable on-boarding fees will
3. Members of the news media often request permission to photograph patients during care
delivery. In these circumstances, it may be impossible to complete the full on-boarding
procedure outlined above prior to the media visit. In these situations, the UW Health
Marketing and Public Affairs staff will complete an abbreviated documentation process,
requiring reporters and photographers to complete questionnaires that collect health risk
assessment information. A confidentiality form will also signed by the reporter and
photographer, and patients’ authorizations will be obtained when required by applicable
privacy laws and regulations. Completed paperwork will then be forwarded to the VLO
after the media visit is complete.
K. Research Personnel Not Employed in Clinical Capacity by a UW Health Entity
1. Research staff who are not employed in a clinical capacity by a UW Health entity, but who
are listed as key personnel on IRB-approved research projects that involve more than
incidental contact with patients (e.g., does not include lab-based research or data analysis)
may observe clinical care in UW Health facilities after being on-boarded by the VLO.
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2. Since key personnel are required to complete IRB training, some on-boarding requirements
may be waived, at the discretion of the VLO, if documentation of previous satisfaction of
the requirement is provided.
3. The principal investigator (PI) of each research project must take responsibility for ensuring
the appropriate behavior of research staff, and compliance with the conditions for
observation set out in the IRB-approved protocol. Research staff are not required to be
supervised during their observation, within the scope of their observation set forth in the
4. Research staff who become concerned about anything they see in the clinical setting (such
as threats to patient safety or unethical behavior), should share those concerns with the study
PI or the supervising host as soon as possible. The PI or supervising host will provide
guidance and contact appropriate UW Health personnel as necessary.
5. Research personnel are expected to follow all requirements set out in this policy, with some
exceptions and clarifications.
a. Electronic devices for collection of data may be used by observers in compliance
with the IRB-approved protocol.
b. The observation period may last days, weeks or months, depending on the scope of
the research project. If the research study exceeds 1 year in length, re-verification
of some on-boarding requirements (e.g., TB testing, SIC competence) will be
1. UW Health reserves the right to exclude any experience Participant from its facilities for
violation of UW Health work rules, policies or procedures, or for conduct that disrupts the
operation of any clinical site or endangers patients, employees, or other persons.
All forms are located On U-Connect under Observer Process.
Surgical Services Departmental Policy 1.24-Visitors in Surgical Services/OR: Students, Observers, Media
Nursing Administrative Departmental Policy 3.22-Guidelines for Site Visits and Clinical Observations
Hospital Administrative Policy 1.45-Visiting Physicians Observing Privileged UWHC Medical Staff
Hospital Administrative Policy 9.16-UW Health Dress Code and Appearance Policy
“UW Health” is not a legal entity. UW Health is comprised of three separate entities: University of
Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc. and the
University of Wisconsin School of Medicine and Public Health. Each of these three entities is responsible
for enforcement of this policy.
VII. COORDINATION (The details of Coordination of UWHC, UWMF and UWSMPH are shown
below. Approval and coordination of this policy by those entities occurs per their individual processes.)
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UWHC Sr. Management Sponsor: Vice President, Quality and Patient Safety
UWHC Author: Director, Center for Clinical Knowledge Management
UWHC Reviewer(s): Program Manager, Vendor Liaison Office; Program Director, Human Resources
UWHC Approval committee(s): Health Link Shared Leaders; COG40; Clinic Operations Committee;
Administrative Policy and Procedure Committee.
UWMF Sr. Management Sponsor: Chief Operating Officer
UWMF Author: Director, Center for Clinical Knowledge Management
UWMF Reviewer: Associate Counsel & Privacy Officer
UWSMPH Approval: UW Administrative Legal Services
President & CEO
Previous revision: 072014
Next revision: 072018