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/policies/administrative/uwmf/uwmf-wide/information-services/is-procedures/ad-pro-001.policy

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Policies,Administrative,UWMF,UWMF-wide,Information Services,IS Procedures

Policy and Procedure Development Procedure (AD-PRO-001)

Policy and Procedure Development Procedure (AD-PRO-001) - Policies, Administrative, UWMF, UWMF-wide, Information Services, IS Procedures

AD-PRO-001


Administrative Departmental Procedure
This department-specific procedure applies to the operations and staff of the Information Services
Department of the University of Wisconsin Hospitals and Clinics Authority as integrated effective July 1,
2015.

Procedure Title: UW Health Policy and Procedure Development
Procedure Number: AD-PRO-001
Effective Date: 5/23/16
Chapter: NA
Version: Revision
I. PURPOSE
This procedure is established to outline the requirements for the creation and maintenance of the
Information Services policy and procedure documents.


II. DEFINITIONS (optional)
NA

III. POLICY ELEMENTS
UW Health Policy and Procedure Development Policy (AD-POL-001)


IV. PROCEDURE

A. Policy & Procedure Proposals
1. Any IS employee may submit a proposal for a policy or procedure document to
the IS Director for their particular area for endorsement. The recommendation
must include the suggested title and a brief purpose statement outlining the
need for the policy.
2. The responsible IS Director adds the proposal to the agenda of the next
available IS Directors meeting and will present the proposal accordingly.
3. If approved, the IS Directors group will set a completion date for the policy.
4. The author will complete the policy and procedure using the approved UW
Health templates available on the UWH-IS Department Workspace.

B. Policy Review
1. Author notifies their Director when the first draft of the policy is ready for
review.
2. The responsible IS Director will add the review to the agenda of the next
available IS Directors meeting and distribute copies prior to the scheduled
review.
3. The responsible IS Director will present the policy and coordinate the
suggested changes or edits to the policy.
4. Policy will continue through review cycle until content is acceptable.

5. If the policy impacts all UW Health employees, the UWH Administrative
Policy and Procedure Committee must review and approve prior to publishing.


C. Publishing Policies and Procedures
1. Upon approval by the IS Directors group, the OCIO, and in some cases the
UWH Administrative Policy and Procedure Committee, the documents will be
sent to UWH – IS Technical Writer UWH – IS Technical Writer will ensure
the policy is:
a. Formatted correctly
b. Sequentially numbered and categorized
c. Sent to eHealth-UWH ehealth@uwhealth.org for posting to the
Policies > Administrative > Information Services page on UConnect
d. Communicated to the UWH – IS Department
i. Name of the new or revised policy or procedure
ii. Summary of the content (new)
iii. Change description (revised)
2. Approved policies and procedures are saved in
U:\UWHealth\IS\ShareAll\Project Management Office\Policies &
Procedures\Reviews\IS Policies & Procedures\Policies and
Procedures\Approved and Published.

D. Revising and Archiving Policies and Procedures
1. When policies and procedures are revised, follow the review and publishing
procedure as outlined above.
2. Save the prior version of the policy and procedure as an archive in
U:\UWHealth\IS\ShareAll\Project Management Office\Policies &
Procedures\Reviews\IS Policies & Procedures\zzArchived_Historical\UW
Health PolicyProcedure_Archived\[YEAR] where the year is the current year
in which the prior version is being archived.
3. Update the filename of the prior version of the policy and procedure to reflect
the date that the policy and procedure were archived, using the format:
[Filename][MM-DD-YEAR].

Example: IS Policy and Procedure Development Policy [12-31-2014]

4. Maintain archived versions for seven (7) years.



V. FORMS (optional)
NA

VI. REFERENCES (optional)
NA

VII. COORDINATION

Sr. Management Sponsor: UW Health IS CTO
Author: UW Health IS Director – Project Management

Reviewer(s): UW Health IS Directors

Approval Committee: UW Health IS Directors

SIGNED BY:
UW Health CIO

Revision Detail:

Effective Date Next Review Summary of Changes Change Authors
5/23/16 5/23/17
Added steps for
communicating
new/revised P&Ps to IS
Department. Also added
verbiage around UWH
Administrative P&P
Committee approvals.
S. Schroeder
1/8/2015 1/8/2018
Added publishing and
archiving steps, per PCI
audit
E. Gerke, J. Leonard, S. Schroeder
1/9/2014 1/9/2017 Original release. S. Schroeder