/policies/,/policies/administrative/,/policies/administrative/uwmf/,/policies/administrative/uwmf/uwmf-wide/,/policies/administrative/uwmf/uwmf-wide/information-services/,

/policies/administrative/uwmf/uwmf-wide/information-services/se-pol-003.policy

201507198

page

100

UWHC,UWMF,

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

Problem Review (SE-POL-003)

Problem Review (SE-POL-003) - Policies, Administrative, UWMF, UWMF-wide, Information Services

SE-POL-003

POLICY




Information Services
Effective Date:
7/1/2015
Administrative Manual

X Other: Information Services
Policy #: SE-
POL-003

X Revision
Total #
Pages: 3
Title: UW Health IS Problem Review
Policy (this policy is used by UWHC and
UWMF)


I. PURPOSE
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.

II. DEFINITIONS

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.

III. POLICY

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
systems.
c) Department / Group: Situations that impair a department or group
from performing their daily job, requiring department downtime
procedures.
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




Page 2 of 3

B. Responsibilities

1. Problem Creation: It is the responsibility of the Help Desk or IS
Management to:
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.

IV. PROCEDURE

UW Health IS Problem Review Procedure (SE-PRO-003)

VI. OTHER

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.




Page 3 of 3

VII. COORDINATION

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
7/1/2015 7/1/2016
Revised for compliance
with ServiceNow S. Juedes, J. Leonard
1/23/2014 1/23/2015 Original release. D. Jaworski, E. Gerke, S. Schroeder