Policies,Clinical,UW Health Clinical,Administrative,Administrative

UW Health Clinical Policies (1.1.1)

UW Health Clinical Policies (1.1.1) - Policies, Clinical, UW Health Clinical, Administrative, Administrative


Policy Title: UW Health Clinical Policies
Policy Number: 1.1.1
Category: UW Health
Type: Inpatient and Ambulatory
Effective Date: July 21, 2016


To provide a process for the development, approval, implementation, and routine multidisciplinary review of
clinical policies. This process is intended to create consistent standards of care across all UW Health
entities with the goals of improving quality and reducing cost in an evidence-based fashion.


A. Policy will be defined as: actions and responsibilities for a given situation designed to describe
expected clinical practice.
B. For the purpose of this policy the term clinical policy describes how UW Health staff and providers
(including students, externs, interns, etc.) interact, touch, and communicate with patients and their
families and involves areas in which clinicians are considered experts. Non-clinical or administrative
policies involve anything from interfacing with technology or equipment to reacting to events such as
weather, and do not require clinician expertise.
C. Clinical policies are mandatory instructional writings that directly affect patient care and are subject to
discipline if not followed. Therefore they must be followed as written and are not to be confused with
guidelines which are considered recommendations or advisory instructional writings and not subject to


A. When a clinical policy is approved under this policy, the clinical policy will apply to all disciplines and in
all settings specified within the clinical policy document.
B. Clinical policies should be designed to apply across patient populations and should be consistent
across specialties, services, and clinics regardless of location or entity.
C. Ambulatory clinical policies shall be developed to encourage adoption of similar clinical policies across
UW Health clinics.
D. Inpatient clinical policies shall be developed to apply to all inpatient care sites to promote consistency.
E. Clinical policies require multidisciplinary review and approval by the appropriate committee(s) before
implementation. All clinical policies must meet the standards outlined in the procedure described
F. The UW Health Clinical Policy Committee provides a system-wide platform for decision making on
clinical standards. The committee supports the development, approval, and distribution of all clinical
policies. The Chair of the committee and their respective staff will work in conjunction with the Center
for Clinical Knowledge Management (CCKM) to coordinate the review of all clinical policies. The UW
Health Compliance and Privacy Officer shall provide oversight to ensure that the committees perform
their respective functions as required by this policy.
G. There are two types of clinical policies: (a) UW Health-wide clinical policies are mandatory policies that
apply to all entities of UW Health regardless of facility or program, and (b) Departmental clinical
policies are also mandatory policies, but they may be developed separately from UW Health-wide
clinical policies by a specific department. Therefore these policies will only apply to members within
that department. The clinical policy shall state the population it applies to, UW Health-wide or the
specific department.


A. Clinical Policy Development Process.
i. Clinical policies may be developed by any discipline. The clinical policy resource guide,
approved by the UW Health Clinical Policy Committee, contains a style guide outlining the
minimum required components within a clinical policy.
ii. Clinical policies must have sufficient content and guidance to provide appropriate patient care
when implemented by a diverse practitioner group to create consistent patient outcomes.
iii. Clinical policies (including changes to clinical policies) should be developed in consultation
with CCKM. CCKM shall ensure that all clinical policies are evidence based, have undergone
multidisciplinary review, and are formatted properly before they are submitted for approval.

Policy Title: UW Health Clinical Policies
Policy Number: 1.1.1

Evidence-based in this context includes clinical trials, other published evidence and/or expert
a. Guidance from the CKM Council will be sought if controversies or discrepancies
occur, exist, or develop between clinical policies and CKM Council approved clinical
tools (clinical practice guidelines, delegation protocols, etc.).
iv. Clinical policies developed by individual departments must be structured, evidence based, and
consistent with UW Health-wide policy standards set forth by the clinical policy resource
a. When a department creates a clinical policy the department assumes responsibility
for the policy including receiving proper approval for the policy.
b. Departments with clinical policies in place prior to the transition to UW Health-wide
policies may keep their policies as long as they report their policies to CCKM for
cataloguing, maintain their policies with regular updates, and properly format the
policies per the style guide.
c. UW Health-wide policies take precedent over departmental policies if they speak to
same or similar topics.
d. Departmental policies only apply to members within the department.
B. Clinical Policy Approval Process
i. Because of their complex nature, clinical policies are reviewed by multiple bodies prior to their
final approval and implementation (refer to the Approval Algorithm in Appendix A).
ii. The approval process must involve committees relevant to the subject matter of the clinical
policy. Clinical policies with content that affects physician practice must go to the Medical
Board. This will be determined by the Chair and Vice Chair of the UW Health Clinical Policy
iii. All clinical policies will be reviewed and approved by the UW Health Clinical Policy Committee.
a. Under extraordinary circumstances email ballot approval may be utilized by the
committee. If this occurs ratification will take place at a subsequent committee
iv. The UW Health Chief Medical Officer (CMO) will provide final approval for all UW Health
clinical policies.
v. The UW Health CMO may request co-review of clinical policies (facilitated by CCKM) with the
President of UW Hospitals, the Associate CMO, other Medical Officers, and/or the Chief
Ambulatory Administrative Officer (CAAO).
vi. If the UW Health CMO decides not to approve a proposed clinical policy, the individuals
developing the policy will need to address the concerns with CCKM support as required.
vii. At this time Clinical Joint Ventures (CJV) will not be included in clinical policy development.
viii. Approved clinical policies will be catalogued and posted on the policy page of the UW Health
intranet through the collaboration of CCKM and eHealth.
C. Clinical Policy Communication, Training, and Initiation.
i. Announcements regarding approval of clinical policies will be made by CCKM through existing
vehicles of communication.
ii. Prior to the approval of a new or revised clinical policy, the author and executive sponsor of
the clinical policy, in collaboration with their department or area, should develop a plan for
implementation of the policy which should be presented to the Clinical Policy Committee with
the policy draft.
iii. After approval of a new or revised clinical policy, the author and executive sponsor of the
clinical policy, in conjunction with the originating department or area, are responsible for
communicating the presence of new clinical policies, revisions to clinical policies and for any
training involved in the implementation of the policy.
D. Review, Revision, and Discontinuation of a Clinical policy.
i. Clinical policies will be reviewed and updated by the author and sponsor at least every 3
years. The Chair of the Clinical Policy Committee may use discretion in extending review
deadlines to allow proper time for integration of clinical policies. Additional changes may be
requested outside of periodic review. The policy author, Senior Management Sponsor and
primary stakeholders will be notified of the requests and if changes are made, the clinical
policy will then need to go through the appropriate approval process as outlined in section
IV.B. Clinical Policy Approval Process.
a. Prior to formal approval of revisions to a policy, tests of change may need to occur to
determine whether the change in policy is appropriate and effective. Tests of change
must be defined in adequate detail in relation to specific content in policy and short
term in nature. Tests of change will not exceed 6 months in duration. Extensions can

Policy Title: UW Health Clinical Policies
Policy Number: 1.1.1

be granted if the circumstances surrounding the test of change warrant a longer
period of test. In order for tests of change to occur, adjustments will need to be made
to the affected policy in the form of an addendum posted alongside the current
version of the policy on the intranet. The addendum must define the timeline for the
test, indicate the specific content affected in the policy, identify the specific
population/location where the test will occur, and contain signature of approval.
Approval for tests of change must be provided (at a minimum) by the Chair and Vice
Chair of the Clinical Policy Committee and a representative of the Medical Board
(Medical Board President or CMO). Approved tests of change will be communicated
by the Chair of the Clinical Policy Committee to the Clinical Policy Committee.
ii. CCKM shall track the review, revision, maintenance and versioning of clinical policies.
iii. If a clinical policy is revised the changes will be communicated to all users and the new
version will be placed on UW Health's Intranet site. Any re-education or training to implement
the changes must be coordinated by the policy author.
iv. All previous versions of clinical policies will be archived indefinitely.
v. When a clinical policy is discontinued: staff and providers will be notified, the policy will be
removed from the policy page on the intranet, and the policy will be archived.


Appendix A: Approval Algorithm


Author: Director, Center for Clinical Knowledge Management
Senior Management Sponsor: UW Health CEO, Dean UWSMPH
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: June 20, 2016

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.


Peter Newcomer
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

Brian Arndt, MD
Vice Chair, UW Health Clinical Policy Committee

Next Revision Due: February 2018
Version: Revision