/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/administrative/,/policies/clinical/uw-health-clinical/administrative/event-reporting-and-grievance/,

/policies/clinical/uw-health-clinical/administrative/event-reporting-and-grievance/131.policy

201509261

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Administrative,Event Reporting and Grievance

Chain of Command for Concerns About Patient Care (1.3.1)

Chain of Command for Concerns About Patient Care (1.3.1) - Policies, Clinical, UW Health Clinical, Administrative, Event Reporting and Grievance

1.3.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Chain of Command for Concerns About Patient Care
Policy Number: 1.3.1
Category: UW Health
Type: Inpatient
Effective Date: July 23, 2015

I. PURPOSE

To insure that both nursing and patient care staff members have a uniform method to notify physicians of
concerns related to patient care.

II. POLICY ELEMENTS

Physician staff w ill be informed of patient care concerns in a systematic manner in accordance w ith these
procedures.

III. PROCEDURE

A. All nursing units and patient care staff w ill have a call schedule of the primary services for that unit along
w ith pager numbers. An up to date list can be obtained from paging at 262-2122 or online at WEB PAGING
at all times.
B. For issues requiring physician notif ication and/or intervention, the nursing or patient care staff caring for the
patient w ill notify physicians in this order:
i. Resident on call
ii. Senior Resident or Fellow on call
iii. Attending Physician on call
iv. Medical Director of the Unit as appropriate, Section Chief, Division Head or Department Chair
v. Sr. Vice President Medical Affairs
vi. If the Sr. Vice President Medical Affairs is unavailable, the back up w ill be the Sr. Vice President
Patient Care Services and Chief Nursing Officer.

At each level, if the nurse or patient care staff does not believe there is resolution of the patient
care issue or if the physician at that level is not available, the nurse or patient care staff w ill then
call the physician at the next level.

C. If the problem remains unresolved after this procedure, the Care Team Leader/Senior Team Member or
charge nurse w ill notify Nursing Management according to the follow ing protocol:
i. Day Shift: the Nurse Manager and/or Clinical Director.
ii. Weekend and Evening/Night Shifts: The Nursing Coordinator is called f irst. The Nurse Manager
and/or Clinical Director and/or Nursing Administrator on call may also be involved if indicated.
D. Issues that remain unresolved after these procedures have been follow ed w ill be addressed by involved staff
and/or management w ith the Department Head of the Clinical Department, Sr. Vice President Patient Care
Services and Chief Nursing Officer, follow ed by the Sr. Vice President Medical Affairs.
E. Documentation of concerns/actions about patients, time frames and persons notif ied should be
professionally and clearly documented in the patient’s medical record.
F. All other disciplines should notify their supervisors and/or department heads w hen there are patient care
issues that remain unresolved.

IV. COORDINATION

Author(s): Director of Nursing Quality, Regulatory Compliance, Labor Relations and Facility Planning
Senior Management Sponsor: SVP, Patient Care Services and Chief Nursing Officer
Review ers: Sr. Vice President Medical Affairs; Nursing Executive Council
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: March 16, 2015

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.



UW HEALTH CLINICAL POLICY 2
Policy Title: Chain of Command for Concerns About Patient Care
Policy Number: 1.3.1


V. APPROVAL

Christopher Green, MD
SVP Medical Affairs and CMO

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

VI. REVIEW DETAILS
Version: Revision
Next Revision Due: July 23, 2018
Formerly Know n as: Hospital Administrative policy #7.43