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UW Health Patient Care Delegation Protocols (1.2.8)

UW Health Patient Care Delegation Protocols (1.2.8) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care


Policy Title: UW Health Patient Care Delegation Protocols
Policy Number: 1.2.8
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 28, 2017


To provide a process for the development, approval, implementation, and routine multidisciplinary review of
patient care protocols that include delegated authority to initiate orders within UW Health inpatient and
ambulatory departments.


A. An ordering provider is defined as an individual authorized to issue an order or set of orders that are within
his or her scope of practice and, if applicable, clinical privileges.
B. A delegation protocol is a predetermined, unalterable set of clinical actions that address a specified clinical
problem allowing ordering providers to delegate medical acts to staff beyond their normal scope of practice.
A delegation protocol may include items where nurses, pharmacists, and other professionals may exercise
judgment based on the patient’s condition to only carry out certain steps when specific test results or
symptoms are present. Delegation protocols are not required for actions that are within a discipline’s
recognized scope of practice (e.g., dose adjustments for medication titration).
C. Note that the term “Protocol” is not exclusively reserved to the above meaning. The term is also used (a) for
research protocols that may not include sets of orders, (b) for structured approaches to professional and
technical practice matters that do not include sets of orders and (c) by Epic to refer to structured oncology
orders known as “Beacon protocols”. In addition there are “practice protocols” that are unalterable sets of
orders/steps that address a specified clinical problem that are within the scope of practice of the non-
ordering provider and do not involve delegation of medical acts. A practice protocol may include items where
nurses, pharmacists, and other professionals may exercise judgment based on the patient’s condition within
a discipline’s recognized scope of practice, for example, dose adjustments by nurses for medication titration.
D. Note that the “unalterable” in the definition refers to the fact that the non-ordering provider following the
protocol cannot deviate from the protocol and continue to act under delegated authority. In situations where
the delegation protocol no longer applies an ordering provider must be consulted for all further orders.


A. When a delegation protocol is approved under this policy, the ordering providers in the area where the
delegation protocol applies have delegated to the disciplines identified in the delegation protocol the
authority to carry out specific actions as outlined in in the delegation protocol.
i. Delegation protocols will identify which ordering provider is delegating authority to perform the
medical act(s) included in the protocol.
ii. If the delegation protocol is initiated by a provider’s order, the authorizing provider for the initiating
order is the delegated provider.
iii. If the delegation protocol is initiated by the patient condition, location or some other circumstance
(not by a specific order), the delegating provider will be identified in the delegation protocol as the
ordering provider responsible for managing the condition or providing care in the location or some
other means of identifying the delegating provider.
B. Delegation protocols may be developed by any healthcare discipline but each delegation protocol must have
(1) an originating department that assumes responsibility for it and (2) a standing committee of the Medical
Board responsible for the oversight of the delegation protocol.
C. Delegation protocols should be designed to apply to patient populations and should be consistent within a
specialty, service, or clinic. Protocols shall be developed in a collaborative fashion to support this
consistency of care.
D. Delegation protocols will not be approved for individual ordering providers or clinics within a service or
specialty. Individual providers and clinical areas cannot opt out of a protocol unless clinically indicated for a
specific patient nor can they chose to delegate differently from what has been approved. If there are
circumstances where the availability of a protocol needs to be restricted, the President of the Medical Staff
or the Chief Clinical Officer may suspend the availability of a protocol in some or all UW Health facilities by
written notice to the Medical Board, and the Chief Nurse Executive (CNE). The Medical Board may end all
or part of the suspension.

Policy Title: UW Health Patient Care Delegation Protocols
Policy Number: 1.2.8

E. The Director of the Center for Clinical Knowledge Management (CCKM) provides direct oversight of all
delegation protocols.
F. Delegation protocols require multidisciplinary review and approval by the appropriate committee(s) before
implementation. All delegation protocols must meet the standards outlined in the following procedure.
Delegation protocols may be initiated in two ways: either a specific provider order or the patient meeting
certain predefined conditions.
i. Protocols that require a specific provider order to be initiated are considered “opt-in”. For example,
the Warfarin management protocol is initiated by the provider placing the “Enroll in Anticoagulation”
order. The orders to implement the protocol must be reviewed and reapproved by the ordering
provider no less than once per year.
ii. Protocols that are initiated when the patient meets certain criteria are considered “opt-out”.
Examples of conditions which might qualify a patient for inclusion in an “opt-out” protocol are
previous provider orders for a specific medication or orders for previsit planning.
G. In situations where orders require co-signature (e.g., Medical Assistant orders that automatically route for
co-signature), orders authorized by the delegation protocol may be carried out prior to obtaining the co-


A. Delegation Protocol Development Process.
i. Delegation protocols may be developed by any healthcare discipline. The Delegation Protocol Style
Guide, approved by the Clinical Knowledge Management Council, contains a template outlining the
minimum required components within a delegation protocol.
ii. Delegation protocols must be designed so that they can be carried out safely within the skill set of
the care providers designated to implement the delegation protocol. When care providers are
directed to apply delegated judgment, the judgment should be within the scope of their practice. If
special training or competencies must be demonstrated, those aspects of the delegation protocol
should be limited to care providers who have that training and/or demonstrated that competency.
iii. Delegation protocols must have sufficient content and guidance to provide appropriate patient care
when implemented by a diverse practitioner group. For example, a delegation protocol which states
“adjust anticoagulant therapy as required” would be insufficient content and guidance to create
consistent patient outcomes, unless the delegation protocol also contains specific guidelines or
clear documentation to define how the anticoagulation therapy would be implemented, monitored
and adjusted.
iv. Delegation protocols (including changes in delegation protocols) should be developed in
consultation with the Center for Clinical Knowledge Management. The CCKM shall ensure that all
delegation protocols are evidence based, have undergone multidisciplinary review, and are
consistent with the template and meet other style guidelines before they are submitted for approval.
Evidence-based in this context includes clinical trials, other published evidence and/or expert
B. Delegation Protocol Approval Process
i. Because of their complex nature, delegation protocols are reviewed by multiple bodies prior to their
final approval and implementation (refer to the Appendix A, Delegation Protocol Approval Process).
ii. The specific approving bodies are determined by the location of the protocol, the nature of the
delegated actions and the discipline of the staff authorized to carry out the protocol.
a. Ambulatory delegation protocols must be reviewed by the UW Health Ambulatory Protocol
b. Delegation protocols affecting nursing must be reviewed by the designated nursing council
or as designated by the Chief Nursing Officer.
c. Delegation protocols involving clinical laboratory orders must be reviewed by the UW
Health Laboratory Practice Committee or as designated by the Clinical Laboratories
Medical Director.
d. Delegation protocols containing medication orders must be reviewed by the Pharmacy
and Therapeutics Committee. Delegation protocols pertaining to anti-infective or
anticoagulation therapy must be reviewed by the Antimicrobial Use and Anticoagulation
Subcommittees, respectively.
iii. The approval process must involve at least one Medical Board Standing Committee (e.g.,
Pharmacy and Therapeutics Committee, Respiratory Care Committee, etc.). If no such committee

Policy Title: UW Health Patient Care Delegation Protocols
Policy Number: 1.2.8

is applicable for the protocol content, the protocol will be reviewed by the Clinical Knowledge
Management Council.
iv. The Medical Board will review all delegation protocols. For ambulatory delegation protocols, final
approval is made by the Chief Clinical Officer. The Associate Chief Medical Officer will provide final
approval for all inpatient delegation protocols.
v. If the Medical Board, Chief Clinical Officer/Associate Chief Medical Officer or any approval bodies
decide not to approve a proposed delegation protocol, the CCKM shall follow-up with the
individuals developing the protocol to address concerns.
vi. Approved delegation protocols will be posted on the designated location on UW Health’s intranet
and internet websites.
vii. Subsequent Reviews – If in subsequent reviews of an approved delegation protocol there are no
changes or only minor changes which do not impact the scope of the delegated act, the Director of
CCKM may, with concurrence of Medical Leadership, approve the revised protocol without
resubmitting to the committees identified above for re-approval. (Confirmation acceptance verbiage
“Per the UW Health policy on delegation protocols, an expedited review process can be used to
approve delegation protocols that are unchanged (when up for scheduled review), or have changed
in ways that do not substantially alter the nature or scope of delegation being authorized. The
expedited approval requires positive response from the CCKM Director, the delegation protocol
champion(s), the chairs of the final approving committees (including the President of the Medical
Board, the Chief Clinical Officer for ambulatory protocols and the Associate Chief Medical Officer
for inpatient protocols. Expedited reviews can occur no more than two times before needing full
committee review.
viii. Pilots – If needed, small scale pilots of delegation protocols are allowed. The pilot must be either
for a limited term, not to exceed 6 months or limited scope, i.e., a small number of clinics or
inpatient care units. Full approval is not required prior to initiating the pilot. Instead the Director of
CCKM in concurrence with Medical Leadership may approve the pilot delegation protocol. Upon
completion of the pilot, the delegation protocol must go through the full approval process before it
can be fully deployed.
ix. Clinical Joint Ventures (CJVs) – Delegation protocols developed for use at clinical joint ventures
sites (e.g. Madison Surgery Center Inc., Wisconsin Dialysis Inc., Transformations Surgery Center
Inc., Generations Fertility Care Inc., Wisconsin Sleep Inc., Chartwell Wisconsin Enterprises, Inc.,
UW Health Rehabilitation Hospital ) must be approved in the manner required by their individual
governing bodies before implementation. If the delegation protocol will only be implemented at
CJVs, the protocol will follow the standard development process and be in the standard template
but will not need approval by the Medical Board or Medical Board Standing Committees. If the
protocol will apply to both UW Health sites and CJVs, the protocol will then need approval by the
process in B.i-iv above and in the manner required by the applicable CJV governance bodies.
C. Delegation Protocol Communication, Training, and Initiation
i. After approval of the delegation protocol or delegation protocol change, the originating department
in conjunction with the CCKM is responsible for communicating the availability of new or updated
delegation protocols and for any training.
ii. Training should include the steps required to activate the delegation protocol for a specific patient,
inclusion and exclusion criteria and specific actions covered by the delegation protocol.
iii. Notification of a Provider – All delegation protocols implemented without a written provider order
must specify the expectations for communicating activation of the delegation protocol with the
ordering provider (e.g., note in medical record, order in the medical record or phone call to
iv. If the clinical situation of the patient does not meet the specific criteria of the delegation protocol,
the delegation protocol does not apply and any orders must be given by an authorized provider.
D. Delegation Protocol Documentation
i. Individual orders resulting from implementation of a delegation protocol and the relevant clinical
information will be documented, signed, dated, and timed in the patient’s medical record. The
orders will then be entered in Health Link using the order mode specified in the delegation protocol.
ii. When an authorizing provider and/or diagnosis is required for an order (e.g., ambulatory laboratory
orders), delegation protocols that permit initiation before a provider order shall specify how the
authorizing provider and/or diagnosis will be selected.
iii. An authorizing provider shall document approval of the use of the delegation protocol in one of the

Policy Title: UW Health Patient Care Delegation Protocols
Policy Number: 1.2.8

ways permitted in the delegation protocol.
E. Review, Revision, and Discontinuation of a Delegation Protocol.
i. Delegation protocols will be reviewed and updated by the author and physician champion at least
every 3 years. Additional changes may be requested outside of the periodic review. The protocol
champion(s) and primary stakeholders will be notified of the requests and if changes are made, the
delegation protocol will then need to go through the appropriate approval process as outlined in
section IV.B. “Delegation Approval Process.”
ii. The CCKM shall track review, revision, maintenance and versioning of delegation protocols.
iii. If a delegation protocol is revised the changes will be communicated to all users and the new
version will be placed on U-Connect and also placed on the public-facing web portal on
iv. All previous versions of delegation protocols will be archived indefinitely.
v. When a delegation protocol is discontinued, staff and ordering providers will be notified and it will
be removed from U-Connect and web portal on uwhealth.org.


A. Ordering providers practicing at UW Health facilities who prescribe medications delegate the authority to
issue renewal prescriptions to designated staff as specified in the approved prescription renewal protocol,
unless the prescribing provider writes an order for the patient which states no renewals by protocol.
B. There is one delegation protocol covering all departments and specialties. Protocols may not be created for
individual providers or clinics within a service or specialty or for individual departments.
C. Renewal of controlled substances may not be delegated. A provider with a Drug Enforcement
Administration (DEA) number must sign renewal orders for controlled substances.
D. The authority to renew prescriptions may only be delegated to UW Health staff qualified to safely and
appropriately evaluate requests for prescription renewal, apply this protocol and document those renewals.
Eligible individuals include:
i. Registered Nurses (RNs)
ii. Pharmacists (RPhs)
iii. Medical Assistants (MAs)


A. Consideration may be given to the available staff in clinical areas.
B. Consideration may be given to differences in the acuity of patients seen in clinical areas.
C. Consideration may be given to the specialty nature of the care provided in some areas (e.g., separate
medication adjustment protocols for diabetes primary and specialty clinics; separate protocols for transplant


Author: Director, Center for Clinical Knowledge Management
Senior Management Sponsor: Vice President, Performance Excellence
Approval committees: Clinical Knowledge Management Council; UW Health Clinical Policy Committee;
Medical Board
UW Health Clinical Policy Committee Approval: November 20, 2017

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, MD
UW Health Chief Clinical Officer

Policy Title: UW Health Patient Care Delegation Protocols
Policy Number: 1.2.8

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


Delegation Protocol Resource Guide


Version: Revision
Last Full Review: December 28, 2017
Next Revision Due: December 2020
Formerly known as: UWHC policy #8.93