Security Management Plan

Effective Date: 08/2016 Page 1 of 5

Review date(s): 05/2017, 08/2017

I. Table of Contents

I. Table of Contents
II. Purpose Statement
III. Scope
IV. Objectives
V. Related Policy
VI. Authority/Reporting Relationships
VII. General Provisions
VIII. Risk Assessment
IX. Staff Development
X. Emergency response and procedures
XI. Inspection, testing, and maintenance
XII. Information collection and evaluation process
XIII. Performance monitoring
XIV. Annual evaluation

II. Purpose Statement

The mission of the Security Management Plan is to provide and promote the safest possible physical
environment using a systematic approach based on the mission and vision of UW Health (UWH).
Consistent with this mission, the UWH Authority Board, medical staff, and administration have established
and provided support for the Security Management Plan described in this program.

The purpose of the Security Management Plan is to describe how the organization will provide and
maintain a safe physical environment and manage staff activities to reduce the risk of personal injury and
property loss.

III. Scope

The Security Program is designed to manage the security risks the environment of UWH presents to
patients, staff, and visitors. The program is designed to assure identification of general and high security
risks and to develop effective response procedures. The safety and security of all patients, visitors,
employees, physicians and property is important and essential in providing safe patient care
environment as part of the hospital's mission. The potential for the occurrence of incidents which can
impact the safety and security of an organization should be identified and appropriate response
measures be implemented to prevent or reduce the impact.

Security provides presence and response at the University Hospital (UH), American Family Children’s
Hospital (AFCH) and The American Center (TAC), Urgent Cares, and ambulatory facilities 24 hours per
day, seven days a week. The in-house security staff is unarmed and will not engage in any type of law
enforcement action. In the event law enforcement services are needed a request will be made to the
designated agency within the jurisdiction. Assignment of security officers will encompass the categories
of patrol and response, with fixed assignments in the Security Dispatch Center, Emergency Department,
and AFCH Security Office. Security patrol activities include, but are not limited to, crime prevention, fire
prevention, identification of maintenance problems and safety hazards and surveillance of various hospital
areas.

IV. Objectives
A. To provide a visible uniformed security presence to deter crime and increase security to patients, visitors,
and staff.

B. To assess risks and identify potential problems in an effort to reduce crime, injury, and other incidents.

C. Analyze security incidents and other data to predict and prevent crime, injury, and other incidents.

D. Train staff to recognize and report potential or actual security incidents to ensure a timely response. Staff
in sensitive areas are trained about the protective measures designed for those areas and their
responsibilities to assist in protection of patients, visitors, staff and property.

E. Staff will be educated on workplace violence and the appropriate response, reporting, and available
resources.
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Effective Date: 08/2016 Page 2 of 5
Review date(s): 05/2017, 08/2017

V. Related Policy(ies)
Policy 1.15 Restricted Areas
Policy 1.27 Parking Policy
Policy 4.26 Weapons and Controlled Substances
Policy 7.27 Management of Patient Belongings
Policy 9.57 Workplace Violence Planning & Prevention
Policy 9.58 Workplace Violence Reporting, Investigation & Discipline
Policy 9.60 New Employee Orientation
Policy 11.19 Regulation of Vendor Representatives and the Vendor Liaison Office
Policy 12.57 Key Control
Policy 12.64 UWH Environment of Care Safety Program
PolicyPolicy 3.3.5 Participation of Patients’ Primary Support and
Visitors
Policy 3.2.1 Patient Identification

VI. Authority/Reporting Relationships

A. UWH has identified the Security Director to coordinate the development, implementation, and monitoring
of the security management activities.

B. The Security Director

1. The Security Director works under the general direction of the VP of Facilities & Support Services.
2. The Security Director in collaboration with other department managers, and the EC Committee,
manages all aspects of the Security Program.
3. The Security Director advises the EC Committee regarding security issues that may necessitate
changes to policies, orientation/education, and purchase of equipment.

C. The VP of Facilities & Support Services collaborates with the Security Director to establish operating and
capital budgets for the Security Program.

VII. General Provisions

A. Timely response to reports of violent activity or requests for assistance with difficult and challenging
patient and family situations, assist in restraining violent or aggressive patients or visitors.

B. Provide escorts, keys and door openings, or other requests for security services.

C. Vehicle movement on hospital grounds is controlled, including control of parking and access to the
Emergency Department.

D. Access to the grounds, buildings, and sensitive areas is limited by enforcement of staff and visitor
identification policies and by participating in the design of processes to minimize unauthorized access.

E. Appropriate and timely action is taken to prevent crime, injury, or property loss.

F. I.D Program
1. The Security Director coordinates the identification program for UWH employees, staff and
contractors. The Vendor Liaison Officer manages the identification of vendors and observers
identified in Administrative policy 11.19. All UWH managers enforce and support the enforcement of
the identification program.
2. All employees are required to display an identification badge on their upper body while on duty. ID
badges are issued to employees at New Employee Orientation. Identification badges are to be
displayed picture side out. Personnel who fail to display identification badges are addressed
individually by their department managers. Identification badges are collected and access removed
from employees upon termination.
3. Visitors to adult inpatient areas are not normally expected to have identification. After hours visitors
must be approved by the patient or designee and must wear a visitor badge. Visitors to the AFCH
inpatient units are issued visitor passes/badges through Security. All employees assist in
enforcement of visitor identification.
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Effective Date: 08/2016 Page 3 of 5
Review date(s): 05/2017, 08/2017

4. Upon admission all patients are provided with identification bands worn on their wrist or ankle to
maintain positive ID in accordance to UWH Clinical Policy 3.2.1.

G. Sensitive Areas
The Security Director works with leadership to identify security sensitive areas. The following
areas are designated as sensitive areas:
1. Psychiatry
2. Areas where cash is handled
3. Emergency Department
4. Human Resources
5. Children's Hospital
6. Pharmacies
7. Areas with a high volume of forensic patients
Personnel are reminded periodically about those areas of the facility that have been designated
as sensitive. Personnel assigned to work in sensitive areas receive department level continuing
education which focuses on special precautions or responses that pertain to their area.
Preventative security measures are taken in sensitive areas by adjusting the schedule of locking
and unlocking areas, creating funnel areas, installation of a card access system, monitoring of
intrusion alarms, routine patrols, surveillance cameras, and panic/duress buttons.

H. Child or Infant Abduction Prevention and Response

1. UWH has designed and implements security procedures that address the precautions for preventing,
and the plans for handling of a pediatric abduction. Staff receives ongoing training and drills to
maintain their awareness. Parents and other designated visitors are also informed of the precautions
and their role.
2. The UWH Emergency Operations Plan Annex L: Missing or Abducted Child provides procedures for
response to a missing or abducted child.
3. The plan is tested periodically, and the responses documented, evaluated, critiqued, and as
appropriate corrective activity, additional training, or program improvements are made.

I. Release of Information
If there should be media inquiries or other requests for information from external parties during or after a
security incident, UWH Marketing and Corporate Communications is the designated department authorized
to make a release. Should a request come from law enforcement; Security will consult with Legal
Services.

J. Vehicular Access to Emergency Care Areas

1. UWH has designed and implemented security procedures to control vehicular access to the Emergency
Department.
2. The University of Wisconsin Parking and Transportation Services Department works with the Security
Director to manage parking on the University Hospital campus. UW Parking and Transportation
enforces parking regulations. UW Police will also enforce parking regulations in urgent situations.
3. During severe snow, emergency care areas are regularly cleared of snowfall, and during emergency
plan implementations (disasters).

VIII. Risk Assessment

A. The potential for workplace violence is evaluated as part of risk assessment, and programs are developed
to manage it.

B. UWH conducts proactive risk assessments to evaluate the potential for adverse impact on the security of
patients, staff, and other people coming to the organization's facilities. Among the elements that are
evaluated is the potential for workplace violence. The Risk Assessments are used to evaluate current
programs, and help identify new programs and activities to better protect the patients, staff, and the
organization.

IX. Staff Development

A. All new employees are required to complete orientation training, which includes all seven management
plans within the Environment of Care (EOC). This orientation is augmented by work area specific training,
which focuses on the work area safety policies and is provide under the direction of the immediate
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Review date(s): 05/2017, 08/2017

supervisor. All employees are also required to participate in annual update training. Additional in-service
or on-going training is provided as necessary to address new safety procedures, information or
expectations.

B. New Employee Orientation (NEO)

All new employees of UW Health are required to attend New Employee Orientation (NEO) their first
scheduled day of work. New employee orientation addresses key issues and objectives of all seven areas
of the EOC including the role each area and staff play in the overall safety program. Training records for
NEO are kept by Human Resources.

C. Department Specific Training

1. Employees receive departmental safety orientation at their respective work areas regarding hazards
and their responsibilities to patients, visitors and co-workers.
2. Department Directors and managers need appropriate information and training to develop an
understanding of safe working conditions and safe work practices within their area of responsibility.
The Safety Department is a resource for this information.
3. Department Managers are responsible for orienting new staff members to the department and, as
appropriate, to job and task specific safety procedures, and for investigation of incidents occurring in
their departments. When necessary, Safety Officer provides department Managers with assistance in
developing department safety programs or policies.
4. Individual staff members are responsible for learning and following job and task specific procedures
for safe operations.

D. Annual Continuing Education

Safety and Infection Control (SIC) Training is mandatory training for all staff, including physicians. Topics
from all seven management plans include current issues. This training is delivered via Computer-based
Training (CBT) and is tracked through the Learning Development System (LDS).

X. Emergency response and procedures

A. UWH has developed and maintains a written management plan describing the processes it implements to
effectively manage emergencies affecting the facility, patients, staff, and to respond to emergencies in the
community that cause an influx of patients.

B. Response is provided for emergencies and requests for assistance in a timely fashion. Crime, fire, injury,
or other incidents are reported and documented. Communication is maintained externally with local, state,
or federal law enforcement and other civil authorities. Internal communications are provided as needed.

C. UWH has designed and implements security procedures that address actions taken in the event of a
security incident. These include:
1. Responses for normal activities (such as door opening, and escorts).
2. Urgent activities (such as requests for assistance and stand-by reports of theft and other crime).
3. Emergency responses (such as active violent intruder, combative or violent individuals, fire alarms,
disasters, and similar activities).

D. General policies for these types of events provide guidance for Security staff, and other hospital staff, and
as necessary provide processes to inform leadership, and as needed implement hospital wide emergency
activity (such as implementing the emergency management plans). In addition, the Security Department,
and other staff are trained and respond to specific emergency management plan codes, as defined in
those plans.

XI. Inspection, testing, and maintenance

A. Security Officers perform routine security checks of UWH to identify and document potential or actual
problems.

XII. Information collection and evaluation process

A. The documentation system for security incidents is managed and used to provide appropriate reports to
leadership and the UWH Environment of Care Safety Committee.

B. Security department activity; including investigations, routine patrol activity, special and routine requests
for assistance, and other activities are appropriately documented through records retention software
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Effective Date: 08/2016 Page 5 of 5
Review date(s): 05/2017, 08/2017

C. UWH uses information from the risk assessment and other sources to select, develop and implement
procedures, activities, and to reduce the probability of security incidents.

D. The EC Safety Officer coordinates the collection and analysis of information about each of the EC
management programs. The information is used to evaluate the effectiveness of the programs and to
improve performance. The information collected includes deficiencies in the environment, staff knowledge
and performance deficiencies, actions taken to address identified issues, and evidence of successful
improvement activities.

XIII. Performance monitoring

A. Security policies and procedures are established and maintained to direct staff performance when
responding to security incidents. Security policies are reviewed and updated when needed by
Security Leadership.

B. The Security Director reports monthly to the UWH Environment of Care Safety Committee about security
issues, trends, significant events, and department initiatives. The Security Director makes periodic
reports of Security incidents involving patients, staff, or others coming to the organization's facilities or
property, to the EC Committee. The reports summarize findings of Patient Safety Net (PSN) incident
reports and other information of security information.

C. The EC Safety Officer is responsible for distributing quarterly reports of performance and experience for
the EC Committee. The reports include ongoing measurement of performance, and summary reports of
incidents, including the results of any Root Cause Analysis (RCA) of Sentinel Events. The EC Safety Officer
establishes performance indicators to objectively measure the effectiveness of the Security program. The
EC Safety Officer utilizes quarterly benchmarking and determines appropriate data sources, data collection
methods, data collection intervals, analysis techniques and report formats for the performance
improvement standards to identify opportunities to improve the Security program.

XIV. Annual evaluation

A. An annual evaluation of the scope, objectives, performance, and effectiveness of the program is conducted
and documented.

B. This plan is evaluated annually, and changed as necessary, based on changes in conditions, regulations
and standards, and identified needs.

C. The EC Safety Officer and managers responsible for the design and implementation of the EC programs
perform an annual review of each EC management plans. The review evaluates the plan to determine if
changes created a need to revise the plan.

D. The EC Safety Officer is responsible for coordinating the annual evaluation of the seven functions
associated with Management of the EC.

E. Annual evaluations examine the scope, objectives, performance and effectiveness of the Security
program. The annual evaluation uses a variety of information sources including: internal policy and
procedure review, incident report summaries, EC Committee meeting minutes and reports, and summaries
of other activities. In addition, findings by outside agencies such as accrediting or licensing bodies, or
qualified consultants are used. The findings of the annual evaluation are presented in a narrative report
supported by relevant data. The report provides a summary of the Security program's performance over
the preceding 12 months. Strengths are noted and deficiencies are evaluated to set goals for the next
year.

F. The annual evaluation is presented to the EC Committee. The Committee reviews and approves the report.

G. Discussions, actions and recommendations of the Committee are documented in the minutes. The
annual evaluation is distributed to the Chief Executive Officer, the Performance Improvement Risk
Management & Safety Committee (PIRMS), and other Department Managers as appropriate. Once the
evaluation is finalized, the Security Director is responsible for implementing the recommendations in the
report as part of the performance improvement process.