New and Revised Policies

Medical Center New and Revised Policies

University New and Revised Policies

Augusta University Policies that were approved in October 2016

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  • Outside Professional Activities (v.2)
    Outside professional activity by faculty or administrators is to be encouraged under appropriate circumstances. However,  since  faculty and  administrative  personnel  have  committed  their primary professional effort to the university, the university has theresponsibility to limit and regulate  such activity. With  certain  exceptions, faculty members are  required  to obtain  the permission  of  the  university  prior  to  engaging  in  outside  professional  activity  and  to  make periodic summary reports on such activity. This policy defines the types of outside professional activities allowed and outlines the procedures for obtaining permission from the university and for reporting such activities to the university.
  • Policy for Responding to Allegations of Research Misconduct (v.1)
    Augusta University expects that all its members maintain the highest standards of ethics in the pursuit of their scholarly endeavors, and accordingly bears responsibility for the prevention, investigation and adjudication of research misconduct. Any form of research fraud is contrary to the institution’s principles and adversely effects the institution and its reputation.  

    The purpose of this policy and procedures is to promote the integrity of research conduct on behalf of Augusta University (“University”) by its faculty, technical staff, residents, fellows, students, trainees, and individuals employed on a contractual basis by providing a process for close scrutiny of alleged research misconduct, for full protection of the rights of any person accused of research misconduct, and for the protection of any person who makes allegations under this policy in good faith.
  • Electronic Data Storage Backup (v.2)
    In order to protect institutional data against loss or destruction, it is required that such data be created  and stored within the system of record utilizing an Information Technology  (IT) approved data storage device (e.g. storage area network space, a shared or home directory). All  contracted  service  providers,  personnel and  students that  establish  or  create electronic data  outside  of  the  IT  storage  service  shall define,  document,  and  implement  a  backup procedure.  Department Heads will assume the role of data trustee for their department’s data and will appoint a data steward and manager. 
  • Sexual Misconduct (v.4)
    Augusta University is committed to ensuring a safe learning environment that supports the dignity of all members of the Augusta University community. Augusta University does not discriminate on the basis of sex or gender in any of its education or employment programs and activities. Augusta University will not tolerate sexual misconduct, which is prohibited, and which includes, but is not limited to, domestic violence, dating violence, sexual assault, sexual exploitation, sexual harassment, and stalking. These policies and procedures are intended to ensure that all parties involved receive appropriate support and fair treatment, and that allegations of sexual misconduct are handled in a prompt, thorough and equitable manner.

    Prevention is one of the primary mechanisms used to reduce incidents of sexual violence on campuses. USG institutions are required to provide prevention tools and to conduct ongoing awareness and prevention programming and training for the campus community including students, faculty, and staff. Such programs are designed to stop sexual violence through the promotion of positive and healthy behaviors. Programming will educate the campus community on consent, sexual assault, alcohol use, dating violence, domestic violence, stalking, bystander intervention, and reporting.
  • Cost Transfer Policy (v.4)
    This policy establishes requirements for processing transfers of direct costs to or from or between sponsored accounts. Federal regulations, generally accept accounting principles, and good management practices require that all costs incurred be appropriate to and for the direct benefit of the project charged, and that accounting records be maintained in a timely and accurate basis. Audit reports routinely question or disallow cost transfers, in particular those that are frequent, tardy, unexplained, inadequately explained, or insufficiently documented. The accuracy of charges made to sponsored program accounts is a key aspect of sound financial management and a significant measure of adequate financial control.

    In accordance with OMB Circular A-81, or the Uniform Guidance (2 CFR Part 200), it is necessary to explain and justify transfers of charges onto sponsored awards, where the original charge was previously recorded elsewhere on the University’s General Ledger. Timeliness and completeness of the explanation of the transfer are critically important factors in supporting the reasonableness, allowability, and allocability of charges made to sponsored accounts in accordance with the Uniform Guidance.
  • Multiple Graduate Degrees (v.1)
    While applicants who are not yet enrolled at the graduate-level at Augusta University may apply to more than one (1) program during the application process, a new student can matriculate initially only into a single program (primary) before they can be admitted to an additional graduate program (secondary).

    Students who have matriculated into a primary program must always receive permission from their primary program and their proposed secondary graduate program (including established dual degree programs) before applying for admission to any secondary program. If either program is part of The Graduate School (TGS), the student must also receive permission from TGS before applying as well.

University Policies that were approved in July 2016

  • No new University policies.

Medical Center Policies that were approved in
October 2016

  • Academic Education for Children
    Hospital / Homebound instruction programs are used for students who have a medically diagnosed condition that will significantly interfere with their education and requires them to be restricted to their home or a hospital for a period of time. During the academic school year, the hospital will arrange for school age children or youth currently enrolled in a school system to receive academic education outside their regular classroom, based on length of stay and condition in accordance with law and regulation.
    Approved: 10/20/2016
  • Contracted Patient Care Services (v.2)
    AU Medical Center will have a systematic process for developing agreements and contracts for any patient care related services. A review, approval and monitoring process will be in place to assure the appropriate individuals have input into the development of the contract, as well as the ongoing administration of the agreement.
    Approved: 10/15/2016
  • AU Medical Center Emergency Operations Plan (v.1)
    Emergencies or disasters may occur at any time on or near AU Medical Center (AUMC) locations. Types of emergencies or disasters range from technological or natural disasters to civil disturbances. Regardless of the type of emergency or disaster, the initial activation and implementation of the AUMC Emergency Operations Plan (EOP) should always be the same. Because stress and confusion are to be expected at the emergency scene, quick, efficient implementation of the plan will provide clear directions, responsibility, and continuity of control for key offices.
    Approved: 10/19/2016
  • Allow Natural Death and Do Not Resuscitate (AND/DNR) (v.1)
    The patient who requests DNR status and the attending physician who writes the DNR order understands that resuscitation means providing full resuscitative measures for cardiac arrest.
    Approved: 10/06/2016
  • Peer Review Committee and Peer Review Process Policy (v.2)
    This policy is to ensure that AU Medical Center (AUMC), through the activities of its professional staff, conduct and document peer review for quality of care provided by the Licensed Independent Practitioner in AUMC. This policy applies only to protected peer review activities completed for quality management purposes.
    Approved: 10/03/2016
  • Physician Orders for Life-Sustaning Treatment (POLST) and Limitations of Care (v.1)
    Patients have the right to make determinations about their medical treatment when competent and capable of doing so. A conscious patient who can communicate his/her wishes regarding medical treatment contemporaneously or in advance to their provider is preferred. A patient may express their medical preference in an advance directive for health care, Physicians Order for Life-Sustaining (POLST) or by a representative of the patient acting with legal authority. The POLST form was developed to enable seriously ill patients to designate which specific life sustaining treatments they want and to ensure that those wishes are honored by medical professionals. The POLST form should be used as a means of translating end-of-life discussions with patients into actual treatment decisions. Nothing in this policy should be understood to contradict an Allow Natural Death (DNR) Order or AU Medical Center’s policy on “Allow Natural Death/(DNR).” This policy should be read in conjunction with the “Allow Natural Death (DNR)” Policy.
    Approved: 10/06/2016
  • Reflex and Composite Testing in the Clinical Pathology Laboratory (v.1)
    AU Medical Center and their Medical Staffs endorse the routine use of the following reflex and composite tests by the Clinical Pathology Laboratory. It is understood that an ordering physician can limit such testing on any submitted specimen by so marking the requisition form or adding an order comment in CPOE. Tests performed by reflex will be billed in accordance with current institutional and payer guidelines and policies. This Policy applies to those tests specifically stated below that are performed in the Clinical Pathology Laboratory or its reference laboratories.
    Approved: 10/28/2016
  • Lactation Support Policy (v.2)
    AU Medical Center (AUMC) recognizes the well documented health advantages of breastfeeding for infants and mothers and the critical nature of workplace support for breastfeeding success, as well as the importance of setting a positive example in support of AU Medical Center employees. The AU Medical Center Lactation Support Policy contains the minimum standards needed for workplace support of the breastfeeding or expressing mother.
    Approved: 10/12/2016
  • Workforce Reduction Policy (v.1)
    It is the policy of AU Medical Center (AUMC) to avoid reductions in workforce whenever possible. However, changing economic circumstances and/or strategic initiatives may require a reduction in workforce levels. If a workforce reduction becomes necessary, AU Medical Center will follow an orderly process to reduce its workforce while adhering to the organization’s commitment to deliver the highest quality patient care in the most cost effective ways. In addition, AU Medical Center shall comply with all applicable laws and policies in carrying out any reduction in workforce.
    Approved: 10/12/2016
  • Sample Medications
    In efforts to ensure patient safety, sample medications will be procured, stored and dispensed via the procedures described below in compliance with all legal and regulatory guidelines as well as hospital policies and procedures.
    Approved: 10/28/2016
  • Infant Feeding Policy
    AU Medical Center recognizes that breastfeeding and human milk are the normative standards for infant feeding, nutrition and perinatal care. Acknowledgment of the evidenced short and long-term health advantages of breastfeeding for mothers and infants makes this policy necessary.
    Approved: 10/28/2016
  • Emergency Eye Wash Policy (v.1)
    Drenching and/or flushing equipment will be provided in areas where there is reasonable potential for exposure to injurious materials to provide minimum standard requirements for performance, use, installation, and testing of equipment that is used for emergency drenching and/or flushing of the eyes and body.
    Approved: 10/11/2016
  • FY2017 Emergency Management Plan (v.1)
    The mission of the AU Medical Center is to lead Georgia and the world to better health. AU Medical Center will focus on health assessment, wellness, and disease prevention through quality primary care services. AU Medical Center will facilitate the treatment of more complex healthcare needs through an integrated network of specialty providers and services.
    Approved: 10/19/2016
  • FY2017 Medical Equipment Management Plan (v.1)
    The purpose of the Medical Equipment Management Plan (MEMP) is to define the program to manage medical equipment maintenance and safety for patients, visitors, and staff.
    Approved: 10/19/2016
  • Interdisciplinary Plan of Care (v.1)
    The purpose of this policy is to establish the expectations for the development and communication of the Interdisciplinary Plan of Care.
    Approved: 10/09/2016
  • Nursing Documentation (v.1)
    The following nursing care documentation guidelines will be adhered to in order to assure care is provided to and documented for each patient based on a nursing assessment. The documentation of assessment, plan, intervention, and patient response should occur as close to the real time of occurrence as possible. The goal of the assessment is to determine the care, treatment, and services that will meet the patient’s initial and continuing needs.
    Approved: 10/09/2016
  • Nursing Staffing Plan (v.1)
    The intent of this policy is to define the processes for managing nursing staff to meet workload demands and to allocate resources.
    Approved: 10/09/2016
  • Code Cart Management (v.1)
    To assure that emergency supply carts containing age appropriate drugs, supplies, monitoring equipment used in the care and initial treatment of cardiopulmonary arrest victims, including emergency airway and defibrillator components, are available and ready for use.
    Approved: 10/18/2016
  • Venous Access Device Policy (v.2)
    This policy provides a framework to guide clinical practice as it relates to vascular access devices. It provides the actions to be followed to provide for appropriate and safe patient care.
    Approved: 10/28/2016
  • Exposure Reporting for Emergency Response Employees (v.1)
    The designated officer will be notified when one of their emergency response
    employees have been exposed to potentially life-threatening infectious diseases.
    Approved: 9/28/2016
  • Infection Prevention and Control Annual Risk Assessment and Plan (v.3)
    Approved: 10/28/2016
  • Low Level Disinfection (v.1)
    Reusable medical equipment will be disinfected between patient uses and according to
    manufacturer’s instructions for use. The patient’s environment is kept clean and
    disinfected regularly to prevent the spread of harmful pathogens amongst patients and
    healthcare workers, with each disciple having defined responsibilities.
    Approved: 9/28/2016
  • Patient Bloodborne Pathogen Exposure (v.3)
    This policy is to provide timely and appropriate follow-up in the event that a patient potentially is
    exposed to blood, body fluids, and other potentially infectious material (OPIM) during their
    course of treatment in the hospitals and clinics.
    Approved: 10/03/2016
  • Tru-D Rapid Room Disinfection (v.1)
    The Tru-D Rapid Room Disinfection Device will be deployed upon terminal cleaning of
    operating rooms involving select, high risk surgical cases (i.e. any orthopedic, trauma, or
    other implant related surgery) and other supporting areas with the ORs as much as
    Approved: 10/23/2016
  • Critical and Unexpected Result Reporting (v.2)
    Health care personnel will perform timely notification and proper verification with readback
    of critical and unexpected significant test results in order to reduce communication
    errors and thereby promote patient safety.
    Approved: 10/28/2016

Medical Center Policies that were approved in
July 2016

  • 3 South Admissions Criteria (v.1)
    This policy addresses clinical admission and exclusion criteria requirements necessary in the determination of individual's necessity and appropriateness for inpatient admission to the acute care Adult/Geriatric Behavioral Health Unit(s) Psychiatric/Mental health care providers involved in the initial assessment of the individual must follow the requirements outlined in this document for determining the need for acute care and stability treatment.
    Approved: 07/28/2016
  • Anticoagulation Management Guidelines for the Adult Perioperative Surgical Setting  (v.1)
    The purpose of these guidelines is to provide recommendations for the management of anticoagulation in the adult perioperative surgical setting. Of note, this information is not intended to replace clinical judgment. 
    Approved: 08/04/2016
  • Children’s Hospital of Georgia Extended-Interval Aminoglycoside Protocol: Gentamicin and Tobramycin (v.1)
    This protocol outlines dosing and monitoring recommendations for once daily aminoglycosides in the pediatric population for clinical pediatric pharmacists.
    Approved: 07/25/2016
  • Determination of Death by Brain Criteria for Adults Policy (v.2)
    This document establishes a uniform approach to rendering a diagnosis of death based on failure of brain function. 
    Approved: 07/28/2016
  • Determination of Death by Brain Criteria for Infants and Children Policy (v.2)
    This document establishes a uniform approach to rendering a diagnosis of death based on failure of brain function for infants and children.  
    Approved: 07/28/2016
  • Disclosing Protected Health Info
    It is the policy of the medical center to release protected health information (PHI) to law enforcement authorities with the individual’s signed HIPAA authorization or without the individual’s signed HIPAA authorization in certain incidents.
    Approved: 08/04/2016
  • Employee Illness Policy (v.2)
    To protect patients, visitors, employees, and staff from infectious diseases; to provide appropriate evaluation, counseling, treatment, referral and documentation of health care workers experiencing illness; and to provide standardized criteria for employee work restrictions related to potentially infectious disease.
    Approved: 07/13/2016
  • Exposure to Infectious Disease or Injury Policy (v.2)
    This policy outlines that provisions for managing employee exposure to infectious disease or injury policy.
    Approved: 07/28/2016
  • General Consent Policy (v.2)
    It is the policy of AU Medical Center to ensure that consent for treatment is obtained on every patient (for pediatric patients, see below II.3) and documented appropriately in the medical record.
    Approved: 08/04/2016
  • Harassment Policy (v.2)
    AU Medical Center (AUMC) is committed to providing and maintaining a work environment free of harassment, discrimination and/or retaliation based on race, color, religion, sex/gender, national origin, age, disability, marital or family status, sexual orientation, gender identity, veteran status, or genetic information. AU Medical Center’s policy on harassment is a zero tolerance policy.
    Approved: 07/13/2016
  • Inpatient Use of Palivizumab (Synagis®) (v.1)
    This protocol exists to ensure appropriate prescribing and dispensing of palivizumab.
    Approved: 07/25/2016
  • IV Weight-Based Heparin Protocol for Continuous Renal Replacement Therapy (CRRT) in Adult Patients (v.1)
    This protocol allows a prescriber to order an IV weight-based heparin protocol for adult patients on continuous renal replacement therapy (CRRT) by means of computerized prescriber order entry.
    Approved: 07/25/2016
  • Laryngoscope Reprocessing Policy (v.2)
    This policy will provide provisions for reprocessing, handling and storage of laryngoscope blades and handles to ensure that they are safe for use.
    Approved: 07/28/2016
  • Local Anesthetic Systemic Toxicity Reversal (v.1)
    This protocol provides guidance on the reversal of systemic toxicities related to Ropivacaine, Bupivacaine, Lidocaine, Procaine, Tetracaine, Mepivacaine, and Etidocaine usage.
    Approved: 07/25/2016
  • Malignant Hyperthermia Crisis Management (v.1)
    This protocol provides guidance on the management of malignant hyperthermia crisis.
    Approved: 07/25/2016
  • Military Leave USERRA Policy (v.2)
    Augusta University Medical Center will grant a military leave of absence to employees who are absent from work because of service in the United States uniformed services, including the National Guard, in accordance with the Uniformed Services Employment and Reemployment Rights Act (USERRA).
    Approved: 07/28/2016
  • MRSA by PCR Screening in the ICU’s (v.1)
    This policy outlines the process by which ICU's will be screened for MRSA by PCR.
    Approved: 07/13/2016
  • Neonatal Starter TPN Preparation and Dispensing for the Children’s Hospital of Georgia (v.1)
    To ensure proper admixture, dilution, and storage, neonatal starter TPN solutions will be prepared only by the Department of Pharmacy. Such admixtures will be prepared in a laminar flow hood and stored under refrigeration in the central pharmacy refrigerator. The neonatal starter TPN will be used for neonates less than 1500 grams (1.5 kg) in the NICU or 7U who require TPN after the TPN order cut-off time (i.e., 2:00 P.M.).
    Approved: 07/26/2016
  • Notice of Privacy Practice – Distribution & Acknowledgement Policy (v.2)
    The medical center will develop a Notice of Privacy Practices (NPP) for patients, distribute the NPP to all patients at the time of their first treatment encounter, periodically review the NPP to determine if the NPP continues to be accurate and, notify patients if any major changes are made in the NPP.
    Approved: 08/04/2016
  • Patient's Right to Request Access to Protected Health Information for Inspection and/or Copying (v.2)
    Patients and their personal representatives have the right to access, inspect and obtain a copy of their protected health information which is maintained in their designated record set.
    Approved: 07/28/2016
  • Phase I Post Anesthesia Recovery Outside of the PACU (v.1)
    The intent of this policy is to ensure that all patients with comparable needs receive the same standard of care, treatment and services throughout AU Medical Center. Patients requiring Phase I post anesthesia recovery observation in any of the intensive care units (ICU), will receive the same standard of care, treatment, and services as patients receiving Phase I post anesthesia recovery observation in the Post Anesthesia Care Unit (PACU).
    Approved: 07/13/2016
  • Pregnant Healthcare Workers Policy (v.2)
    This policy refers to the practice and provisions for providing the pregnant healthcare worker assessments for any potential risk of exposure to specific infectious agents in the workplace. Employee Health and Wellness follows the provision set forth in this policy.
    Approved: 07/28/2016
  • Securely Disposing of Electronic Media (v.1)
    AU Health has adopted this policy to outline the security measures required to protect electronic information systems and related equipment from unauthorized access upon disposal and transfer.
    Approved: 07/28/2016
  • Standard Drip Concentrations in Adult Hospital  (v.2)
    This protocol outlines standardized concentrations for continuous infusion drips ordered in the adult hospital setting.
    Approved: 07/25/2016
  • Standardized Doses (v.2)
    This protocol outlines the standardization of doses for more practical and accurate measurement of doses of medication.
    Approved: 07/25/2016
  • The Rights of a Patient’s Personal Representative Regarding Protected Health Information Policy (v.2)
    The medical center will afford a patient’s personal representative certain defined protected health information (PHI) disclosure rights, provided, that the individual has met the criteria for a personal representative under HIPAA and Georgia State law, and has been identified as the lawful personal representative.
    Approved: 08/04/2016
  • Tobacco-Free Policy (v.1)
    This policy outlines AU Medical Center's committeement to a tobacco-free environment.
    Approved: 08/04/2016
  • Transcranial Magnetic Stimulation (v.1)
    The policy ensures responsible licensed personnel, who direct or provide patient care will comply with standards of care within their scope of practice for all patients that receive transcranial magnetic stimulation therapy (TMS).
    Approved: 07/13/2016
  • Transitional Duty Program Policy (v.2)
    AU Medical Center recognizes the value of our employees and is committed to their retention even when injuries or illnesses intervene and limit their ability to work. The purpose of this program is to provide assistance for employees who are temporarily unable to perform some or all of their regular job duties and responsibilities because of an injury or illness and to return them to productive work in a safe and timely manner.
    Approved: 08/04/2016

University Policies that were approved in July 2016

No new University policies.