New and Revised Policies

Medical Center New and Revised Policies

University New and Revised Policies

Augusta University Policies that were approved in October 2016

Login is required to view the policy

  • 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 the responsibility 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.

Medical Center Policies Approved April 2018


  • Lost, Found, and Abandoned Property Policy (v.1)
    Lost and found property that has been deposited with AU Medical Center (AUMC) for safekeeping is managed in a reasonable and organized manner, to include appropriate documentation and release of the lost/found property only to the patient or their personal representative when possible. The management of a patient’s home medications is outside the scope of this policy. Approved: 4/3/2018

  • Transfer of Patient via AUMC Transfer Center Policy (v.1)
    This policy applies to all transfer requests managed by the AUMC Transfer Center or Emergency Communications Center (ECC). The policy states that all requests from outlying hospitals for transfers of patients to AU Medical Center (AUMC) are managed in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C., Section 1395, all applicable Federal regulations and interpretive guidelines promulgated thereafter, and the tenets of this policy.  Process & Procedures address emergency department to emergency department transfer, emergency department to In-patient unit transfer, and inpatient unit to inpatient unit transfer.  Also addressed in the policy is the transfer center escalation process and denials in each transfer scenario. Approved: 4/6/2018

  • Blood Administration Policy (v.4)
    This is an AU Medical Center policy governing the obtaining of informed consent and administration of blood and blood components. Approved: 4/6/2018

  • Diversion of Patient Transfer/Transport Policy (v.3)
    AU Medical Center (AUMC) is committed to assuring that adequate resources are available to provide appropriate care to those who seek health care services at this institution. In order to assure safe care for those most in need of AUMC’s resources, certain transfer requests from other external organizations may be redirected for a limited time. Moreover, in the event that specific resources cannot be made available to provide adequate, safe care for additional critically ill or injured patients who may be transported through the EMS System, there will be a procedure to notify Regional EMS and other appropriate parties to accomplish the temporary diversion of patients to other facilities.  This policy applies to all patient care units that admit within AUMC and CHOG. Approved: 4/6/2018



Medical Center Policies Approved January – March 2018


  • Management of Patients Valuables and Personal Property Policy (v.2)
    Valuables and personal property that have been deposited with AU Medical Center (AUMC) for safekeeping are managed in a reasonable and organized manner, to include appropriate documentation and release of the valuables/personal property only to the patient or their personal representative when possible.  The management of a patient’s home medications is outside the scope of this policy.  
    Approved: 3/28/2018

  • Living Organ Donor Leave Program Policy (v.1)
    This policy applies only to an employee who actually donates an organ or marrow and who presents to the appropriate supervisor a statement from a licensed medical practitioner or hospital administrator that the employee is making an organ or marrow donation.
    Approved: 3/28/2018

  • Departmental Personnel Files – Structure and Content Policy (v.1)
    AU Medical Center (AUMC) departmental personnel files are maintained in a structured, consistent manner to ensure regulatory compliance. Personnel files are randomly audited to ensure the inclusion and order of required documentation. Approved: 3/23/2018

  • Infection Prevention and Control Annual Risk Assessment and Plan (v.4)
    AU Medical Center (AUMC) documents a risk assessment each year that describes the infection risks unique to AUMC’s hospitals and clinics used to determine the Annual Infection Prevention and Control Plan. Monitoring the on-going status of infection risks and occurrences involves a systematic review of patient outcomes using surveillance indicators.
    Approved: 3/23/2018

  • Emergency Medical Treatment & Labor Act (EMTALA) Policy (v.2)
    All individuals requesting an examination for a possible emergency medical condition, including women in active labor, are entitled to, and will receive, the appropriate care as outlined in the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C., Section 1395 and all applicable Federal regulations and interpretive guidelines promulgated thereafter.  Individuals are provided with an appropriate medical screening examination (MSE) and stabilizing treatment prior to dismissal or transfer.  Requests for transfers to and from AUMC are managed in accordance with EMTALA and the tenants of this policy.
    Approved: 3/14/2018

  • Code Stroke Policy (v.1)
    This policy includes the guidelines and procedure for the rapid assessment and treatment of acute stroke patients in the Emergency Department (ED). It outlines a safe and consistent process for the triage, stability assessment, expedited CT scan, and treatment of this subset of ED patients. It establishes a process for the safe and rapid management of acute strokes so that eligible patients may receive thrombolytic and/or endovascular therapy.
    Approved: 3/9/2018

  • Anticoagulation Management Policy (v.2)
    This policy and the associated anticoagulation guidelines describing the evidence-based utilization of these medications were developed to assure individualized therapy that maximizes efficacy by promoting appropriate dosing, minimizes the incidence of anticoagulation-related adverse drug events by performing recommended monitoring and optimizes patient compliance by providing education in accordance with The Joint Commission National Patient Safety Goal, NPSG.03.05.01.
    Approved: 3/8/2018

  • Discontinuation of Services Policy (v.2)
    This policy assists the AU Medical Center, Inc. and AU Medical Associates in a health-system coordinated procedure to withdraw from providing clinical care to existing patients who exhibit behaviors of noncompliance, abusiveness, or violence when efforts to modify the behavior or transfer care to another provider has failed.
    Approved: 3/5/2018

  • Asset Management Policy (v.1)
    AU Medical Center (AUMC) shall ensure technology assets are acquired, recorded, and disposed of according to standards outlined in this policy in order to reduce fraud, waste and abuse, comply with applicable federal regulations, and properly manage technology assets at AUMC.
    Approved: 2/22/2018

  • Standard Precautions Policy (v.2)
    Standard Precautions are designed to reduce the risk of transmitting microorganisms from both recognized and unrecognized sources of infection in hospitals and are a key component to the Bloodborne Pathogen Exposure Control Plan. Standard Precautions are used for the care of all patients regardless of their diagnosis or presumed infection status. Standard Precautions apply to (1) blood; (2) all body substances, secretions and excretions (except sweat, regardless of whether or not the substances contain visible blood; (3) non-intact skin; (4) mucous membranes; and (5) unpreserved tissues. 
    Approved: 2/20/2018

  • Code Blue Policy (v.3)
    “Code Blue” is the designated identification for announcing a medical emergency. AU Health will ensure that cardiopulmonary arrest “Code Blue” procedures are performed timely, efficiently, and effectively by appropriately trained staff while utilizing readily available necessary emergency equipment.
    Approved: 2/20/2018

  • Focused Professional Practice Evaluation (FPPE) Policy (v.3)
    To enhance the quality and safety of patient care, each clinical department (Clinical Service Chief or designee) is responsible for monitoring and evaluation of the professional practice of their privileged staff.  A period of appropriate focused professional practice evaluation (FPPE) occurs in specific circumstances, as outlined in policy, and results are used to facilitate improvements in the quality of care offered to patients and to ensure a practitioner’s continued privilege specific competency. 
    Approved: 2/20/2018
  • Ongoing Professional Practice Evaluation (OPPE) Policy (v.2)
    To enhance the quality and safety of patient care, each clinical service (Clinical Service Chief or designee) is responsible for monitoring the professional practice of their privileged staff.  This is conducted through review of provider practice patterns as well as through peer review activity that assesses a practitioner’s practice behavior and his/her ability to perform requested privileges.  Results of ongoing professional review are used to facilitate improvements in the quality of care offered to patients and to ensure a practitioner’s continued privilege-specific competency.
    Approved: 2/20/2018

  • Rapid Response Team (RRT) and Pediatric Evaluation Team (PET) Policy (v.1)
    AU Medical Center (AUMC) and The Children’s Hospital of Georgia (CHOG) Rapid Response Team (RRT)/ Pediatric Evaluation Team (PET) provides immediate assistance to any non-emergency department patient in the AUMC and CHOG hospitals and clinics (joined by Crosswalks to main hospital) experiencing symptoms of urgent concern to patient/family or his/her professional caregiver up to, but not including (imminent) cardiopulmonary arrest.
    Approved: 2/20/2018

  • Management of Sentinel Events Policy (v.3)
    All adverse events that meet The Joint Commission definition of a sentinel event will be reported immediately to Risk Management and investigated. The investigation will not focus on individual staff performance, but rather system issues that contributed to the event. Patients, and when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.
    Approved: 2/20/2018

  • Management of Patient Grievances Policy (v.3)
    This policy establishes the AU Medical Center (AUMC) formal grievance/complaint resolution process. The patient and/or the patient’s representative have the right to have their complaints reviewed by the health system. The goal of this policy is to define the means by which complaints and grievances are addressed and to provide a process to deal with patient and/or patient’s representative’s complaints and grievances in a fair, timely, and consistent manner.
    Approved: 2/14/2018

  • Medical Staff Bylaws (v.4)
    The Medical Staff of AU Medical Center (AUMC) operates under the guidance and direction of the AUMC Board of Directors, Chief Medical Officer (CMO), and the Medical Staff Bylaws, which create a governance framework.  These Bylaws, Rules and Regulations and supporting Policies and Procedures create a framework for governance of Medical Staff activities and accountability to the Board of Directors within which Medical staff members can act with a reasonable degree of freedom and confidence and will ensure Medical Staff representation and participation in any AUMC and/or CHOG deliberation affecting the discharge of staff responsibilities.
    Approved: 2/5/2018

  • Alleged Assault, Battery or Untoward Treatment of a Patient by Another Patient, Visitor or Staff Member Policy (v.1)
    AU Medical Center (AUMC) patients, families, visitors, and staff have the right to be safe and free from assault, battery, or other untoward treatment resulting in patient/family discomfort or injury while receiving care at AUMC. AUMC does not tolerate these behaviors and takes immediate action to ensure the safety and well-being of patients, families, visitors, and staff.  This policy outlines the procedure for identifying and responding to allegations or suspicions of assault, battery, or other untoward treatment of a patient by another patient, visitor, or staff member.
    Approved: 2/5/2018

  • Service Recovery Policy (v.3)
    It is the policy that AUMC that patients and/or the patient’s representatives receive care in a patient-and-family-centered environment and every effort is made to ensure that all patient experiences at AUMC are positive. The goal is of the policy is to empower “staff present” to identify and to take action during potential instances of patient dissatisfaction or service failure.
    Approved: 1/24/2018

  • Enterprise Risk Management Policy (v.2)
    AU Medical Center (AUMC) maintains an enterprise-wide approach directed towards the effective management of patient opportunities and adverse effects associated with the institution’s academic, administrative, and business/healthcare activities.
    Approved: 1/23/2018

  • FY2018 Medical Equipment Management Plan (v.2)
    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: 1/18/2018

  • FY2018 Utility Systems Management Plan (v.2)
    The purpose of the Utility Systems Management Plan is to support a safe patient care environment at AUMC by managing risk associated with the safe operation and functional reliability of all utility systems. The plan includes the processes for maintenance and training that are designed to promote safe and effective use of utility systems while minimizing risks to patients and staff.  The Utility Systems Management Plan applies to hospital functions at all designated AUMC locations as identified in our Statement of Conditions.
    Approved: 1/18/2018

  • FY2018 Safety & Security Management Plan (v.2)
    The Safety and Security Management Program is designed to reduce the risk of injury of patients, staff and visitors. The Security Management Plan is used to reduce the risk of personal injury and property loss.
    Approved: 1/18/2018

  • FY2018 Life Safety Code Management Plan (v.2)
    The purpose of the Life Safety Management Plan is to define the program to protect building occupants from fire and related hazards to include, but are not limited to, minimizing products of combustion, providing unobstructed emergency exits and appropriate fire alarm and suppression devices. It is designed to assure appropriate, effective response to fire or other emergency situations that could affect the safety of the patients, staff and/or the environment of AUMC buildings.
    Approved: 1/18/2018

  • FY2018 Hazardous Materials & Waste Management Plan (v.2)
    The Hazardous Materials and Waste Management Plan describes the process and mechanisms by which AUMC manages hazardous materials and waste in a manner that protects the health, safety, and environment of patients, staff, and the community. This plan also supports the mission of the medical center.
    Approved: 1/18/2018

  • FY2018 Fire Safety Management Plan (v.2)
    The purpose of the Fire Safety Management Plan is to define the program to protect building occupants, equipment, and other materials from fire and the products of combustion.  It is designed to assure appropriate, effective response to fire emergency situations that could affect the safety of patients, staff, visitors, and/or the environment.  It is also designed to assure compliance with applicable codes and regulations.
    Approved: 1/18/2018

  • FY2018 Emergency Management Plan (v.2)
    The purpose of the Emergency Management Program is to develop processes used by the Emergency Operations Plan (EOP) to respond effective and timely to events that pose an immediate danger to the health and safety of AUMC’s patients, staff, and visitors. This document also services to delineate CEPaR’s responsibilities under the Joint Commissions Environment of Care (EC) and Emergency Management (EM) standards. The EOP consists of a number of procedures designed to respond to those situations most likely to disrupt the normal operations of the hospital. It also addresses the medical needs of victims involved in community based incidents.
    Approved: 1/18/2018

  • Paid Time Off Policy (v.4)
    Paid time off is a benefit provided to employees of AUMC to allow time for scheduled and unscheduled time off from work for reasons to include illness or injury, holidays and bereavement.
    Approved: 1/11/2018

  • Charge Reconciliation Policy (v.1)
    This policy establishes AUMC guidelines for appropriate and consistent daily charge reconciliation practices for all revenue generating departments.  It applies to all patient types: inpatients, outpatients, emergency patients, and ambulatory surgery patients. This policy applies to charges that are processed and received via bath by HealthQuest nightly from the sending systems (i.e. CPOE, PathNet, RadNet, PharmNet).
    Approved: 1/2/2018