New and Revised Policies

AU Medical Center New and Revised Policies

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September 2019

    • Personal Protective Equipment Policy (v2), #927

      The appropriate Personal Protective Equipment (PPE) is worn when the risk of contact with blood, body substances or infective material is anticipated or when required based on type of Transmission Based Precautions. The health care worker (HCW) must evaluate the need for PPE, as well as the type of PPE needed prior to initiating procedures. PPE is not to be worn in public access areas (e.g. hallways, waiting rooms, Terrace Dining etc.) unless required for patient transport (see Guidelines for Transporting Patients on Transmission-based Precautions) or as otherwise required by Occupational Safety and Health Administration (OSHA). Department Managers will assess the type and quantity of PPE required in their specific department(s) and will ensure that the PPE is available for all staff via the transmission-based precautions carts, and/or cabinet/area designated for PPE.

    •  Daily Testing of Disinfection Equipment SOP (v1), #5178

      Equipment and Chemicals used in the Cleaning, Disinfection, High Level Disinfection and Sterilization should be tested weekly or Daily per AAMI and Manufacturer’s recommendation to ensure the equipment is functioning to manufacturer standards for cleaning, disinfecting or sterilizing.

    • Intra Hospital Patient Transport Policy (v3), #219

      The safe and expeditious transport of all patients within AU Medical Center (AUMC), Children’s Hospital of Georgia (CHOG) and outlying AU Health facilities, where applicable, is a high priority for this institution. The purpose of this policy is to ensure that all appropriate patients transported within AU

      Health are done so by trained personnel (minimum requirements - current basic life support) and that the appropriate level of transportation is provided. The appropriate level of transport will be based upon the current medical need of the patient.

  • Master Policy on the Use and Disclosure of Protected Health Information – with and without an Authorization – Policy (v3), #187
    Basic standards must be met when using or disclosing protected health information (PHI) to protect individuals’ rights to privacy, adhere to state and federal laws addressing the privacy and security of individually identifiable health information, and to allow necessary access for individual care and health care operations. 

  • Safeguarding the Privacy of Protected Health Information Policy (v3), #199 
    When maintaining, using or disclosing individually identifiable health information (or when requesting individually identifiable health information from other health care providers, health plans and health care clearinghouses), the Augusta University Health (AU Health) will make reasonable efforts to safeguard protected health information (PHI) to minimize the potential for unauthorized access, use or disclosure of PHI under its jurisdiction. To do so, the AU Health has in place appropriate administrative, technical, and physical safeguards to protect the privacy of PHI that augment established security safeguards.

  • Minimum Necessary Use, Disclosure and Request for Protected Health Information Policy (v3), #188
    The minimum necessary standard, a key protection of the HIPAA Privacy Rule, is derived from confidentiality codes and practices in common use today. It is based on sound current practice that protected health information (PHI) should not be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. Augusta University Health (AU Health) must ensure reasonable steps are taken to limit PHI to the minimum necessary to accomplish the intended purpose of the use or disclosure.

  • Water Management and Legionella Prevention Policy (v1), #4605
    It is the intent of AU Medical Center Facilities to reduce the risk of Legionnaire’s disease by using various strategies to minimize the pathogenic and biological agents in cooling towers, domestic hot and cold water, and aerosolizing water systems, to ensure that water services are safe for use by patients, staff and visitors.

  • Critical Congenital Heart Disease (CCHD) Screening Policy (v1), #4484
    Screening for Critical Congenital Heart Disease is mandated by the State of Georgia and is recommended by the American Academy of Pediatrics (AAP). Pulse Oximetry can assist in detection of babies who have a congenital heart defect that has not been detected prenatally or on an initial newborn exam. A pulse oximetry screen is recommends at 24 hours of life or before discharge, whichever comes first.

  • Neonatal Resuscitation Team Policy (v1), #4506
    In accordance with the Guidelines for Perinatal Care, 8th edition along with recommendations of the American Academy of Pediatrics Neonatal Resuscitation Program, hospitals should have designated personnel available to provide specialized care and resuscitation of the newborn available for all deliveries. Approximately 10% of all newborns require some assistance at birth and 1% require extensive assistance at birth. Outcomes can be improved if an organized plan is in place to provide this specialized care not only in L&D but throughout the entire hospital.

  • Escalation Chain of Authority Involving Patient Care Issues of Concern Policy (v2), #714
    The purpose of this policy is to escalate concerns for ensuring safe, quality patient care. Team members are obligated to work toward resolution of identified real and potential problems within the system that may affect patient care. If the team member is unable to resolve such issues independently, the team member is obligated to present the issue of concern in a timely manner to successively higher levels of command until a satisfactory resolution is achieved.

  • Automated Time and Attendance Policy (v3), #409 
    This policy applies to all employees and staff of legal entities of the health system to include AU Medical Associates (AUMA), AU Medical Center (AUMC), Roosevelt Warm Springs Rehabilitation & Specialty Hospitals (RWSH) and AU Health System (AUHS), performing duties within the scope of their employment at any site.
    To provide a procedure for the tracking and reporting of hours worked and leave taken for AUHS entityemployees utilizing the Automated Time and Attendance System.

  • Code Stroke and Endovascular Stroke Policy (v3), #3868 
    This policy includes the guideline 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.

  • Communication of Critical and Unexpected Diagnostic Imaging Results Policy (v2), #2257
    The purpose of this policy is to define procedures for timely critical and unexpected diagnostic imagingreporting to promote optimal patient care.

  • Safe Medication Practices Policy (v4), #310 
    Safe medication use practices must be followed at every step in the medication-use process (i.e., ordering, preparation, dispensing, administration, patient monitoring, documentation and related communications) to minimize the risk of medication errors and optimize patient care. The standards outlined within this policy apply to both the inpatient and ambulatory care settings and to all healthcare professionals participating in the medication-use process, including (but not limited to) physicians, dentists, podiatrists, medical assistants, optometrists, nurses, nurse practitioners and nurse midwives, pharmacists, physician assistants, respiratory therapists, physical therapists, dieticians and technicians.

  • Total Parenteral Nutrition (TPN) Policy (v2), #854 
    This policy exists to provide staff with guidelines to promote patient safety and evidence-based practice for the ordering, preparation, administration and monitoring of parenteral nutrition. This policy applies to all parenteral nutrition orders requested by all patient care services (i.e., adult, pediatric, neonatal) and will be used in conjunction with guidelines established and approved by the Pharmacy and Therapeutics (P&T) Committee for parenteral nutrition.

  • Point of Care Testing Policy (v3), #311
    The Medical Director of each CLIA-certified laboratory has the responsibility, authority, and jurisdiction for selecting, implementing, monitoring, and evaluating all laboratory testing that is performed outside of the Clinical Pathology Laboratory. Point-of-Care Testing guidelines are consistent with requirements as outlined by the College of American Pathologists (CAP), Georgia Department of Community Health (GDCH), and The Joint Commission (TJC) regulatory agencies.

  • Reflex and Composite Testing in the Clinical Pathology Laboratory Policy (v3), #314
    AU Medical Center (AUMC) 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 adding an order comment in CPOE or by marking the requisition form if necessary. 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 IP Products Policy (v2), #844 
    The use of all antiseptics, disinfectants, sterilants, cleaning agents, and skin products at AU Medical Center (AUMC) must be approved by the Infections Committee and the Value Based Purchasing.

  • Catheter Associated Urinary Tract Infection (CAUTI) Prevention Policy (v2), #1094
    Urinary catheterization to facilitate urine drainage will be used only when medically necessary. Indwelling urinary catheters should be evaluated daily for necessity and promptly removed when no longer necessary. The following bundle elements will be used during insertion and/or maintenance to prevent associated infections.

  • Compromised Host/Neutropenic Precautions Policy (v2), #835
    All patients with an absolute neutrophil count less than or equal to 1000 must be placed in neutropenic precautions.

  • High Level Disinfection Policy (v3), #867
    The purpose of this policy is to ensure team members follow the proper reprocessing standards and infection prevention principles in the cleaning and high-level disinfection (HLD) of semicritical, reusable items (e.g., flexible endoscopes, transesophageal ultrasound probes, endocavitary ultrasound probes, respiratory therapy equipment that touches mucous membranes, etc.). Proper high-level disinfection reprocessing will ensure patient safety, prevent cross contamination, prevent damage to equipment, and maintain integrity of semi-critical items.

  • Plants in Patient Care Areas Policy (v2), #916
    AU Medical Center (AUMC) prohibits live plants and flowers in critical and special care areas or in rooms of patients on Neutropenic Precautions in an effort to provide a safe environment. This policy applies to all such areas within AU Health hospitals and clinics. All HCWs are responsible for the care and safety of compromised, neutropenic, critical and special care patients.

  • Reprocessing Flexible Endoscopes Policy (v1), #4606
    To ensure proper reprocessing standards are followed in the cleaning and high-level disinfection of all flexible endoscopes. Proper endoscope reprocessing will ensure patient safety, prevent cross contamination, prevent damage to the endoscope, and maintain integrity of the endoscope.

  • Safety Device Policy (v2), #845 
    AU Medical Center (AUMC) implements a comprehensive Bloodborne Pathogen Exposure Control Plan to prevent needlestick and sharp injuries. As part of AUMC’s Bloodborne Pathogen ECP, the Employee Health and Wellness will review needlestick and sharp injuries and share with the Value Based Purchasing Committee to identify and recommend opportunities for improvement which includes the committee’s authority to approve selected safety devices.

  • Sterilization Policy (v2), #371
    The ability to sterilize instruments and equipment for use during operative or other invasive procedures is critical to promoting successful patient outcomes and preventing infections. This policy defines the standard for sterilization of reusable medical equipment and devices.
    At a minimum, items requiring sterilization per manufacturer’s instructions for use (IFU) for enteringsterile body sites or systems are sterilized following the provisions below.

  • Procurement of Information Technology Policy (v1), #4357 
    All AU Health System (AUHS) request of technology resources, services and products must be reviewed and approved by the Vice President for Information Technology and Chief Information Officer (CIO), or their designee prior to their purchase.
    Procurement of all AUHS technology resources, services, and products is centrally managed by Information Technology in collaboration with the Purchasing Department, and following institutional policies and procedures. As such, Information Technology is responsible for the evaluation-and selection, - of technology resources, products and services. Additionally, Information Technology in conjunction with the Purchasing Department shall be responsible for the negotiation of the product and services. Purchasing shall ultimately be responsible for the procurement of these products and services as approved by Information Technology.

  •  Suicide Risk Assessment Policy (v3) #232 
    The purpose of this policy is to describe the process for assessing suicide risk and providing evaluation, treatment and discharge plans for at-risk patients. A risk assessment that identifies specific patient characteristics that may increase or decrease the risk for suicide will be conducted. Any patient presenting with a new or acute primary behavioral or emotional diagnosis or complaint, or if it becomes obvious during the course of treatment there is an underlying behavioral or emotional diagnosis, will be screened for suicide ideation. An evidence-based screening tool that is appropriate to age and diagnosis will be used.

  • Post-Offer Physical Examinations and Annual Health Screening Requirements Policy (v4), #295 
    This policy applies to all employees and staff of legal entities of the Health System to include AU Medical Associates, AU Medical Center, and AU Health System, performing duties within the scope of their department at any site. This policy is intended to support all clinical areas providing patient care, regardless of role or job duties within any clinic and hospital area. It is intended to ensure that the Health System has appropriate safeguards in place to protect patients and employees from exposure to preventable disease, by utilizing screening tools annually and during times of potential workplace exposures.

  • Pregnant Healthcare Workers Policy (v3), #296  
    This policy refers to the fetal risks associated with infectious agents, the source, and effects on the fetus, transmission rate to fetus, maternal screening and prevention by Employee Health and Wellness as outlined.

  • Nursing Orientation Policy (v2), #3623 
    The purpose of nursing orientation at AU Medical Center (AUMC) is to provide the essential components related to policies, procedures, standards, and documentation for both experienced and inexperienced nurses employed at (AUMC). The goal of nursing orientation is to support newly hired healthcare professionals and successfully integrate with the AUMC vision, mission, values, goals, and organizational structure. This policy intends to provide a clear orientation timeframe applicable to both novice and experienced nurses.

  • Supplier Diversity Business Development Policy (v2), #253  
    AU Health System (AUHS) is committed to providing a platform for supplier diversity ensuring minority businesses are afforded an opportunity to participate in the AU Health System purchasing process. AU HS’s management makes a reasonable effort to ensure minority and small businesses are included in the contracting and procurement processes. In addition, AUHSs Purchasing Department stands ready to mentor minority businesses to help improve their opportunities for success throughout the community.

    • Acceptance of Business Courtesies & Contributions Policy (v2), #174 
      At AU Health System, we strive to maintain a culture marked by the highest standards of institutional and professional ethics; we expect all employees to assist in cultivating and maintaining these ethical standards. While there are situations when modest gifts are offered to convey a thoughtful “thank you” and courtesies are offered to strengthen a business relationship, in healthcare, business courtesies and contributions pose a risk for conflicts of interest or fraud and/or abuse related to anti-kickback laws and regulations. In recognition of these issues, this policy provides guidelines for acceptance or refusal of any business courtesies and contributions. Where federal health care programs are involved, it is a violation of the federal anti-kickback law to accept gifts from patient referral sources and from vendors, unless the gift is truly nominal, as defined in OIG policy statements, is clearly and completely unrelated to past or future referrals of patients or purchases, or is very unlikely to influence referrals or purchases.
    • Signage Policy (v2), #149
      AU Health ensures that the AU signage meets the quality standards of aesthetic appeal, uniformity, and simplicity, while being highly functional in providing necessary information.
    • Board Member Travel Policy (v3), #261
      This policy applies to all members of the Board of Directors of AU Health System (AUHS), AU Medical Associates (AUMA), AU Medical Center (AUMC), and Roosevelt Warm Springs Rehabilitation & Specialty Hospitals (RWSH) for use in regular travel to attend board meetings and/or board sub-committee meetings. This policy also pertains to Board member travel associated with special events such as conferences and workshops that pertain to the work of the Board..
    • Vacated Space Policy (v2), #150
      AU Health ensures that policies and procedures are in place for the proper handling of vacated space occupied by AU Health. When a space is vacated, the user department will ensure that the space is properly clean, secured, and cleaned. Additionally, the user department will properly notify other departments, as appropriate.
    • Self-Administrations of Medications Policy (v2), #2248
      This policy assures the safe and accurate administration of medications by a patient or non-hospital staff member. The administration of medications by patients and/or non-staff members is discouraged because of the difficulty in ensuring the proper use of the medication and in documenting medication administration.

      However, there are occasions when medications may be administered by a patient or a non-staff member for the purposes of education, training, maintaining patient independence and optimizing patient satisfaction. Administration of medications by a patient or a non-staff member should only be in accordance with the following procedures to guide the safe and accurate administration of medications and ensure appropriate supervision and documentation.

    • Contracted Patient Care Services Policy (v3), #265 
      AU Health System (AUHS) has a systematic process for developing agreements and contracts for any patient care related services. A review, approval and monitoring process is in place to assure the appropriate individuals have input into the development of the contract, as well as the ongoing administration of the agreement.
    • The Legal Health Record Policy (v3), #246
      A “Legal Health Record” (LHR) is maintained on every patient registered and seen by a healthcare professional in the AU Medical Center, Children’s Hospital of Georgia or AU Medical Center Clinic. The content of specific encounter records varies based on the level of services provided; however, each record must:
      • Contain sufficient information to justify the diagnosis, treatment and outcome of the patient.
      • Provide a record of the patient’s health status including observations, measurements, history, and prognosis.
      • Provide a method for clinical communication and care planning among the individual healthcare practitioners serving the patient; therefore, the information must be available at all times via an enterprise-wide medical record system.
      • Serve to document evidence of the quality of patient care, complying with state and federal rules of evidence. Specifically, the records must be made in the normal course of business, must be completed within a reasonable timeframe following the episode of care, must be legible, must be reproducible, and must be certifiable by the Medical Record Custodian.standards and state and federal rules an.Provide a method for clinical communication and care planning among the individual healthcare.
      • Serve as the legal business record for AU Medical Center, complying with accreditation standards and state and federal rules.
    • Fans for Patient Use Policy (v2), #915
      AU Medical Center (AUMC) hospitals and clinics safely uses fans when additional measures are needed
      in providing for patient comfort.
    • Notifiable Diseases Policy (v2), #3346
      AU Medical Center (AUMC) will comply with the Rules and Regulations for Notification of Diseases, Chapter 290-5-3, Georgia Department of Human Resources (GDHR), and the Official Code of Georgia Annotated (OCGA). 

      Additionally, Infection Prevention will comply with South Carolina public health authorities per South Carolina State Law # 44-29-10, Regulation # 61-20, State Laws # 44-1-110 and 44-1-140.

    • Phase I Post Anesthesia Recovery Outside of the PACU Policy (v2), #1040 
      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).
      • Code Stroke & Endovascular Stroke Policy (v2), #3868 
        This policy includes the guideline 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.
      • Nutrition Services Policy (v1), #3870 
        Clinical nutrition coverage is provided by a registered dietitian 7 days a week at AU Medical Center (AUMC) to assure adequate and appropriate nutrition care to all patients. This policy outlines the dietary services provided.
      • “Critically Ill” As Defined for Point-of-Care Glucometer Testing Policy (v2), #703 
        This policy is written to comply with the Center for Clinical Standards and Quality/Survey & Certification Group memorandum of November 21, 2014, S & C: 15-11-CLIA, Directions on the Off-Label/Modified Use of Waived Blood Glucose Monitoring Systems (BGMS). This memorandum also requires the hospital to define “critically ill’ for the purpose of Point-of-Care testing (POCT
      • Classification on Non-Operating Expense policy (v1), #4627 
        This policy is to define the classification of operating versus non-operating expenses as it relates to the business of AU Health System.
      • Unclaimed Property Policy (v2), #3708 
        The “Disposition of Unclaimed Property Act”, O.C.G.A. Section 44-12-190 et. seq., protects the rights of owners of abandoned property and relieves those holding the property of the responsibility to account for the property. Under the Act, AUHS entities must remit unclaimed property and unclaimed wages to the Georgia Department of Revenue. Once these funds are remitted, the state serves as the custodian which allows the owners an opportunity to claim the property in the future.
      • Inpatient Use of medical Marijuana, Cannabis and Low THC Oil Policy (v2), #3765 
         This policy exists to promote compliance with federal law and policy as well as ensure patient safety. Of note, commercially available cannabidiol products approved by the Food and Drug Administration (FDA) are outside the scope of this policy. Furthermore, the healthcare system may participate in investigational treatment protocols and clinical research using cannabidiol, a pharmaceutical product regulated by the FDA as an Investigational New Drug (IND). Use of marijuana and its derivatives under an IND is outside of the scope of this policy. The Department of Pharmacy should be contacted with questions or concerns regarding FDA approval and/or IND status.
      • Look-Alike and Sound-Alike Drugs Policy (v4), #901 
        To prevent errors associated with drugs that have brand and/or generic names that may be confused, the following list and associated safeguards will be maintained and followed. The list will be reviewed annually and revised, if necessary.
      • Medication Administration Policy (v2), #920 
        This policy exists to promote patient safety and high quality patient care by delineating guidelines for the safe administration of medications. Medications are administered in compliance with federal and state laws, standards of professional practice and hospital policies by authorized and qualified personnel (including but not limited to licensed independent practitioners, licensed practical nurses, registered nurses, respiratory therapists, paramedics, pharmacists and physical therapists within their scope) who have been deemed competent to administer medications to patients as well as those individuals under the supervision of authorized and qualified personnel.
      • Prohibited Abbreviations and Symbols Policy (v3), #902 
        To improve the effectiveness of communication of caregivers at AU Medical Center and thereby improve patient safety, the following list of prohibited abbreviations and symbols will be maintained and followed. The prohibited abbreviations and symbols will not be used in any clinical documentation.
      • AU Health System Patient Safety Plan 2020-2021 (v4), #815 
        The AU Health System’s (AU Health) Patient Safety Plan (“Plan”) is a description of the AU Health system-wide strategy to support AU Health’s mission, vision, and values through the patient safety process. The Plan is systematic, data driven, and reflects the complexity of the services provided by AU Health. The Plan is a component of the AU Health’s Quality Assurance Performance Improvement (QAPI) Plan, which outlines AU Health’s organizational approach to monitoring and improving quality, patient safety, and performance. 

        AU Health’s mission is to provide leadership and excellence in teaching, discovery, clinical care, and service as a student-centered comprehensive research university and academic health center with a wide range of programs from learning assistance through postdoctoral studies.

        AU Health’s vision is to be a top-tier university that is a destination of choice for education, health care, discovery, creativity, and innovation.
      • AU Health System Quality Assessment & Performance Improvement Plan (QAPI) Strategic Plan 2020-2021 (v3), #693 
        This plan applies to all service and sites of care provided at AU Health System. The Quality Assessment and Performance Improvement (QAPI) Plan establishes a system that includes ongoing assessment using internal and external knowledge and experience, to prevent error and maintain and improve health care safety and quality. AU Health System recognizes that patients and families, physicians and staff, visitors, and our community have the right to expect the best possible clinical outcomes, a safe environment, and an error/failure-free care experience. Therefore, AU Health System commits to continuously analyzing data, and designing, monitoring and sustaining performance improvement while undertaking a proactive approach to identify and mitigate healthcare risk and error. The AU Health System Patient Safety Plan, a separate document, describes the system and infrastructure that outlines the organization’s response error prevention and harm reduction
      • Transmission Based Precautions Policy (v2), #929 
        Transmission-based precautions (TBP) will be initiated and discontinued as per the Centers for Disease Control and Prevention’s (CDC) guidelines in efforts to prevent disease exposure and transmission amongst patients, visitors, and healthcare workers.
      • Vascular Access Device Policy (v3), #236 
        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.
      • Extra Pay Policy (v3), #896 
        It is the policy of AU Health System to provide a uniform policy for the administration of extra pay for exempt employees performing work outside of their regular job responsibilities within the employee’s home department.
      • Telework and Flextime Policy (v3), #3847 
        AU Health System has unique needs that require certain services to be available at all times. We strive to deliver excellent, compassionate health care services to our patients and therefore our managers are responsible for establishing work schedules and designating work locations for staff to complete their assigned duties. While most positions require staff to report to official health system locations, the duties of some positions can be accomplished from alternative or remote work locations on a regular basis. 

        The purpose of this policy is to define the program for working from an alternate location (also known as teleworking) and flexible work schedules (also known as flex scheduling), and the guidelines and rules under which it will operate. It is different from any informal practice of staff occasionally working from home, but rather establishes a formal flexible work arrangement at an alternate location, for one or more days a week. This policy would also apply to injured employees with the ability to work from home that meet the requirements of this policy. 

        The policy is also designed to help managers and employees understand this type of work environment and their associated rights and responsibilities, provide a general framework for alternate work and flex scheduling, and is not intended to interfere with schedules driven by clinical and/or other non-clinical responsibilities, which can vary daily.
  • Communication with Families of Augusta State Medical Prison (ASMP) Patients Policy (v2)
    There are occasions when the care of forensic patients from the Georgia Department of Corrections requires communication with families, either to advise them of a patient’s condition or to seek permission if the patient is unable to make their own decisions. Because of the need for security, we must take precautions not to disclose the patient’s location (unless a visit by family has been authorized by the Warden at Augusta State Medical Prison (ASMP)) or the names and/or phone numbers of the team providing care. This policy addresses the guidelines for communication with families of incarcerated patients receiving clinical care at AU Medical Center (AUMC).
  • Policy on Policies (v2)
    Organization and Department Policies, Clinical Protocols and Standing Orders, Clinical and Non-clinical Guidelines, and Scopes of Services, hereafter “documents,” are formally developed, approved, issued, and maintained as outlined herein. Documents are managed in a consistent manner with approved formats that are maintained in the electronic policy management system. Documents are reviewed, maintained, and made available to the organization to promote awareness, compliance, and accountability. 

    Each document is, at a minimum, reviewed on a triennial basis, or earlier as necessary to maintain operational and/or regulatory compliance.

  • Telework and Flextime Policy (v3)
    AU Health System has unique needs that require certain services to be available at all times. We strive to deliver excellent, compassionate health care services to our patients and therefore our managers are responsible for establishing work schedules and designating work locations for staff to complete their assigned duties. While most positions require staff to report to official health system locations, the duties of some positions can be accomplished from alternative or remote work locations on a regular basis. 

    The purpose of this policy is to define the program for working from an alternate location (also known as teleworking) and flexible work schedules (also known as flex scheduling), and the guidelines and rules under which it will operate. It is different from any informal practice of staff occasionally working from home, but rather establishes a formal flexible work arrangement at an alternate location, for one or more days a week. This policy would also apply to injured employees with the ability to work from home that meet the requirements of this policy. 

    The policy is also designed to help managers and employees understand this type of work environment and their associated rights and responsibilities, provide a general framework for alternate work and flex scheduling, and is not intended to interfere with schedules driven by clinical and/or other non-clinical responsibilities, which can vary daily.
  • Service Recovery Policy (v4)
    This policy is to establish the AU Health System (AUHS) Service Recovery Program process. The goal of this policy is to empower "staff present" to identify and to take action during potential instances of patient dissatisfaction or service failure. 

    It is the policy of AU Health System (to include but not limited to, AU Medical Center and all of its AU Health clinical facilities) that patients and/or the patient’s representatives receive appropriate care in a patient-and family-centered environment and all efforts are made to ensure that all experiences at AUMC are positive for every person, every encounter, every time (E3). The service recovery program demonstrates our dedication to immediately resolve patient complaints and concerns when this goal is not achieved. This policy is designed to accomplish this goal by: 1) Outlining a systematic approach to identifying patient dissatisfaction and service failures; 2) Encouraging staff present to be diligent patient advocates and foster strong relationships with our patients and/or the patient’s representatives; 3) Return aggrieved patients and/or the patient’s representatives to a state of satisfaction with our organization; and 4) Support the organizational goal to improve our services to patients and/or the patient’s representatives.

    The patient and/or patient’s representative have the right to express complaints or grievances without coercion, discrimination or reprisal.

  • Acute Care Restraints and Seclusion Policy (v3)
    All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. 

    Restraint or seclusion will only be implemented when least restrictive methods have been employed and/or are determined ineffective for preventing patients from interfering with medical regimens (non-violent/non self-destructive) or harming themselves or others (violent/self-destructive).

  • Handling of Deceased Patients Policy (v2)
    To establish uniform procedures for the handling of deaths so that physicians, Patient Care Services, Bed Management, Anatomic Pathology, Pastoral Counseling, Risk Management and Health Information Management Services can expedite the appropriate protocol for the safe and efficient release of deceased patients from AU Medical Center.
  • Helideck Operations Policy (v2)
    The use of the AU Medical Center (AUMC) Helideck (FAA Site # 03646.05*H) must meet local, state, and federal operational guidelines. Access to the helideck will be tightly controlled in order to ensure the safety of AUMC patients, employees, students, faculty, and those authorized individuals utilizing the site. Only helicopters transporting patients to or from either the AUMC Hospital and Clinics or Children’s Hospital of Georgia (CHOG) (or arriving to pick up one of the CHOG Transport Teams) may land on the helideck. Helicopters transporting patients to other health care facilities other than the Hospital and Clinics or CHOG are not permitted to land on the helideck. A maximum of TWO (2) helicopters will be allowed on the AUMC helideck at any given time. In addition to medical transports, the helideck can be used for the purposes of training exercises for the military and/or a governmental agency. The agency will require permission and there will be a complete communication of the helideck information to said agency. The Emergency Communication Center (ECC) will be notified of any scheduled training exercise. Flight helideck exercises MUST be aborted at any time there is a real-time transport event. All incoming and outbound flights will be coordinated through the ECC. Only “Authorized Employees” will be allowed to access the helideck and assist with transferring a patient to or from the helicopter. “Non-Authorized Employees” will not be granted access to the helideck for any reason during live flight operations, and during non-live events MUST be escorted by an authorized employee at all times.
  • Automatic Therapeutic Interchange Policy (v2)
    This policy promotes healthcare cost containment while maintaining positive therapeutic and safety outcomes of patients within AU Medical Center through judicious use of an automatic therapeutic interchange program. All medications or medication classes included in the automatic therapeutic interchange program will be reviewed and deemed appropriate for interchange by the Pharmacy and Therapeutics (P&T) Committee prior to implementation as well as approved by the Medical Executive Committee (MEC).
  • Disinfection Level Determination Policy (v3)
    All reprocessible patient care equipment and medical devices will be appropriately disinfected or sterilized in between patients to prevent the transmission of potentially infectious pathogens. This policy will assist with determining the appropriate method of disinfection or sterilization based on the type of device, level of invasiveness, and manufacturer’s recommendations.
  • Construction Management Policy (v2)
    Selection of consultants and contractors, the competitive bidding process associated with that selection, and authorization of performance to work on AU Medical Center (AUMC) projects must be in strict adherence with AUMC Policies and the Master Lease Agreement between the Board of Regents of the University System of Georgia and AUMC. The purpose of this policy is to establish uniform criteria to ensure that construction projects are managed in a fiscally prudent, cost-effective, efficient, and coordinated manner in accordance with AUMC policies.
  • CY2019 Fire Safety Management Plan (v3)
    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. This plan applies to hospital functions at all designated AUMC locations identified in our Statement of Conditions.
  • CY2019 Hazardous Materials & Waste Management Plan (v3)
    AU Medical Center (AUMC) 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 applies to hospital functions at all designated AUMC locations identified in our Statement of Conditions.
  • CY2019 Life Safety Code Management Plan (v3)
    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. The Utility Systems Management Plan applies to hospital functions at all designated AUMC locations identified in our Statement of Conditions.
  • CY2019 Medical Equipment Management Plan (v3)
    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.
  • CY2019 Safety & Security Management Plan (v3)
    The purpose of the Safety and Security Management Plan is to define the Safety and Security Program. The Safety 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.
  • CY2019 Utility Systems Management Plan (v3)
    The purpose of this Utility Systems Management Plan is to support a safe patient care environment at AU Medical Center (AUMC) by managing risks 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 identified in our Statement of Conditions.
  • Infection Prevention and Control Annual Risk Assessment and Plan (v6)
    Annually, AU Medical Center (AUMC) documents a risk assessment which describes the infection risks unique to Augusta University Medical Center’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.
  • Medicare Secondary Payer Questionnaire Policy (v1)
    As a Medicare enrolled provider, and according to section 1862(b) of the Social Security Act, AUHS must determine whether Medicare is the primary or secondary payer for each inpatient admission or outpatient encounter (does not include reference laboratory encounters or Medicare Advantage beneficiaries) prior to submitting a claim to Medicare. This is accomplished by asking Medicare beneficiaries, or their spouse or legal representatives, about other insurance coverage related to
    Employer Group Health Plans, Liability insurance, No-Fault insurance, End Stage Renal Disease within 30 months of COBRA and Worker’s Compensation. A series of questions developed by CMS is commonly known as Medicare Secondary Payer Questionnaire (MSPQ). AUHS will retain a copy of the most recent responses to completed MSPQs for at least 10 years after the date of service in the form of electronic files.
  • Name Entry and Changes Policy (v2)
    The purpose of this policy is to establish a standardized process for patient name and demographics entry into the IDX Enterprise Scheduling and Visit Management Systems which will feed all other downstream systems.
  • Orders for Hospital-Based Outpatient Rehabilitation and Respiratory Services Policy (v3)
    This policy will define the circumstances under which a practitioner is permitted to order outpatient rehabilitation and respiratory hospital-based services at AU Medical Center.
  • Use and Disclosure of Protected Health Information for Fundraising Purposes (v4)
    AU Medical Center (AUMC) will inform patients and/or legal guardians through its Joint Notice of Privacy Practices that it may use patient demographic information and limited health information to contact patients and/or the legal guardian of patients under the age of 18 years old for fundraising purposes or to share with an institutional-related charity foundation and that all patients and/or the legal guardian have a right to opt out of receiving fundraising communications.

    Any and all fundraising efforts activities involving the use or disclosure of patient information may only be undertaken after being approved by the Office of Advancement (Advancement).

    Any fundraising material or oral communications to patients and/or legal guardians will contain language in a “clear and conspicuous manner” that allows the patient and/or legal guardian to “opt-out” from receiving further fundraising communications.

    AUMC will refrain from conditioning treatment or payment on an individual’s choice regarding fundraising communications.
  • Anticoagulation Reversal for Adult Patients Guidelines (v3)
    The purpose of these guidelines is to provide recommendations for the reversal of or management of bleeding associated with anticoagulants. Of note, information provided in this document is not intended to replace clinical judgment. Recommendations regarding the management of anticoagulation in the adult perioperative surgical setting can be found in the Anticoagulation Management Guidelines for the Adult Perioperative Surgical Setting.
  • Asepsis Program Policy (v2)
    All incoming medical residents and medical students, including those who are visiting AU Medical Center (AUMC) must complete the Asepsis Program. The purpose of the policy is to assure that the incoming medical residents, medical students, whether a part of AUMC or visiting from another facility have training in the guidelines for aseptic/sterile technique utilized at AUMC.
  • Attendance Policy (v3)
    AU Health is open to deliver patient care on a 24-hour, 365 day basis. To meet its mission, regular attendance and punctuality are expected of all employees. Employees of AU Health are obligated to work the days or shifts for which they are scheduled, even during times of hazardous or inclement weather conditions. AU Health strives to be fair, consistent, and maintain appropriate staffing. AU Health incorporates the no-fault concept of attendance monitoring in order to increase managerial objectivity and consistency. It eliminates the need for management staff to determine whether an absence or tardy is excused, unexcused, chargeable or non-chargeable, legitimate or illegitimate.
  • Billing and Collections Policy (v2)
    To establish a systematic process for the billing and collections of medical services provided by AU Medical Associates (AUMA) and medical services provided at AU Medical Center (AUMC). The Billing and Collections policy together with the Financial Assistance policy is intended to meet the requirements of the applicable federal, state and local laws, including without limitation, section 501(r) of the Internal Revenue Code of 1986, as amended, and the regulations thereunder. This policy applies to all employees and staff of legal entities of the health system to include AUMA and AUMC, performing duties within the scope of their employment at any site.
  • Blood Administration Policy (v5)
    This is an AU Medical Center (AUMC) policy governing the obtaining informed consent and administration of blood and blood components.
  • Bloodborne Pathogen Exposure Control Plan (v2)
    AU Medical Center (AUMC) shall establish a written Exposure Control Plan (ECP) designed to eliminate or minimize occupational exposure to blood or other potentially infectious material (OPIM). The ECP and supporting documents will be reviewed and updated at least annually and as necessary. This document contains information for all levels of the AUMC organization and is applicable at all AUMC locations with a potential for occupational exposure to blood or OPIM.
  • Credentialing Medical Staff Policy (v6)
    The Medical Staff Office coordinates the credentialing process of all prospective members to the Medical and Advance practice providers for AU Medical Center Inc. Collection of all application forms and supporting documentation, verification of all required credentials, maintenance of a credentialing database system and communication, are handled by one office. This one office supports the Credentials Committee review and recommendations for appointment/reappointment and privileging in each hospital and clinics within the healthcare system. The AU Medical Center Inc. Medical Staff Office does not sub-delegate any credentialing functions to an outside source. The recommendations of the hospital Credentials Committee and Medical Executive Committee (MEC) are reported to the Board of Directors (Governing Body). Therefore, in order for there to be uniformity of credentials documentation and information and to reduce the burden of overseeing the application process, all credentialing information will be shared within AU Medical Center Inc. Credentialing information is peer review protected and all new members of peer review committees (such as Credentials Committee, Medical Executive Committee, PI Peer Review) will be oriented to the confidentiality process and will sign a confidentiality agreement. All information obtained during the initial and re-credentialing process is confidential. PHI is not used in the credentialing process but if submitted with the application, this information is destroyed, returned or blinded.
  • Discharge Planning Policy (v3)
    Each patient admitted to AU Medical Center (AUMC) will have an individualized evaluation of continuing care needs following discharge from the hospital. AUMC staff will work closely with the patient/patient’s representative and appropriate community agencies to ensure continuity of care is addressed and regulatory requirements are met. This policy provides a process that addresses the patient’s need for continuing care, treatment, and services after discharge or transfer.
  • Empiric Precautions Policy (v2)
    All patients will be assessed for infectious diseases or pathogens upon presentation in all settings. Proper transmission-based precautions will be initiated based on clinical presentation and likely pathogens; then, maintained until a diagnosis is confirmed or ruled out.
  • Infection Prevention and Control Authority Statement and Administrative Policy (v2)
    Infection Prevention and Control policies and provisions are essential to an effective Infection Prevention and Control program; therefore, they are corporate policies and apply to AU Medical Center (AUMC) hospitals and clinics. These polices must be followed by all physicians, AUMC personnel, Augusta University (AU) personnel, contractors, volunteers and students working in AUMC.  Authority and responsibility is defined to implement Infection Prevention and Control policies and provisions.
  • Informed Consent Policy (v3)
    AU Health will obtain informed consent for all patients (for pediatric patients, see below III A.3) regarding any surgical or invasive procedure performed under general anesthesia, spinal anesthesia, or major regional anesthesia or an amniocentesis diagnostic procedure; or a diagnostic procedure which involves intravenous injection of a contrast material.
  • Laryngoscope Processing Policy (v3)
    AU Medical Center (AUMC) reprocesses laryngoscope blades as semi-critical devices between each patient use and in accordance with the manufacturer’s instructions. Laryngoscope blades are packaged and stored in a manner to prevent recontamination. As manufacturer’s instructions for the handles vary from low level disinfection to sterilization, manufacturer’s instructions for reprocessing laryngoscope handles will be followed and handles will be stored and managed in a manner to prevent contamination. Devices such as laryngoscope blades and handles, may be exposed to potentially infectious material during indicated use, and can become contaminated through direct contact with the patient’s skin, mucous membranes, secretions, and blood. To reduce the risk of infection, the importance of standardizing the reprocessing and storage of laryngoscope blades and handles is emphasized. This policy will provide provisions for reprocessing, handling and storage of laryngoscope blades and handles to ensure that they are safe for use.
  • Monitoring for Hazardous Air Contaminants Policy (v2)
    It is the policy of AU Health to minimize air contaminants exposure to employees by providing for proper monitoring of air contaminants. Contaminants monitored include, but are not limited to, waste anesthesia gases, formaldehyde, glutaraldehyde, and xylene.
  • Ordering Radiology/Imaging Studies Policy (v3)
    In order to perform a Radiology/Imaging study for Inpatients and Outpatients at AU Medical Center (AUMC), an appropriate clinical indication and a signed order are required from a physician or other provider.
  • Organ Donation After Cardiac Death and Imminent Death Potential Organ Donation Policy (v2)
    This policy outlines the procedure for referral, authorization, medical management, and recovery of organs for transplantation through donation after cardiac death (DCD). This policy highlights the rights of patients and their families related to options for organ donation and decision making regarding these options when timing of death is determined by withdrawal of mechanical support. With the reality of individuals dying every day awaiting organs for transplantation, AU Medical Center (AUMC) will make reasonable efforts to identify potential organ donors and to cooperate in the procurement of anatomical gifts.
  • Organ, Eye, Tissue Donation Policy (v3)
    The purpose of this policy to establish guidelines for communication with families of potential donors and to develop procedures to follow in coordinating the procurement of eyes, organs and tissues. Recognizing that eye, organ, and tissue donation saves lives and improves quality of life and that anatomical gifts offer consolation to the bereaved next-of-kin/guardian of a donor, AU Medical Center (AUMC) actively participates in eye, organ, and tissue donation programs. To this end, the next-of kin/guardian of medically suitable potential eye, organ, and tissue donors will be informed of the option of making anatomical gifts. Hospital management will maintain a working relationship with the AUMC’s Tissue and Donor Services, LifeLink of Georgia Organ Procurement Organization, and the Georgia Eye Bank to facilitate the implementation of next-of kin/guardian desires regarding eye, organ, and tissue donation.
  • Personal Appearance Policy (v5)
    AU Medical Center (AUMC) employees are expected to maintain a high standard of neatness and personal hygiene. Personal appearance must meet safety and cleanliness standards to ensure patient and staff protection. If an employee is uncertain about dress requirements in his/her department, the employee should consult with his/her immediate supervisor.
  • Portable Medical Gas Policy (v2)
    This policy establishes procedures to be followed when cylinders are required to be store on a unit or smoke compartment for emergency or transport use.
  • Serious Reportable Events Policy (v2)
    The NQF-Endorsed® Serious Reportable Events are an ongoing effort to enable healthcare quality and safety improvement through introduction of tools for assessing, measuring, and reporting organizational performance. The purpose of the NQF-endorsed list of Serious Reportable Events in Healthcare is to facilitate uniform and comparable public reporting to enable systematic learning across healthcare organizations and systems and to drive systematic national improvements in patient safety based on what is learned—both about the events and about how to prevent their recurrence. AU Medical Center (AUMC) is committed to reducing and eliminating Serious Reportable Events. As such, this policy is intended to standardize AUMC’s response to a potential Serious Reportable Event and to facilitate the investigation, response to the patient and reporting of such events.
  • Surgical Attire Policy (v2)
    Personnel working in an operating room (OR), OR-like, Hybrid suites will wear the appropriate surgical attire relative to each traffic zone and personnel status as listed below while adhering to AORN Recommended Guidelines.
  • Temperature and Humidity Monitoring in Operating Suites Policy (v2)
    It is the intent of AU Medical Center (AUMC) Facilities Support Services to provide all Operative Services with proper HVAC equipment and controls to monitor temperature and humidity levels. Facilities Support Services will reference the following guidelines for temperature and humidity ranges, AIA Guidelines for Construction, The American Institute of Architects, and AORN - Association of Perioperative Registered Nurses.
  • Transfer of Patient via AUMC Transfer Center Policy (v2)
    All requests from outlying hospitals for transfer 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/or the tenets of this policy. All transfer requests are managed by the AUMC Transfer Center or AUMC Emergency Communications Center (ECC), both available at 706-721-5600. The Transfer Center and ECC are staffed 24 hours per day, seven (7) days a week. AUMC does not determine a patient's stability for transfer. The transferring physician does. Transfer Center and ECC calls include Attending Physician to Attending Physician discussions regarding referrals for care, e.g., inpatient, procedures, consults, inquiries, etc. Transfer Center and ECC calls are recorded for quality assurance and training purposes.
  • Vascular Access Device Policy (v1)
    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.'