New and Revised Policies

Medical Center New and Revised Policies

University New and Revised Policies

University Policies


Medical Center Policies that were approved in October 2018

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  • Financial Assistance Policy (v3)
    To establish a systematic process for the provision and determination of indigent and charity
    care services commensurate with resources and the mission of AU Health. This policy covers
    the financial screening process for uninsured patients seeking medically necessary services
    provided by AU Health.
  • Emergency Eye Wash Policy (v2)
    Drenching and/or flushing equipment is 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.
  • Airflow Testing and Balancing Policy (v3)
    AU Medical Center (AUMC) is committed to providing an environment for Special Procedure
    Rooms, Operating Suites, Isolation Rooms, Autopsy Rooms, Stem Cell Transplant, Electro
    Physiology Laboratory, General Laboratories, Cardiac Catheterization Laboratory and Central
    Sterile Reprocessing that meet guidelines pertaining to minimum air changes per hour and
    pressure relationships to adjoining areas. This policy provides procedures for testing and
    balancing of identified areas by Facilities Support Services and Infection Prevention.

  • Hazardous Materials Spill Plan Policy (v2)
    Safe and appropriate response to an accidental release or spill of hazardous materials is
    essential to the safety of employees, patients and visitors. In order to ensure that the employees
    of AU Medical Center (AUMC) can perform their responsibilities in case of a spill or release, the
    following procedures are provided.
  • Emergency Operations Plan
    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. The planning activities used to develop this EOP were conducted by the Critical Events Preparedness and Response (CEPaR) office, in conjunction with healthcare system leadership and medical staff.
  • Falls Prevention and Management Policy (v4)
    It is AU Medical Center’s (AUMC) policy to establish a multidisciplinary approach to prevent falls
    and reduce risk of injury from falls. This policy will outline the AUMC Falls Prevention and
    Management Program to include establishment of procedures to assess fall risk,
    implementation of fall reduction strategies and description of documentation procedures and
    post-fall management.

  • Document Retention Policy (v1)
    AU Medical Center (“AUMC”) is required to retain certain records for specified periods
    according to state and federal law. In order to maintain compliance with the document
    retention requirements for healthcare providers this policy will provide the guidelines
    necessary for adherence to these regulations.

  • Interim-Life Safety Measures policy (v4)
    This policy establishes minimal procedures to be followed during periods of construction or other situations which may interfere with or temporarily interrupt life safety measures present in AU Medical Center (AUMC). The purpose of this policy is to define criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.
  • Acceptable Use of Electronic Mail & Electronic Messaging Policy (v1)
    This policy establishes standards for the acceptable use of electronic messaging and applies to
    electronic mail (email), instant messaging, and any other messaging technology as defined in
    the policy. Augusta University utilizes the domain for its email platform, and this is
    the single official university email system.

Medical Center Policies that were approved in September 2018

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  • Solicitation and Visitor Policy (v3)
    AUMC prohibits the solicitation, distribution and posting of materials on or at AUMC property by an employee or non-employee, except as may be permitted by this policy. The sole exceptions to this policy are charitable and community activities supported by AUMC and AUMC-sponsored programs related to AUMC products and services.
    Approved 9/25/2018
  • Reporting of Abuse, Rape, Sexual Assault, and Domestic Violence Policy (v3)
    All healthcare providers are responsible for recognizing and reporting the signs of possible abuse. Healthcare providers are responsible for following the guidelines for reporting any suspicion of possible abuse as outlined in this policy, and for following the mandatory reporting of suspected child abuse under Georgia law. See OCGA § 19-7-5, copy attached. The policy is not a substitute for mandatory reports of child abuse under Georgia law.
    Approved 9/24/2018
  • Substance Abuse Policy (v2)
    AU Health System (AUHS) is committed to providing a safe work environment and to fostering the well-being and health of its employees. That commitment is jeopardized when any AUHS employee illegally uses drugs on or off the job, comes to work under the influence of drugs or alcohol, or possesses, distributes or sells drugs in the workplace.
    Approved 9/24/2018
  • Fraud, Waste and Abuse Prevention Policy (v2)
    This policy reiterates AUMC’s commitment to obey all federal and state laws and to implement procedures to detect fraud, waste and abuse with respect to payments from federal and state programs that provide payments for patient care, and to protect those who report suspected or actual wrongdoing.
    Approved 9/24/2018

Medical Center Policies that were approved in August 2018

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  • Relocation Assistance Policy (v3)
    As a part of AUMC’s commitment to recruiting the most qualified candidates, we also recruit candidates from locations outside of the immediate area. Therefore, we may provide monetary assistance and reimbursement to new employees who accept an offer of employment with us and may choose to relocate from another area. Under the IRS guidelines, AUMC has a Non-Accountable Plan.
    Approved 8/29/2018
  • Serious Reportable Events Policy (v1)
    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.

    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.
    Approved 8/28/2018

  • Adult Patient Elopement Policy (v5)
    The purpose of this policy is for AUMC to enact the proper and appropriate procedures for maintaining the safety of patients, staff and others at all times. It is the policy of AUMC that the medical center shall take responsibility for individuals placed in its inpatient facilities for treatment regardless of voluntary or involuntary status. Patients who have eloped, that is absent themselves from the treatment modality without permission, are interrupting their treatment. This interruption is detrimental to the patient, and shall be viewed as a serious matter. It is the responsibility of AUMC to respond appropriately in the event of an elopement of patients with various legal statutes.
    Approved 8/14/2018
  • Workplace Violence Prevention Policy (v3)
    AUMC is committed to keeping the workplace safe where employees, patients, families, and visitors are free from the threat of workplace violence. AUMC’s policy on workplace violence is a zero tolerance policy. This policy defines behavior that constitutes workplace violence and defines procedures for responding to and resolving workplace violence.
    Approved 8/14/2018
  • Transport between Charlie Norwood Veterans Affairs Medical Center and AU Medical Center Policy (v3)
    This policy outlines the process for safe transport, while executing a facility-to-facility transfer, between the CNVAMC and AUMC. In most cases transport occurs by utilization of the 2nd floor crosswalk that links both institutions. All transfers follow the same process to ensure consistency and standardization between the two institutions. Transfers can occur for various reasons, i.e. inpatient admissions, emergent conditions, or utilization of each institution’s procedural areas.

    This policy also contains addendums that map out the process in detail for various specific types of situations. These situations include the AUMC to CNVAMC process, the CNVAMC to AUMC Non-Emergent process, the CNVAMC to AUMC Emergent process, the CNVAMC to AUMC Transfers for Imaging process, and the CNVAMC STEMI Alert process.
    Approved 8/14/2018

  • Utilization Review Plan (v3)
    AUMC strives to delivery safe, quality patient centered care in order to achieve improved patient health outcomes in an efficient and cost effective manner. The Utilization Review Plan is designed to align with the Quality Indicators of the hospital and enhance the patient care process through the systematic assessment and continuous improvement of both clinical and operational performance. This plan is developed in accordance with the requirements of the Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation and Georgia Medicaid Conditions of Participation.
    Approved 8/14/2018
  • Purchasing Card Policy (v1)
    The Purchasing Card (PCard) provides an efficient method for making business related purchases. Purchases are charged directly to the department's designated cost center and AUMC issues one monthly payment for all PCard purchases. The card may be used for most small dollar purchases.
    Approved 8/11/2018
  • Indoor Air Quality Policy (v2)
    AUMC is committed to ensuring that pollutants/contaminants from other sources are reported and investigated in order to provide a safe indoor environment for patients, visitors and staff. This policy addresses issues of Indoor Air Quality (IAQ) on a proactive, maintenance and emergency response basis and commits the facility to the correction of IAQ deficiencies.
    Approved 8/2/2018
  • Rules and Regulations FY 19 (v6)
    Approved 8/2/2018
  • Medication and Tubing Labeling in Patient Care Areas Policy (v4)
    All personnel must label any medication, medication container or other solution that is prepared on and off the sterile field with the name of the medication/solution, the concentration/strength, the amount (i.e., if not apparent from the container), expiration date when not used within 24 hours and expiration time when expiration occurs in less than 24 hours. Items prepared and immediately administered by the same person not to leave that individual’s hands (e.g., IV push, etc.) are exempt from the labeling requirement.

    Items prepared by the Department of Pharmacy are outside of the scope of this policy.
    Approved 8/2/2018

  • Focused Professional Practice Evaluation (FPPE) Policy (v4)
    To enhance the quality and safety of patient care, each clinical department is responsible for monitoring and evaluation of the professional practice of their privileged staff. The process for ongoing professional practice evaluation (OPPE) is outlined in Policy No. 164. In addition to the OPPE, a period of appropriate focused professional practice evaluation (FPPE) occurs in certain circumstances.
    Approved 8/2/2018
  • Patient Rights and Responsibilities Policy (v4)
    AUMC is committed to providing safe, quality medical care to every patient. It is our policy to respect the individuality and dignity of every patient. We support the patient’s right to know about their medical condition and the right to participate in the decisions that affect their well-being.

    Each patient, or when appropriate, the patient’s legal representative, will be informed of the Patient Rights and Responsibilities in a language or manner that the patient or the patient’s representative can understand. Whenever possible, this notice will be provided before providing or stopping care.
    Approved 8/2/2018

  • Family Presence Visitation Policy (v3)
    AUMC promotes and supports a patient- and family-centered approach to care. Patients and their families (spouse, life partner, or partners in care) are respected as essential members of the health care team, helping to ensure quality and safety. Patients define their family and how they will be involved in care, care planning, and decision-making. Family members, as identified by patients when possible, provide support, comfort, and important information. While we strongly encourage the presence of family and care partners, occasional limitations and/or exceptions are at the discretion of the interdisciplinary team responsible for the patent’s care and include consideration of the following: the patient’s request, care and treatment, patient’s safety and sense of security or to enhance the patient’s response to treatment.

    The purpose of this policy is to define and set expectations for family presence with families, guests, and partners in care. Our commitment is in accordance with AU Health’s nondiscrimination statement which provides access without regard to race, color, sex, national origin, disability, age, religion, marital status, citizenship, gender identity, gender expression, sexual orientation, and/or other legally protected classification.
    Approved 8/2/2018

Medical Center Policies that were approved in July 2018

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  • Scheduled Medical Gas interruption Policy (v2)
    This policy establishes a process for the scheduled interruption of medical gases within the AU
    Medical Center (AUMC).
    Approved 7/5/2018
  • Provider Coverage for Clinics Policy (v3)
    It is the policy of AU Medical Center (AUMC) that providers are present in the clinic at the time of the first scheduled appointment and remain until all of their patients have been seen. There is scheduled coverage during normal clinic hours (8AM to 5PM) or at the start of the earliest open clinic. Providers coordinate schedules to facilitate minimum patient wait times.
    Approved 7/8/2018
  • Emergency Medical Treatment & Labor Act (EMTALA) Policy (v3)
    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 AU Medical Center (AUMC) are managed in accordance with EMTALA and the tenants of this policy. Care is provided to individuals seeking emergency services without regard to their ability to pay, race, ethnicity, religion, national origin, citizenship, age, sex, preexisting medical condition, physical or mental handicap, or insurance status.
    Approved: 7/16/2018
  • Rules of Conduct Policy (v4)
    AU Medical Center (AUMC) is committed to providing and maintaining a productive, professional work environment. AUMC expects and requires every employee to meet certain behavioral standards and observe basic rules of conduct. Rules of conduct are necessary to protect the health and safety of employees, patients, and visitors, maintain the quality of services provided, and ensure a high level of professional behavior is maintained by employees. Employees who violate AUMC rules of conduct will be subject to disciplinary action, up to, and including termination of employment. Disciplinary action will be fairly and consistently applied in proportion to the seriousness of the violation. Disciplinary action may include verbal coaching, written counseling, and/or discharge of employment.
    Approved: 7/18/2018
  • Tobacco-Free Policy (v2)
    University and AU Medical Center (AUMC) prohibits the use of tobacco products on any property owned, leased Augusta or controlled by Augusta University, AMC or AU Medical Associates (AUMA). The use of tobacco products is widely accepted as a leading cause of avoidable death. The mortality and morbidity of tobacco use has adverse effects among tobacco users and non-users alike including respiratory disorders, heart disease and various forms of cancer. Tobacco smoke contains over 7,000 chemical compounds, more than 70 of which are known or suspected to cause cancer. People exposed to second hand smoke absorb nicotine and other toxic chemicals just as smokers do. Because of the deleterious effects of tobacco use, Augusta University, AUMC and AUMA have committed to a tobacco-free campus for the purpose of promoting a health environment for all persons, including faculty, students, staff, visitors, and others who visit the campus.
    Approved: 7/18/2018
  • Adult Patient Elopement Policy (v4)
    AU Medical Center (AUMC) is committed to the safety of all patients. Therefore, formal policies and procedures have been established to ensure an effective response in the event of a patient elopement.
    Approved: 7/22/2018
  • Badge Identification Policy (v2)
    AU Medical Center (AUMC) is committed to ensure that additional safeguards are in place for the safety and security of all AU Health Caregivers, Patients and Families. All Caregivers to include credentialed medical staff, employees, agents, students and volunteers as well as all vendors requiring badge identification are issued and are required to carry or wear a photo identification badge while on duty or conducting business on AU Health grounds and facilities.
    Approved: 7/30/2018

Medical Center Policies that were approved in June 2018

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  • Look-alike/Sound-alike List and Medication Error Prevention Strategies (v3)
  • Information Security Risk Management Policy (v2)
    It is the policy of AU Medical Center (AUMC) to conduct thorough and timely risk assessments of the potential threats and vulnerabilities to the confidentiality, integrity, and availability of its electronic protected health information (ePHI) (and other confidential and proprietary electronic information) and to develop strategies to efficiently and effectively mitigate the risks identified in the assessment process as an integral part of the organization’s information security program.
    Approved: 6/12/2018 
  • Equipment- Appliances for Non Patient Care Use Policy (v3)
    AU Medical Center (AUMC) shall take every precaution to protect all persons and building contents from hazards arising from the use of non-patient care, electrically-powered, line operated equipment in patient rooms and all other areas of the facility and AUMC properties. This policy outlines the requirements for all equipment and appliances and staff responsibility.
    Approved: 6/18/2018
  • Decorations and Displays Policy (v2)
    AU Medical Center (AUMC) makes every effort to assure the maximum safety for all patients, visitors, and staff. One of the greatest fire risk occurs as a result of decorations and displays. AUMC is committed to providing a safe environment, free from these potential risks as well as providing guidelines for the use of safe and appropriate decorations and displays. These rules apply year round and to all AUMC properties.
    Approved: 6/18/2018
  • Re-Hiring of Employees Policy (v3)
    AU Medical Center may consider former employees for employment provided the individual meets the requirements for the position and is eligible for rehire.
    Approved 6/18/2018
  • Patient Meals, Nourishments and Floorstock Policy (v1)
    Patient meals and snacks are provided through Expressly for You Dining Program, which is a host/hostess room service dining program. The host/hostesses, called Food and Nutrition Service Ambassadors, work directly with the nursing units, the clinical dietitians, and Food Services staff to take appropriately ordered meal selections from the patients, fill the selections and deliver meals and nourishments appropriately. Ambassadors also deliver floor stock and snacks to the units.
    Approved 6/18/2018
  • Document Development, Approval and Maintenance Policy (v1)
    Policies and Procedures, Clinical and Nonclinical Guidelines, Clinical Protocols, and Standard
    Operating Procedures (SOP), 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 PolicyTech, AUMC’s electronic policy library. AUMC documents are thoroughly reviewed, maintained, and made available to the AUMC community to promote awareness, compliance, and accountability.
    Approved 6/18/2018
  • Employee Transfer Policy (v2)
    It is the policy of AU Medical Center (AUMC) to allow employees the opportunity to further their professional development by applying for open positions. AUMC is committed to the career development of employees who have demonstrated their competency and contributed positively to the organization. Transfer selections are based upon the operational needs of the organization and the hiring department. The goal is to select the best-qualified candidate. Managers should be supportive of their staff who want to enhance their skills or develop new competencies to pursue different or greater responsibilities internally.
    Approved: 6/18/2018
  • Resident Bedside Procedure Policy (v1)
    This is an AU Medical Center (AUMC) policy governing resident’s performing bedside procedures.
    Approved 6/22/2018
  • Handling of Deceased Patients Policy (v1)
    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 (AUMC).
    Approved 6/22/2018