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November 2019
Acute Care Restraints and Seclusion Policy (v4), #942
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).
Adult High Risk Airway Response Team Policy (v1), #4626
To provide process for a multidisciplinary high risk airway team (HRAT) composed
of personnel who have specialized training in managing adult tracheostomy, laryngectomy,
T-tube, post airway reconstruction and other high risk airway patients, and who can
respond in an emergency with specialized equipment to assist with airway management.
Autopsy Policy (v3), #477
It is the policy of AU Health to promote a compassionate and consistent approach
to matters related to autopsies. This includes obtaining proper consent for autopsies,
performance of autopsies and use of information gathered from autopsies. Results and
information obtained will be provided to the family by Health Information Management
Services (HIMS) and may be used for the education of medical students, residents,
medical staff and other healthcare workers as necessary.
Bed Bug Prevention and Response Policy (v2), #1091
Any suspicion of a bed bug activity is grounds for immediate action and notification
of the appropriate team members. Vigorous action, treatment and re-inspection will
continue until there is no further evidence or indication of bedbug activity or potential
for infestation. Facilities services representative provides the official word that
no activity is found and patient care space can be utilized. This policy provides
requirements for establishing and maintaining protocol to promote safe, efficient,
and environmentally-preferred strategies designed to prevent or control bedbug activity
that may adversely affect health, impede operations, and/or damage property.
Charge Capture and System Testing Policy (v1), #4637
Successful optimization of a hospital patient accounting system is defined early
by minimal impact to gross revenue organization-wide and for each individual cost
center. To achieve this success, significant efforts should focus on design, build,
testing, and auditing of appropriate for both professional and facility.
Chlorhexidine Gluconate (CHG) Daily Bathing SOP (v2), #671
This SOP provides direction on daily bathing with chlorhexidine gluconate (CHG).
Bathing will be performed on patients greater than two months of gestational age in
an intensive care unit and the Bone Marrow Transplant unit, except the Neonatal Intensive
Care Unit. Patients with acute leukemia regardless of their bedded location will also
receive daily CHG bathing provided they are greater than two months of age.
Clinical Laboratory Specimen Labeling Policy (v4), #312
The policy applies to all specimens submitted to the Clinical Pathology Laboratory
of the AU Health System, whether for testing in-house or by referral to a CLIA-approved
reference laboratory. The policy also applies to specimens submitted to the Histocompatibility
Immunology Laboratory except as noted. Adherence to the specimen labeling requirements
contained herein is necessary to ensure that all testing and reporting is performed
on specimens with unique and accurate patient identification and to meet the requirements
of regulatory agencies.
Conflict Resolution Policy (v3), #112
It is the policy of AU Health to give employees an outlet to voice suggestions, issues,
or complaints to internally resolve employee conflicts, disagreements, and issues
with work or working conditions fairly, promptly and at the lowest organizational
level through the chain of command.
Consent and Authorization for Patient Photograph, Videotaping and other Imaging for
Treatment and Operations Policy (v3), #179
The purpose of this policy is to establish guidelines for the use of cameras and
video recording devices and to protect the privacy and security of patients and their
confidential information.
Credentialing and Privileging for Robotic Surgical Platforms Policy (v1), #4257
This policy is intended to guide and regulate the process for credentialing of surgical
staff for privileges for robotic surgical systems (e.g. Da Vinci Surgical Robot).
De-Identification of Protected Health Information and Limited Data Sets (v3), #180
This policy outlines how AU Health may use protected health information (PHI) to
create de-identified information, that is, information that has been stripped of any
elements that may identify the patient, relatives, employers, and household members
of the patient, such as name, birthdate, or Social Security number. AU Health may
disclose properly de-identified information for any purpose.
Discharge Dispute Policy (v4), #830
It is the policy of AU Health (AUHS) to allow employees recently discharged involuntarily
the opportunity to internally dispute the discharge.
Electroconvulsive Therapy Policy (v2), #899
The policy is intended to provide guidelines for delivery of care for patients receiving
electroconvulsive therapy (ECT). The policy ensures responsible licensed personnel,
who direct or provide patient care will comply with standards of care within their
scope of practice for all patients that receive ECT. Specific practices will be integrated
into the assessment, planning, prioritizing, delivery and documentation of patient
care. ECT is provided for inpatients and outpatients for whom this treatment is indicated,
as determined by the ECT Attending. These include, but are not limited to the following
indications: Depressive Disorders, Bipolar and Related Disorders, Schizophrenia Spectrum
and other Psychotic Disorders, Schizoaffective Disorder, Catatonia, Medication-Induced
Movement Disorders and Other Adverse Effects of Medication, Parkinson’s disease, Status
Epilepticus.
Employee Benefits Policy (v3), #140
AU Health System (AUHS) provides comprehensive and cost-efficient benefits to eligible
medical center employees and their dependents based on employment status, length of
service, and other criteria, as part of their total compensation package. In addition
to core benefits, such as health, dental, vision and life insurance, the Health System
also offers family-friendly benefits and employee assistance unique to medical center
employees.
Employee Care Program Policy (v3), #141
This policy outlines the types of programs offered to health system employees in
need of assistance who may be experiencing financial difficulties due to temporary
unforeseen or emergent personal crises.
Employee Transfer Policy (v3), #133
It is the policy of the health system to allow employees the opportunity to further
their professional development by applying for open positions. The health system 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 wish to enhance their skills or
develop new competencies to pursue different or greater responsibilities internally.
Enteral Feedings Policy (v2), #1167
Infection prevention and control standards are followed to prevent contamination
during the administration and maintenance of enteral tube feedings.
Environment of Care (EOC) Rounds Policy (v2), #655
A multidisciplinary team conducts Environment of Care (EOC) rounds in patient care
areas semi-annually and in non-patient care areas annually to identify environmental
deficiencies, hazards and unsafe practices associated with infection prevention, safety
and security, fire, hazardous materials and waste, medical equipment, and utility
systems. Proactive interventions will be implemented to mitigate identified risks.
Healthcare personnel will be educated regarding the elements of a safe environment
during the rounds.
Equipment Pre Order-Pre Use Evaluations Policy (v2), #266
AUHS will ensure that all equipment purchased and installed for use within the AUHS
entities meets all applicable health and safety codes, and standards and licensure/
accreditation requirements for their effective and safe operation.
Formulary Management, Drug Selection, Drug Procurement and Drug Storage Policy (v2),
#1052
This policy exists to assure the safe use of medications, including selection, purchase,
storage and maintenance of an adequate inventory of all pharmaceuticals, intravenous
solutions and supplies for dispensing and administering to patients.
Hiring of Relatives (Nepotism) Policy (v3), #134
It is the policy of AU Health System that relatives of persons currently employed
by any entity within the health system may be hired as long as the hire does not result
in the existence of a subordinate-superior relationship between such individual and
any relative of such individual through any line of authority. Relationship by a family
or marriage shall constitute neither an advantage nor a disadvantage.
Hours Worked Policy (v3), #333
The Fair Labor Standards Act (FLSA) requires nonexempt employees be paid at least
the minimum wage for “hours worked” and be paid overtime wages for “hours worked”
in excess of forty(40) during any workweek. Broadly defined, “hours worked” includes
any time an employee is required to be at work or on duty, is under the employer’s
control, or is performing activities which are primarily of benefit to the employer.
Human Milk Misadministration Management Policy (v3), #1089
All AU Medical Center (AUMC) employees administering human milk will follow the Human
Milk Storage and Handling policy to prevent misadministration. The following provisions
will be followed should an incident of misadministration occur.
Infection Prevention and Control for Cystic Fibrosis Patients Policy (v2), #656
Based upon best practices for the care of cystic fibrosis patients, expanded infection
prevention and control guidelines are to be implemented and used when caring for all
cystic fibrosis (CF) patients to minimize the risk of transmitting pathogenic organisms.
Investigational Drug Services policy (v2), #2250
This policy exists to ensure compliance with all regulations and standards governing
investigational drug use in patients within AU Medical Center (AUMC). Investigational
drug studies and other clinical trials conducted at AUMC facilities and campus buildings
must contain adequate safeguards for the institution, its staff, the scientific integrity
of the study and, especially, the patient. All studies involving drug use in humans
at Augusta University (AU) must be reviewed and approved by a university recognized
institutional review board (IRB). Hospital approval is also required when a study
or research project plans to conduct research (and/or recruit patients) at an AUMC
location or access any institutional patient information. The medical center has a
procedure to review and accommodate patient’s continued participation in a protocol
that is independent of the hospital.
The Clinical Research Pharmacy is responsible for the receipt, storage, labeling,
dispensing, accountability and record-keeping for all research medications used in
research studies involving humans throughout AUMC, including the adult Medical Center,
the Children’s Hospital of Georgia, Georgia Cancer Center, the Medical Office Building
and the Georgia War Veterans’ Nursing Home (GWVNH). These services are also provided
to other components of Augusta University or Augusta University Health upon request.
The Clinical Research Pharmacist (Pharmacy Manager) is responsible for implementation
of this policy.
Lactation Support Policy (v3), #324
AU Health recognizes the well documented health advantages of breastfeeding for infants
and mothers and the critical nature of workplace support for breastfeeding success,
as well as the importance of setting a positive example in support of AU Health employees.
The AU Health Lactation Support Policy contains the minimum standards needed for workplace
support of the breastfeeding or expressing mother.
Management of Corrugated Cardboard policy (v1), #4345
This policy applies to all AU Health workforce members working in the clinical areas
of the hospital and clinics. Exceptions to this policy include kitchens and dining
facilities, which are subject to the inspection by state and/or county health departments,
and laboratory areas which are subject to the inspection by the College of American
Pathologists.
AU Health maintains processes to assure safe management of raw corrugated cardboard.
The purpose of this policy is to mitigate infection risks related to medical equipment,
devices, and supplies stored in raw corrugated cardboard boxes.
It is the responsibility of the local leadership in clinical areas to apply this
policy to their space. Unit staff are to dispose of the corrugated cardboard in the
designated locations as assigned by EVS. For routinely ordered PAR items, Supply Chain
personnel will remove all items from raw corrugated cardboard boxes prior to stocking
the PAR location. Those items ordered on the bulk template must be signed for, dated,
and time recorded at the time of delivery from Receiving. Bulk supplies delivered
to nursing units in corrugated boxes must have said boxes broken down by unit staff
and removed from the unit within 24 hours of delivery.
Management of Hand Dermatitis and Natural Rubber Latex Sensitivity Policy (v3), #292
Out of concern for employee health and safety, AU Health System, Inc., has replaced
almost all latex products in the hospital and clinics with non-latex alternatives
and by minimizing latex exposure to a level as low as is reasonably achievable. This
policy delineates the responsibility of Employee Health and Wellness, Human Resources
in monitoring and managing of occupational-related hand dermatitis due to contact
with irritants, including, but not limited to, soap/water hand hygiene, cleaning supplies,
protective equipment, natural rubber and other workplace irritants.
Medical Product, Device & Recalls Policy (v3), #251
AU Health System, to include AU Medical Center and AU Medical Associates (“AU Health”),
will receive medical product and device safety alerts and recalls via multiple sources:
letter, facsimile, telephone, email- or through subscription with independent services
(i.e. ECRI Alerts Tracer Web-based system). Departmental end-users will take appropriate
action to resolve these notifications by following this policy’s provisions concerning
medical product device and recalls.
All medical product and device safety alerts and recalls are distributed to appropriate
individuals and departments, so that corrective action may be taken and monitored
to ensure the safety of AU Health patients, visitors, and staff. A comprehensive,
organization-wide process, which is in compliance with requirement for accreditation
for regulatory agencies (i.e. Joint Commission, FDA, College of American Pathologists),
has been established for receiving, reviewing, resolving and reporting on all medical
product and device safety alerts and recalls.
Medical Record Forms Management Policy (v3), #242
Only forms approved by the Medical Record Forms Committee should become part of the
AU Medical Center patient’s permanent medical record.
The Medical Record Forms Committee will ensure that every approved medical record
form serves a desired purpose and is clearly identified as an AU Medical Center medical
record form. The committee will reject unnecessary, non-standard, or poorly designed
forms that interfere with the efficient administration of patient care and result
in inadequate data collection, laxity in documentation, erroneous information, duplication
of effort, and other mistakes. In addition, the Medical Record Forms Committee will
ensure that only necessary forms are maintained, all forms are readily available to
users and can be permanently archived electronically and/or in hard copy in compliance
with hospital, state, and federal medical record retention policies.
Medication and Tubing Labeling in Patient Care Areas Policy (v5), #660
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. Personnel must also label all access lines and drains with
preprinted, color coded labels. Drain labels must have type of drain written on label.
Labels must be placed at the distal port of the tubing or drain closest to the access
site.
Items prepared by the Department of Pharmacy are outside of the scope of this policy.
Medication Order Revisions Policy (v2), #2249
This policy exists to assure the safe, effective and timely delivery of patient care
by describing the revisions that may be made by a pharmacist to a medication order
entered via computerized prescriber order entry. If the prescriber does not wish for
the order to be modified, he or she may write “Do Not Modify,” and the order will
be filled as prescribed.
Medication Reconciliation Policy (v1), #5163
This policy defines the standardized process used by AU Health for development, reconciliation,
and communication of an accurate medication list throughout the continuum of care.
Medication reconciliation prevents medication errors such as omissions, duplications,
contraindications, incorrect dosing, interactions, unclear information, and errors
of transcription. This policy applies in all AU Health settings where medication-related
patient care occurs (e.g., ambulatory, emergency and urgent, inpatient, and procedure
areas).
Mitigation for Improper Use and Disclosure of Protected Health Information Policy
(v3), #189
AU Health must mitigate to the extent practicable any harmful effects that become
known as a result from an improper and/or impermissible access, acquisition, use or
disclosure of protected health information (PHI) or in violation of the AU Health
privacy policies and procedures.
Non-Patient Invoicing Policy (v3), #722
To provide AUHS employees guidance on having non-patient invoices prepared and adjusted.
This policy focuses on invoicing and adjustments due to non-patient activity that
results in a related party or external company owing payment to AUHS.
Nursing Documentation Policy (v2), #3299
The nursing care documentation guidelines in this policy will be adhered to in order
to assure care is provided to and documented for each patient based on a nursing assessment.
The documentation of assessment, plan, intervention, and patient response shall occur
as close to the real time of occurrence as possible. The goal of the assessment is
to determine the care, treatment, and services that will meet the patient’s initial
and continuing needs.
Patient Radiation Dose Management Policy (v2), #3850
AU Medical Center (AUMC) is committed to the safe and effective use of diagnostic
radiation. Medically necessary imaging procedures can give radiation exposure to the
patient and, since excess radiation exposure carries risks, efforts are made to eliminate
avoidable exposure.
The purpose of this policy is to provide guidelines for radiation dose management
and patient follow up related to imaging procedures at AUMC.
Patient Safety Event Reporting Policy (v4), #379
*The Management of Sentinel Events Policy and Serious Reportable Events Policy have
been combined with the Patient Safety Event Reporting Policy. These separate policies
have been archived and are no longer viewable on PolicyTech.
AU Health System is committed to improve the quality and safety of patient care through
the following:
Within a culture of safety, there is continuous reporting of patient safety events,
near misses and hazardous conditions so these occurrences can be analyzed and processes
can be changed or systems improved.
Reporting is essential to the identification and evaluation of errors for the purpose
of identifying root causes and trends which leads to improving processes which is
essential to reduce risk and prevent patient harm. All team members are required to
participate in the detection and reporting of any error, medication error, near miss,
hazardous/unsafe condition, process failure, injuries involving patients, visitors
and staff or a sentinel event.
Patient Skin Antisepsis for Operative and Invasive Procedures Policy (v1), #4437
The goal of skin antisepsis is to remove dirt, skin oil and transient organisms at
the surgical site to reduce the risk of surgical site infection. This policy applies
to all staff AUMC staff who perform skin preparations for surgical and/or invasive
procedures.
Patient’s Right to Request Access to Protected Health information for Inspection and/or
Copying Policy (v3), #1135
Patients and their personal representatives have the right to access, inspect and
obtain a copy of their protected health information (PHI) that is maintained in the
designated record set unless an exception applies.
PHI maintained electronically in the designated record set must be provided in the
electronic form and format that the patient or personal representative requested if
the PHI can be produced in the electronic form and format requested by the patient
or personal presentative.
Pediatric High Risk Airway Response Team Policy (v1), #5125
To provide process for a multidisciplinary high risk airway team (HRAT) composed
of personnel who have specialized training in managing pediatric tracheostomy, laryngectomy,
T-tube, post airway reconstruction and other high risk airway patients, and who can
respond in an emergency with specialized equipment to assist with airway management.
Pest Prevention and Control Policy (v2), #1092
For patient safety, and to increase compliance with environment of care standards,
outside food and drink must not be allowed in patient care areas within the Intensive
Care Units (ICUs). Food and drink brought from outside the medical center and stored
in a patient’s room on a general inpatient unit should be done in a manner preventing
the attraction of pests.
The Centers for Disease Control (CDC) recommends well developed pest control strategies
in high risk areas and areas prone to infestation, as infestation can be linked to
infection. The Association for Professionals in Infection Control and Epidemiology
(APIC) recommends educating staff, patients, and care partners/families to ensure
no food is kept in drawers/closets of patient rooms to prevent pest related disease/infection.
Pharmaceutical Waste Management Policy (v1), #5192
The purpose of this policy is to define the process of proper disposal for pharmaceutical
waste in compliance with the Environmental Protection Agency, the Drug Enforcement
Agency, and other regulatory bodies.
Pre-Admission Communicable Diseases Screening Policy (v2), #843
This policy will establish mechanisms to readily identify patients who may be incubating
a common, communicable disease, in order to promptly initiate Transmission-based Precautions,
thereby preventing transmission to unknown, susceptible individuals. These diseases
include, but are not limited to, varicella zoster (chickenpox), herpes zoster (shingles),
rubella (German measles, three-day measles), rubeola (measles, red measles), infectious
parotitis (mumps), Bordetella pertussis (whooping cough), and Mycobacterium tuberculosis
(MTB, TB).
Pre-Cleaning and Transportation of Instrumentation Policy (v1), #4607
To ensure infection prevention practices are followed during pre-cleaning and transport
of reusable contaminated instruments or devices to the reprocessing area.
Prevention and Management of Clostridioides (Clostridium) Difficile Policy (v1), #4715
Clostridium difficile (C. difficile) is a spore-forming, gram positive anaerobic
bacillus that produces two exotoxins, toxin A and toxin B, which cause diarrhea and
colitis in susceptible patients whose normal colonic bacterial flora has been disrupted
by antimicrobial treatment. C. difficile infection may result in pseudomembranous
colitis, toxic megacolon, perforation of the colon, or sepsis.
Surgical Attire Policy (v3), #909
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.
Surveillance of Occupational Exposure to Hazardous Drugs and Chemicals Policy (v3),
#294
The medical surveillance of employees who are potentially exposed to chemical hazards
is to be monitored systematically with the intention to prevent occupational injury
and disease. The purpose of this surveillance program is to identify the earliest
reversible biologic effects so that exposure can be reduced or eliminated before the
employee sustains irreversible damage.
Transcranial Magnetic Stimulation policy (v2). #1137
The policy is intended to provide guidelines for delivery of care for patients receiving
transcranial magnetic stimulation therapy (TMS). The policy ensures responsible licensed
personnel, who direct or provide patient care will comply with standards of care within
their scope of practice for all patients that receive TMS. Specific practices will
be integrated into the assessment, planning, prioritizing, delivery and documentation
of patient care. TMS is provided for outpatients for whom this treatment is indicated,
as determined by the TMS Attending. Acceptable indications for TMS include but are
not limited to: poor response to antidepressant medications, contraindication for
antidepressant medication use or ECT, and past positive response to TMS. Indications
and exclusionary criteria for TMS are those generally consistent with FDA-approved
TMS devices, in conjunction with clinical judgment and the published evidence base
for this treatment modality.
Transporting Protected Health Information Policy (v2), #931
All protected health information (PHI) on paper and electronic protected health information
(ePHI) must be transported and stored in a secure manner to safeguard it against improper
disclosure and/or loss. ePHI will be securely stored or transported outside secure
network servers only when necessary and should not be printed or recorded for unapproved
purposes. Workforce members must remotely access electronic ePHI via Citrix or approved
virtual private network (VPN) instead of physically transporting PHI. Only the minimum
amount of PHI necessary to accomplish the purpose of the use/disclosure should be
transported.
Valuation of Inventory Policy (v2), #254
The inventory of AU Health is valued in a consistent manner and accurately reflected
in the AU Health Financial statements in accordance with Financial Accounting Standards
Board (FASB) guidelines and Generally Accepted Accounting Principles (GAAP). Inventory
is a valuable AU Health System asset and will be properly safeguarded. Consistent
compliance with the provisions of this policy reduces costs and ensures that supplies
are available when needed.
Vendor Access and Control Policy (v3), #164
This intent of this policy is to establish a uniform process for the management of
all vendor representatives doing or soliciting business with AU Health System entities;
ensure that all Vendor Representatives will adhere to AU Health System policies and
procedures, and will abide by the laws and regulations of the United States of America,
the State of Georgia, applicable accrediting agencies, and other regulatory standards
of practice. In addition, the policy provides guidance to control and monitor vendor
activity and assure appropriate vendor access to AU Health System entities; provide
guidance for appropriate vendor behavior throughout AU Health System entities; and
to ensure that all equipment and supply purchases, including new technology and pharmaceuticals,
are in compliance AU Health System’s Purchasing and Contracting practices.
Ventilator Initiation and Adjustments Policy (v1), #4048
The intent of this policy is to identify best practices and safe initiation and management
of mechanical ventilation.
Withholding or Withdrawing Medical Treatment Policy (v2), #425
This policy serves as a reference for understanding the medical-ethical questions
involved in decisions regarding withholding or withdrawing medical treatments. Whenever
there are questions regarding difficult or complicated cases involving withholding
or withdrawing medical treatments, the AU Medical Center Ethics Committee is available
for support. An ethics consult may be initiated by any staff member by calling 721-7475
(1-RISK) to speak with an attorney in the AU Health System Legal Office. After consultation
with the Legal Office, if an ethics consult is appropriate, the Legal Office will
be responsible for coordinating a day and time for the consult.
Work Restrictions Policy (v3), #299
Work restrictions for infectious diseases will be based upon the Centers for Disease
Control and Prevention’s (CDC) recommendations for health care workers and are listed
below. Return to work for these diseases is permissible when approved by the employee’s
Primary Care Practitioner or Employee Health and Wellness, Human Resources (EH&W).
When neither is available, the employee’s immediate Supervisor may approve their return.
Other potentially infectious conditions or diseases should be reported to EH&W. Employee
Health and Wellness may implement work restrictions based on the mode of transmission
and epidemiology of the disease.
The pregnant health care worker is not to be excluded from the care of patients with
particular infections solely on the basis of the pregnancy or intent to become pregnant.
Use of standard precautions is required by everyone regardless of pregnancy to reduce
exposure risks.
Workplace Violence Prevention Policy (v4), #889
AU Health System, Inc. (AUHS) is committed to keeping the workplace safe where employees,
patients, families, and guests are free from the threat of workplace violence. The
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 IN OCTOBER 2019
Petty Cash Reimbursement Policy (v2), #3703
The petty cash fund allows for reimbursement of minor business expenses of AUHS entities in an efficient and cost effective manner.
Equal Employment Opportunity Policy (v3), #114
AU Health believes a strong commitment to equal employment opportunity (EEO) is more than a legal and moral obligation. It is also a sound business practice to realize the potential of every individual. AU Health is committed to providing equal employment opportunities without regard to race, color, religion, sex/gender, national origin, age, disability, marital or family status, sexual orientation, gender identity, veteran status, or genetic information. This extends to all aspects of employment including, but not limited to recruiting, hiring, placement, promotion, demotion, transfer, disciplinary actions, termination, staff reductions, rate of pay and other forms of compensation, selection for training, and participation in system sponsored employee activities.
Employee Assistance Program Policy (v3), #139
The Employee Assistance Program (EAP) provides employee short-term counseling, assessment and referral services for personal and work related problems, critical incident management, and assistance with the Employee Care Program Policy. The EAP can be accessed in three ways:
Supervisors and managers are encouraged to consult EAP regarding employees who have persistent performance or attendance problems, because these are often associated with personal problems. The EAP counselor will determine whether EAP counseling could be helpful, but the ultimate decision to pursue counseling is made by the employee.
INS Compliance and Employment of Aliens Policy (v2), #169
It is occasionally necessary to employ alien non-citizen personnel into certain positions which may be specialized in nature and/or challenging to recruit. The health system shall verify the employment eligibility of each person hired.
For aliens requiring visas to work in the United States, the process, as defined by Department of Labor (DOL) and Immigration and Naturalization Services (INS), is followed to facilitate obtaining the appropriate visa.
Licensure and Certification Policy (v2), #943
AU Health employees that are required by law, regulation or policy to be hired in a job classification requiring licensure or certification (other than Physicians (MD, DO or equivalent), dentists (DDS or DMD) and Allied Health providers (APRN, PA, CRNA, CNS, CNM, DA) including administrative officials who request medical staff membership or clinical privileges in the Medical Center) must furnish proof of licensure or certification to the Talent Acquisition & Management Section of the Human Resources Division prior to their employment by the organization. Subsequent proof of current license or certification in job classifications where this is required must be furnished to the Records Section of the Human Resources Division by the employee’s department as soon as the license or certification is renewed.
Management of Occupational Exposures to Blood Borne Pathogens Policy (v3), #127
To provide guidance and services for all health care personnel whose activities involve contact with patients or with blood or other body fluids from patients in a health care setting, laboratory, public safety setting, or research facility. The provisions of such services are based on the regulatory guidelines set forth by the Centers for Disease Control (CDC) and the United States Public Service Health Guidelines for the Management of Occupational Exposures. Treatment for occupational exposures to HBV, HCV, and HIV following the recommendations for post- exposure prophylaxis are offered.
Military Leave USERRA Policy (v3), #128
AU Health will grant a military leave of absence to employees who are absent from work because of service in the United States uniformed services, including the National Guard, in accordance with the Uniformed Services Employment and Reemployment Rights Act (USERRA).
Tobacco-Free Policy (v3), #1106
Augusta University and AU Medical Center (AUMC) prohibits the use of tobacco products on any property owned, leased or controlled by Augusta University, AUMC or 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 healthy environment for all persons, including faculty, students, staff, visitors, and others who visit the campus.
Pre-Construction Risk Assessment Policy (v4), #284
AU Health is committed to protecting the health and safety of patients, staff, and visitors at all times. During construction and renovation, facilities management staff and appropriate members of the AU Health staff assesses the potential impact of each construction, renovation or demolition project on the ability of AUMC to meet the needs of patients, staff and others. The risks identified are used to develop a plan designed to minimize disruption of AU Health patient care services and risks to AU Health staff and visitors. Every effort is made to minimize disruption of services and care related to the construction process. However, in all cases, patient care considerations have the highest priority. AU Health will not compromise patient care quality or patient safety.
Patient No Show Policy (v2), #418
To ensure a consistent management of patient no shows. These guidelines apply to patients being rescheduled at AU Medical Center (AUMC) operated properties.
It is the policy of AUMC that a patient’s appointment status will be appropriately assigned “no show” in IDX when a patient has failed to keep an appointment and has not contacted the office to cancel or reschedule. The responsible provider will be notified and asked to determine if the patient needs to be contacted for follow-up, based on service-specific clinical guidelines.
APPROVED IN 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.
APPROVED IN AUGUST 2019
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.
APPROVED IN JULY 2019
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.
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:
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).
APPROVED IN JUNE 2019
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.
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.
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.
APPROVED IN MAY 2019
Each document is, at a minimum, reviewed on a triennial basis, or earlier as necessary to maintain operational and/or regulatory compliance.
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.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.
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).
APPROVED IN FEBRUARY- APRIL 2019
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.APPROVED IN JANUARY 2019
