New and Revised Policies

Medical Center New and Revised Policies

University New and Revised Policies

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Augusta University 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

Augusta University 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

Medical Center Policies Approved May 2018

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• Adult Patient Elopement Policy (v3)
  AU Medical Center 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. The purpose of this policy is for AU Medical Center to enact the proper and appropriate procedures for maintaining the safety of patients, staff and others at all times. The medical center shall take responsibility for individuals placed in its inpatients facilities for treatment regardless of voluntary or involuntary status.
  Approved: 5/31/2018

• Fire Watch Policy (v3)
  The purpose of this policy is to supplement the existing fire detection and response systems and to provide additional compensatory activity to assure the safety of patients, visitors and staff in adjacent areas. The fire watch is intended to identify and report hazards, for correction action, and to document findings.
  Approved: 5/30/2018

• Infection Prevention and Control Annual Risk Assessment and Plan (v5)
  Annually, AU Medical Center documents a risk assessment which describes the infection risks unique to its’ hospitals and clinics used to determine the Annual Infection Prevention and Control Plan.
  Approved: 5/5/2018

• Medical Gas Policy (v3)
  To provide a policy for the installation, performance, maintenance, monitoring and testing of medical piped gas systems for AU Medical Center. Medical Gases are maintained and monitored by Facilities Support Services to ensure safe and uninterrupted operation for the purpose of patient care.
  Approved: 5/28/2018

• Moderate Sedation (Conscious Sedation) Policy (v2)
  Establishes specific recommendations for the safe care of patients undergoing moderate sedation and/or analgesia administered during diagnostic, therapeutic, or invasive procedures performed by non-anesthesiologists for out of operating room areas throughout AU Medical Center. Applies only to the care of patients undergoing moderate sedation level only.
  Approved: 5/7/2018

• Monitored Anesthesia Care/Deep Sedation Policy (v2)
  Establishes specific recommendations for the safe care of patients undergoing deep sedation and/or analgesia administered during diagnostic, therapeutic, or invasive procedures performed by non-anesthesiologists for out of operating room areas throughout AU Medical Center. Applies only to the care of patients undergoing deep sedation.
  Approved: 5/7/2018

• No Information Patients Policy (v2)
  To define the procedure for AU Health workforce members in ensuring that the appropriate steps are taken to use or disclose protected health information (PHI) for its Facility Directory and protect the confidentiality of “no-information” patients admitted to AU Health.
  Approved: 5/7/2018

• Paint Policy (v2)
  To provide a uniform policy and procedure to identify painting needs and painting process for AU Medical Center through Facilities Support Services. This policy applies to all building structures for AU Medical Center.
  Approved: 5/28/2018

• Personal Appearance Policy (v4)
  AU Medical Center employees are expected to maintain a high standard of neatness and personal hygiene. Personal appearance must meet safety and cleanliness standards to ensure patient and staff protection. If an employee is uncertain about dress requirements in his/her department, the employee should consult with his/her immediate supervisor.
  Approved: 5/30/2018

• Pneumatic Tube System Policy (v2)
  Establishes procedures and guidelines for the operation of the pneumatic tube system. Defines materials that are suitable for and/or prohibited from transport within the system.
  Approved: 5/28/2018

• Position Classification Policy (v2)
  Position classification at AU Medical Center serves to provide a written description of job responsibilities and requirements, establish a basis for determining the position title, pay range and exemption status according to FLSA guidelines, establish a basis for performance evaluations, and provide job specifications for hiring.
  Approved: 5/7/2018

• Rules of Conduct Policy (v3)
  AU Medical Center is committed to providing and maintaining a productive, professional work environment. AU Medical Center 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.
  Approved: 5/30/2018

• Staff Rights and Responsibilities Policy (v3)
  AU Medical Center has the responsibility to care for and treat patients by providing Patient-and-Family Centered Care. It also has a responsibility to its employees. However, when the rights of employees conflict with the needs of patients, such conflicts should be handled in a manner consistent with legal and professional standards of practice. This policy provides clear guidelines to assure uninterrupted patient care should a conflict over employee assignments, instructions and duties occur.
  Approved: 5/30/2018

• Volunteer Services Policy (v2)
  AU Medical Center is committed to the development and implementation of volunteer engagement and utilization by all areas of the organization. Volunteers are not compensated and perform services without promise, expectation or receipt of compensation, future employment or any other tangible benefit. Volunteers servicing AU Medical Center are not to provide direct patient care.
  Approved: 5/30/2018

Medical Center Policies Approved April 2018

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

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

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

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