New and Revised Policies


Medical Center New and Revised Policies


Medical Center Policies that were approved in February—April 2019

Login is required to view the policy

  • Automatic Therapeutic Interchange Policy (v2)
    This policy promotes healthcare cost containment while maintaining positive therapeutic and safety outcomes of patients within AU Medical Center through judicious use of an automatic therapeutic interchange program. All medications or medication classes included in the automatic therapeutic interchange program will be reviewed and deemed appropriate for interchange by the Pharmacy and Therapeutics (P&T) Committee prior to implementation as well as approved by the Medical Executive Committee (MEC).
  • Disinfection Level Determination Policy (v3)
    All reprocessible patient care equipment and medical devices will be appropriately disinfected or sterilized in between patients to prevent the transmission of potentially infectious pathogens. This policy will assist with determining the appropriate method of disinfection or sterilization based on the type of device, level of invasiveness, and manufacturer’s recommendations.
  • Construction Management Policy (v2)
    Selection of consultants and contractors, the competitive bidding process associated with that selection, and authorization of performance to work on AU Medical Center (AUMC) projects must be in strict adherence with AUMC Policies and the Master Lease Agreement between the Board of Regents of the University System of Georgia and AUMC. The purpose of this policy is to establish uniform criteria to ensure that construction projects are managed in a fiscally prudent, cost-effective, efficient, and coordinated manner in accordance with AUMC policies.
  • CY2019 Fire Safety Management Plan (v3)
    The purpose of the Fire Safety Management Plan is to define the program to protect building occupants, equipment, and other materials from fire and the products of combustion. This plan applies to hospital functions at all designated AUMC locations identified in our Statement of Conditions.
  • CY2019 Hazardous Materials & Waste Management Plan (v3)
    AU Medical Center (AUMC) Hazardous Materials and Waste Management Plan describes the process and mechanisms by which AUMC manages hazardous materials and waste in a manner that protects the health, safety, and environment of patients, staff, and the community. This plan applies to hospital functions at all designated AUMC locations identified in our Statement of Conditions.
  • CY2019 Life Safety Code Management Plan (v3)
    The purpose of the Life Safety Management Plan is to define the program to protect building occupants from fire and related hazards to include, but are not limited to minimizing products of combustion, providing unobstructed emergency exits and appropriate fire alarm and suppression devices. The Utility Systems Management Plan applies to hospital functions at all designated AUMC locations identified in our Statement of Conditions.
  • CY2019 Medical Equipment Management Plan (v3)
    The purpose of the Medical Equipment Management Plan (MEMP) is to define the program to manage medical equipment maintenance and safety for patients, visitors, and staff.
  • CY2019 Safety & Security Management Plan (v3)
    The purpose of the Safety and Security Management Plan is to define the Safety and Security Program. The Safety Management Program is designed to reduce the risk of injury of patients, staff and visitors. The Security Management Plan is used to reduce the risk of personal injury and property loss.
  • CY2019 Utility Systems Management Plan (v3)
    The purpose of this Utility Systems Management Plan is to support a safe patient care environment at AU Medical Center (AUMC) by managing risks associated with the safe operation and functional reliability of all utility systems. The plan includes the processes for maintenance and training that are designed to promote safe and effective use of utility systems while minimizing risks to patients and staff. The Utility Systems Management Plan applies to hospital functions at all designated AUMC locations identified in our Statement of Conditions.
  • Infection Prevention and Control Annual Risk Assessment and Plan (v6)
    Annually, AU Medical Center (AUMC) documents a risk assessment which describes the infection risks unique to Augusta University Medical Center’s hospitals and clinics used to determine the Annual Infection Prevention and Control Plan. Monitoring the on-going status of infection risks and occurrences involves a systematic review of patient outcomes using Surveillance Indicators.
  • Medicare Secondary Payer Questionnaire Policy (v1)
    As a Medicare enrolled provider, and according to section 1862(b) of the Social Security Act, AUHS must determine whether Medicare is the primary or secondary payer for each inpatient admission or outpatient encounter (does not include reference laboratory encounters or Medicare Advantage beneficiaries) prior to submitting a claim to Medicare. This is accomplished by asking Medicare beneficiaries, or their spouse or legal representatives, about other insurance coverage related to
    Employer Group Health Plans, Liability insurance, No-Fault insurance, End Stage Renal Disease within 30 months of COBRA and Worker’s Compensation. A series of questions developed by CMS is commonly known as Medicare Secondary Payer Questionnaire (MSPQ). AUHS will retain a copy of the most recent responses to completed MSPQs for at least 10 years after the date of service in the form of electronic files.
  • Name Entry and Changes Policy (v2)
    The purpose of this policy is to establish a standardized process for patient name and demographics entry into the IDX Enterprise Scheduling and Visit Management Systems which will feed all other downstream systems.
  • Orders for Hospital-Based Outpatient Rehabilitation and Respiratory Services Policy (v3)
    This policy will define the circumstances under which a practitioner is permitted to order outpatient rehabilitation and respiratory hospital-based services at AU Medical Center.
  • Use and Disclosure of Protected Health Information for Fundraising Purposes (v4)
    AU Medical Center (AUMC) will inform patients and/or legal guardians through its Joint Notice of Privacy Practices that it may use patient demographic information and limited health information to contact patients and/or the legal guardian of patients under the age of 18 years old for fundraising purposes or to share with an institutional-related charity foundation and that all patients and/or the legal guardian have a right to opt out of receiving fundraising communications.

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

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

    AUMC will refrain from conditioning treatment or payment on an individual’s choice regarding fundraising communications.

Medical Center Policies that were approved in January 2019

  • Anticoagulation Reversal for Adult Patients Guidelines (v3)
    The purpose of these guidelines is to provide recommendations for the reversal of or management of bleeding associated with anticoagulants. Of note, information provided in this document is not intended to replace clinical judgment. Recommendations regarding the management of anticoagulation in the adult perioperative surgical setting can be found in the Anticoagulation Management Guidelines for the Adult Perioperative Surgical Setting.
  • Asepsis Program Policy (v2)
    All incoming medical residents and medical students, including those who are visiting AU Medical Center (AUMC) must complete the Asepsis Program. The purpose of the policy is to assure that the incoming medical residents, medical students, whether a part of AUMC or visiting from another facility have training in the guidelines for aseptic/sterile technique utilized at AUMC.
  • Attendance Policy (v3)
    AU Health is open to deliver patient care on a 24-hour, 365 day basis. To meet its mission, regular attendance and punctuality are expected of all employees. Employees of AU Health are obligated to work the days or shifts for which they are scheduled, even during times of hazardous or inclement weather conditions. AU Health strives to be fair, consistent, and maintain appropriate staffing. AU Health incorporates the no-fault concept of attendance monitoring in order to increase managerial objectivity and consistency. It eliminates the need for management staff to determine whether an absence or tardy is excused, unexcused, chargeable or non-chargeable, legitimate or illegitimate.
  • Billing and Collections Policy (v2)
    To establish a systematic process for the billing and collections of medical services provided by AU Medical Associates (AUMA) and medical services provided at AU Medical Center (AUMC). The Billing and Collections policy together with the Financial Assistance policy is intended to meet the requirements of the applicable federal, state and local laws, including without limitation, section 501(r) of the Internal Revenue Code of 1986, as amended, and the regulations thereunder. This policy applies to all employees and staff of legal entities of the health system to include AUMA and AUMC, performing duties within the scope of their employment at any site.
  • Blood Administration Policy (v5)
    This is an AU Medical Center (AUMC) policy governing the obtaining informed consent and administration of blood and blood components.
  • Bloodborne Pathogen Exposure Control Plan (v2)
    AU Medical Center (AUMC) shall establish a written Exposure Control Plan (ECP) designed to eliminate or minimize occupational exposure to blood or other potentially infectious material (OPIM). The ECP and supporting documents will be reviewed and updated at least annually and as necessary. This document contains information for all levels of the AUMC organization and is applicable at all AUMC locations with a potential for occupational exposure to blood or OPIM.
  • Credentialing Medical Staff Policy (v6)
    The Medical Staff Office coordinates the credentialing process of all prospective members to the Medical and Advance practice providers for AU Medical Center Inc. Collection of all application forms and supporting documentation, verification of all required credentials, maintenance of a credentialing database system and communication, are handled by one office. This one office supports the Credentials Committee review and recommendations for appointment/reappointment and privileging in each hospital and clinics within the healthcare system. The AU Medical Center Inc. Medical Staff Office does not sub-delegate any credentialing functions to an outside source. The recommendations of the hospital Credentials Committee and Medical Executive Committee (MEC) are reported to the Board of Directors (Governing Body). Therefore, in order for there to be uniformity of credentials documentation and information and to reduce the burden of overseeing the application process, all credentialing information will be shared within AU Medical Center Inc. Credentialing information is peer review protected and all new members of peer review committees (such as Credentials Committee, Medical Executive Committee, PI Peer Review) will be oriented to the confidentiality process and will sign a confidentiality agreement. All information obtained during the initial and re-credentialing process is confidential. PHI is not used in the credentialing process but if submitted with the application, this information is destroyed, returned or blinded.
  • Discharge Planning Policy (v3)
    Each patient admitted to AU Medical Center (AUMC) will have an individualized evaluation of continuing care needs following discharge from the hospital. AUMC staff will work closely with the patient/patient’s representative and appropriate community agencies to ensure continuity of care is addressed and regulatory requirements are met. This policy provides a process that addresses the patient’s need for continuing care, treatment, and services after discharge or transfer.
  • Empiric Precautions Policy (v2)
    All patients will be assessed for infectious diseases or pathogens upon presentation in all settings. Proper transmission-based precautions will be initiated based on clinical presentation and likely pathogens; then, maintained until a diagnosis is confirmed or ruled out.
  • Infection Prevention and Control Authority Statement and Administrative Policy (v2)
    Infection Prevention and Control policies and provisions are essential to an effective Infection Prevention and Control program; therefore, they are corporate policies and apply to AU Medical Center (AUMC) hospitals and clinics. These polices must be followed by all physicians, AUMC personnel, Augusta University (AU) personnel, contractors, volunteers and students working in AUMC.  Authority and responsibility is defined to implement Infection Prevention and Control policies and provisions.
  • Informed Consent Policy (v3)
    AU Health will obtain informed consent for all patients (for pediatric patients, see below III A.3) regarding any surgical or invasive procedure performed under general anesthesia, spinal anesthesia, or major regional anesthesia or an amniocentesis diagnostic procedure; or a diagnostic procedure which involves intravenous injection of a contrast material.
  • Laryngoscope Processing Policy (v3)
    AU Medical Center (AUMC) reprocesses laryngoscope blades as semi-critical devices between each patient use and in accordance with the manufacturer’s instructions. Laryngoscope blades are packaged and stored in a manner to prevent recontamination. As manufacturer’s instructions for the handles vary from low level disinfection to sterilization, manufacturer’s instructions for reprocessing laryngoscope handles will be followed and handles will be stored and managed in a manner to prevent contamination. Devices such as laryngoscope blades and handles, may be exposed to potentially infectious material during indicated use, and can become contaminated through direct contact with the patient’s skin, mucous membranes, secretions, and blood. To reduce the risk of infection, the importance of standardizing the reprocessing and storage of laryngoscope blades and handles is emphasized. This policy will provide provisions for reprocessing, handling and storage of laryngoscope blades and handles to ensure that they are safe for use.
  • Monitoring for Hazardous Air Contaminants Policy (v2)
    It is the policy of AU Health to minimize air contaminants exposure to employees by providing for proper monitoring of air contaminants. Contaminants monitored include, but are not limited to, waste anesthesia gases, formaldehyde, glutaraldehyde, and xylene.
  • Ordering Radiology/Imaging Studies Policy (v3)
    In order to perform a Radiology/Imaging study for Inpatients and Outpatients at AU Medical Center (AUMC), an appropriate clinical indication and a signed order are required from a physician or other provider.
  • Organ Donation After Cardiac Death and Imminent Death Potential Organ Donation Policy (v2)
    This policy outlines the procedure for referral, authorization, medical management, and recovery of organs for transplantation through donation after cardiac death (DCD). This policy highlights the rights of patients and their families related to options for organ donation and decision making regarding these options when timing of death is determined by withdrawal of mechanical support. With the reality of individuals dying every day awaiting organs for transplantation, AU Medical Center (AUMC) will make reasonable efforts to identify potential organ donors and to cooperate in the procurement of anatomical gifts.
  • Organ, Eye, Tissue Donation Policy (v3)
    The purpose of this policy to establish guidelines for communication with families of potential donors and to develop procedures to follow in coordinating the procurement of eyes, organs and tissues. Recognizing that eye, organ, and tissue donation saves lives and improves quality of life and that anatomical gifts offer consolation to the bereaved next-of-kin/guardian of a donor, AU Medical Center (AUMC) actively participates in eye, organ, and tissue donation programs. To this end, the next-of kin/guardian of medically suitable potential eye, organ, and tissue donors will be informed of the option of making anatomical gifts. Hospital management will maintain a working relationship with the AUMC’s Tissue and Donor Services, LifeLink of Georgia Organ Procurement Organization, and the Georgia Eye Bank to facilitate the implementation of next-of kin/guardian desires regarding eye, organ, and tissue donation.
  • Personal Appearance Policy (v5)
    AU Medical Center (AUMC) employees are expected to maintain a high standard of neatness and personal hygiene. Personal appearance must meet safety and cleanliness standards to ensure patient and staff protection. If an employee is uncertain about dress requirements in his/her department, the employee should consult with his/her immediate supervisor.
  • Portable Medical Gas Policy (v2)
    This policy establishes procedures to be followed when cylinders are required to be store on a unit or smoke compartment for emergency or transport use.
  • Serious Reportable Events Policy (v2)
    The NQF-Endorsed® Serious Reportable Events are an ongoing effort to enable healthcare quality and safety improvement through introduction of tools for assessing, measuring, and reporting organizational performance. The purpose of the NQF-endorsed list of Serious Reportable Events in Healthcare is to facilitate uniform and comparable public reporting to enable systematic learning across healthcare organizations and systems and to drive systematic national improvements in patient safety based on what is learned—both about the events and about how to prevent their recurrence. AU Medical Center (AUMC) is committed to reducing and eliminating Serious Reportable Events. As such, this policy is intended to standardize AUMC’s response to a potential Serious Reportable Event and to facilitate the investigation, response to the patient and reporting of such events.
  • Surgical Attire Policy (v2)
    Personnel working in an operating room (OR), OR-like, Hybrid suites will wear the appropriate surgical attire relative to each traffic zone and personnel status as listed below while adhering to AORN Recommended Guidelines.
  • Temperature and Humidity Monitoring in Operating Suites Policy (v2)
    It is the intent of AU Medical Center (AUMC) Facilities Support Services to provide all Operative Services with proper HVAC equipment and controls to monitor temperature and humidity levels. Facilities Support Services will reference the following guidelines for temperature and humidity ranges, AIA Guidelines for Construction, The American Institute of Architects, and AORN - Association of Perioperative Registered Nurses.
  • Transfer of Patient via AUMC Transfer Center Policy (v2)
    All requests from outlying hospitals for transfer of patients to AU Medical Center (AUMC) are managed in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C., Section 1395, all applicable Federal regulations and interpretive guidelines promulgated thereafter, and/or the tenets of this policy. All transfer requests are managed by the AUMC Transfer Center or AUMC Emergency Communications Center (ECC), both available at 706-721-5600. The Transfer Center and ECC are staffed 24 hours per day, seven (7) days a week. AUMC does not determine a patient's stability for transfer. The transferring physician does. Transfer Center and ECC calls include Attending Physician to Attending Physician discussions regarding referrals for care, e.g., inpatient, procedures, consults, inquiries, etc. Transfer Center and ECC calls are recorded for quality assurance and training purposes.
  • Vascular Access Device Policy (v1)
    This policy provides a framework to guide clinical practice as it relates to vascular access devices. It provides the actions to be followed to provide for appropriate and safe patient care.'