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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.
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.
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
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),
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),
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
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.
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.
APPROVED IN JUNE 2019
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