New and Revised Policies

Medical Center New and Revised Policies

University New and Revised Policies

Augusta University Policies that were approved in October 2016

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  • Outside Professional Activities (v.2)
    Outside professional activity by faculty or administrators is to be encouraged under appropriate circumstances. However, since  faculty and administrative personnel have committed their primary professional effort to the university, the university has the responsibility to limit and regulate  such activity. With certain exceptions, faculty members are required to obtain the permission of the university prior to engaging in outside professional activity and to make periodic summary reports on such activity. This policy defines the types of outside professional activities allowed and outlines the procedures for obtaining permission from the university and for reporting such activities to the university.
  • Policy for Responding to Allegations of Research Misconduct (v.1)
    Augusta University expects that all its members maintain the highest standards of ethics in the pursuit of their scholarly endeavors, and accordingly bears responsibility for the prevention, investigation and adjudication of research misconduct. Any form of research fraud is contrary to the institution’s principles and adversely effects the institution and its reputation.  

    The purpose of this policy and procedures is to promote the integrity of research conduct on behalf of Augusta University (“University”) by its faculty, technical staff, residents, fellows, students, trainees, and individuals employed on a contractual basis by providing a process for close scrutiny of alleged research misconduct, for full protection of the rights of any person accused of research misconduct, and for the protection of any person who makes allegations under this policy in good faith.
  • Electronic Data Storage Backup (v.2)
    In order to protect institutional data against loss or destruction, it is required that such data be created  and stored within the system of record utilizing an Information Technology  (IT) approved data storage device (e.g. storage area network space, a shared or home directory). All contracted  service  providers, personnel and students that establish or create electronic data  outside of the IT storage service shall define, document, and implement a backup procedure. Department Heads will assume the role of data trustee for their department’s data and will appoint a data steward and manager. 
  • Sexual Misconduct (v.4)
    Augusta University is committed to ensuring a safe learning environment that supports the dignity of all members of the Augusta University community. Augusta University does not discriminate on the basis of sex or gender in any of its education or employment programs and activities. Augusta University will not tolerate sexual misconduct, which is prohibited, and which includes, but is not limited to, domestic violence, dating violence, sexual assault, sexual exploitation, sexual harassment, and stalking. These policies and procedures are intended to ensure that all parties involved receive appropriate support and fair treatment, and that allegations of sexual misconduct are handled in a prompt, thorough and equitable manner.

    Prevention is one of the primary mechanisms used to reduce incidents of sexual violence on campuses. USG institutions are required to provide prevention tools and to conduct ongoing awareness and prevention programming and training for the campus community including students, faculty, and staff. Such programs are designed to stop sexual violence through the promotion of positive and healthy behaviors. Programming will educate the campus community on consent, sexual assault, alcohol use, dating violence, domestic violence, stalking, bystander intervention, and reporting.
  • Cost Transfer Policy (v.4)
    This policy establishes requirements for processing transfers of direct costs to or from or between sponsored accounts. Federal regulations, generally accept accounting principles, and good management practices require that all costs incurred be appropriate to and for the direct benefit of the project charged, and that accounting records be maintained in a timely and accurate basis. Audit reports routinely question or disallow cost transfers, in particular those that are frequent, tardy, unexplained, inadequately explained, or insufficiently documented. The accuracy of charges made to sponsored program accounts is a key aspect of sound financial management and a significant measure of adequate financial control.

    In accordance with OMB Circular A-81, or the Uniform Guidance (2 CFR Part 200), it is necessary to explain and justify transfers of charges onto sponsored awards, where the original charge was previously recorded elsewhere on the University’s General Ledger. Timeliness and completeness of the explanation of the transfer are critically important factors in supporting the reasonableness, allowability, and allocability of charges made to sponsored accounts in accordance with the Uniform Guidance.
  • Multiple Graduate Degrees (v.1)
    While applicants who are not yet enrolled at the graduate-level at Augusta University may apply to more than one (1) program during the application process, a new student can matriculate initially only into a single program (primary) before they can be admitted to an additional graduate program (secondary).

    Students who have matriculated into a primary program must always receive permission from their primary program and their proposed secondary graduate program (including established dual degree programs) before applying for admission to any secondary program. If either program is part of The Graduate School (TGS), the student must also receive permission from TGS before applying as well.

Medical Center Policies Approved April 2018


  • 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



Medical Center Policies Approved May 2018


  • 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