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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.
- AU Health System Quality Assessment & Performance Improvement Plan (QAPI) Strategic
Plan 2020-2021 (v3), #693
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.
- Extra Pay Policy (v3), #896
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.
- Communication with Families of Augusta State Medical Prison (ASMP) Patients Policy
(v2)
There are occasions when the care of forensic patients from the Georgia Department
of Corrections requires communication with families, either to advise them of a patient’s
condition or to seek permission if the patient is unable to make their own decisions.
Because of the need for security, we must take precautions not to disclose the patient’s
location (unless a visit by family has been authorized by the Warden at Augusta State
Medical Prison (ASMP)) or the names and/or phone numbers of the team providing care.
This policy addresses the guidelines for communication with families of incarcerated
patients receiving clinical care at AU Medical Center (AUMC).
- Policy on Policies (v2)
Organization and Department Policies, Clinical Protocols and Standing Orders, Clinical
and Non-clinical Guidelines, and Scopes of Services, 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 the electronic
policy management system. Documents are reviewed, maintained, and made available to
the organization to promote awareness, compliance, and accountability.
Each document is, at a minimum, reviewed on a triennial basis, or earlier as necessary
to maintain operational and/or regulatory compliance.
- Telework and Flextime Policy (v3)
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.
- Service Recovery Policy (v4)
This policy is to establish the AU Health System (AUHS) Service Recovery Program process.
The goal of this policy is to empower "staff present" to identify and to take action during potential instances of patient dissatisfaction
or service failure.
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.
- Acute Care Restraints and Seclusion Policy (v3)
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).
- Handling of Deceased Patients Policy (v2)
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.
- Helideck Operations Policy (v2)
The use of the AU Medical Center (AUMC) Helideck (FAA Site # 03646.05*H) must meet
local, state, and federal operational guidelines. Access to the helideck will be tightly
controlled in order to ensure the safety of AUMC patients, employees, students, faculty,
and those authorized individuals utilizing the site. Only helicopters transporting
patients to or from either the AUMC Hospital and Clinics or Children’s Hospital of
Georgia (CHOG) (or arriving to pick up one of the CHOG Transport Teams) may land on
the helideck. Helicopters transporting patients to other health care facilities other
than the Hospital and Clinics or CHOG are not permitted to land on the helideck. A
maximum of TWO (2) helicopters will be allowed on the AUMC helideck at any given time.
In addition to medical transports, the helideck can be used for the purposes of training
exercises for the military and/or a governmental agency. The agency will require permission
and there will be a complete communication of the helideck information to said agency.
The Emergency Communication Center (ECC) will be notified of any scheduled training
exercise. Flight helideck exercises MUST be aborted at any time there is a real-time
transport event. All incoming and outbound flights will be coordinated through the
ECC. Only “Authorized Employees” will be allowed to access the helideck and assist
with transferring a patient to or from the helicopter. “Non-Authorized Employees”
will not be granted access to the helideck for any reason during live flight operations,
and during non-live events MUST be escorted by an authorized employee at all times.
APPROVED IN FEBRUARY- APRIL 2019
- 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.
- 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.'
