AU Medical Center New and Revised Policies

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JUNE 2020

  • Controlled Substances: Waste and Witness of Waste Policy (v2), #3671
    Controlled substances that cannot be re-used or returned for destruction via the reverse distributionprocess must be wasted. Two individuals are required for each waste process, the person recording thewaste and the witness of the process. Both persons must be in a position that has been approved foraccess to controlled substances. All wasting of controlled substances will occur in accordance with stateand federal law.Approved: 06/01/2020
  • Nonformulary Medication Orders Policy (v2), #2251
    This policy exists to ensure the safe and appropriate use of nonformulary medications in both theinpatient and ambulatory care settings. The use of nonformulary medications is discouraged because oflack of built-in safety measures, potential for delayed patient care and increased costs to the institution.Inpatient and ambulatory care nonformulary medication orders will be evaluated on an individual basisand used only in accordance with the following procedures.Approved: 06/02/2020
  • Vascular Access Device Policy (v4), #236
    This policy provides a framework to guide clinical practice as it relates to vascular access devices. Itprovides the actions to be followed to provide for appropriate and safe patient care.Approved: 06/02/2020
  • Medical Student Entries in the medical Record policy (v3), #244
    Junior and Senior Medical Students working under the direct supervision of a licensed physician aregranted the privilege of making entries in the AU Medical Center legal medical record. These entries arelimited in type to those proportionate with the individuals' training and appropriate to the individual'sscope of practice as determined by his or her supervising physician.Approved 06/02/2020
  • Surgical Site Infection Prevention Policy (v2), #1168
    AU Medical Center (AUMC) identifies and adheres to evidence based practice guidelines for the care ofthe surgical patient. Guidelines identified are targeted to the care provided preoperatively, intraoperatively, and post-operatively to provide safe care while enhancing surgical outcomes.Approved: 06/02/2020
  • Cohorting Patients Policy (v1), #5189
    Cohorting can improve the effectiveness of controlling an outbreak. Cohorting patients according to thepresence or absence of a specific pathogen along with detail to hand and environmental hygiene candecrease the risk of cross transmission. Approved: 06/02/2020
  • Employee Care Program Policy (v4), #141 
    This policy outlines the types of programs offered to health system employees in need of assistance who may be experiencing financial difficulties due to temporary unforeseen or emergent personal crises. Approved: 05/14/2020 

  • Family Medical Leave Act (FMLA) Policy (v3), #126 
    This policy provides guidelines to management and employees regarding the Family and Medical Leave Act (FMLA) entitlements and to define parameters for utilization of FMLA to be in compliance with the law. In the event of any conflict between this policy and the applicable law, employees will be afforded all rights required by law. Employees eligible for leave under the Family and Medical Leave Act (FMLA) are granted time off without risk to their employment status. Such time off is not grounds for disciplinary action and is not included in attendance records utilized as a factor in staff reductions. Payment for FMLA is provided from the employee’s Paid Time Off (PTO) balance. Employees without sufficient Paid Time Off (PTO), shall continue to be covered under FMLA without pay. Approved: 05/21/2020 

  • Pneumatic Tube System Policy (v3), #148 
    This policy will establish procedures and guidelines for the operation of the pneumatic tube system. It will define materials that are suitable for and/or prohibited from transport within the system. Approved: 05/21/2020 

  • Attendance Policy (v4), #111 
    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. Approved: 05/21/2020 

  • Breach Notification- Protected Health Information Policy (v3), #178 
    Breach notification will be carried out in compliance with the American Recovery and Reinvestment Act (ARRA)/Health Information Technology for Economic and Clinical Health Act (HITECH), Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act (Omnibus Rule), as well as any other federal or state notification law addressing the privacy and security of individually identifiable health information. Approved: 05/21/2020 

  • Cash Handling Policy (v1), #3781 
    To provide employees in all AUHS entities guidance on having non-patient invoices prepared and adjusted. This policy focuses on invoicing and adjustments due to non-patient activity that results in a related party or external company owing payment to an AUHS entity. Approved: 05/21/2020 

  • Code RED Policy (v3), #270 
    The immediate response and reporting of a fire or suspected fire activates a prompt response by Facilities Services, Maintenance, Safety, and Security personnel, with the intention of preventing unnecessary loss of life, injury, and major property damage. This policy outlines the steps that AU Medical Center (AUMC) takes in order to ensure the safety of all staff, faculty, students, patients, and visitors. Approved: 05/21/2020 

  • Coding of Services Rendered Policy (v3), #238
    Health Information Management Services will utilize accurate and consistent clinical coding practices, in accordance with coding guidelines, for the classification of medical record documentation to support billing and reimbursement activities. Approved: 05/21/2020 

  • Compensation Structure Policy (v3), #829 
    AU Health System will assure all employees are treated equitably and consistently under the Compensation Program and define the rules for both the supervisors responsible for administering pay and the employees who will be affected by pay decisions. Approved: 05/21/2020 

  • Credential Pay Policy (v4), #331 
    Credential pay serves as a means of providing an incentive to encourage staff to obtain credentials that add value to the organization beyond those required for one’s position. Eligibility for credential pay is determined based upon several factors including market practice, the critical nature of the position, and the requirements for attaining and maintaining the credential. Forms of credential pay include payment for degrees, certifications, and service line pay. A listing of eligible job titles for credential pay is maintained in the Compensation and Performance Management section of Human Resources. Approved: 05/21/2020 

  • Extended Medical Leave Bank Policy (v4), #138 
    Sick leave hours accrued under the University System or AU Medical Associates and, under specific circumstances, were carried over into AU Heath System are maintained by the Health System in an Extended Medical Leave Bank (EMLB). These hours are available for extended absences due to illness, maternity, disability or bereavement. The bank does not accrue new hours and dissolves when the balance is zero. Unlike PTO, when an employee terminates from AUMC or AUHS, EMLB hours arenot paid out to the employee. Approved: 05/21/2020 

  • External Audit Policy (v4), #618 
    Notices of external audits or requests to conduct an external audit received by AU Health System personnel should be brought to the attention of the Vice President, Audit, Compliance, Ethics and Risk Management (ACERM), who is responsible for the coordination of external audit activities. The V.P. ACERM will coordinate with department personnel, the Chief Business Officer, AU Health General Counsel and other key stakeholders to ensure the external auditors receive all required assistance and information. A copy of the notification should be sent to the V.P ACERM. Approved: 05/21/2020 

  • Maintaining Appropriate Documentation Regarding HIPAA Privacy Regulations Policy (v3), #186 
    AU Health has implemented privacy policies and procedures to comply with the Privacy Rule. Updates to the privacy policies and procedures are made to comply with changes to the Privacy Rule. AU Health periodically reviews its privacy policies and procedures and may make nonmaterial changes. The AU Health Notice of Privacy Practices (NPP) is updated when material changes are made to the AU Health privacy policies and procedures. Approved: 05/21/2020 

  • Patient’s Right to Request Confidential Communications Policy (v3), #197 
    AU Health permits patients to request to receive communications of PHI by alternative means or at alternative locations regarding their PHI. AU Health must take necessary steps to accommodate reasonable requests by patients to receive communications of protected health information (PHI) by alternative means or at alternative locations. Approved: 05/21/2020 

  • Retro Pay Policy (v3), #132 
    It is the policy of AU Health System to provide supervisors and employees with appropriate guidelines regarding the request, approval, and processing of retro-pay. Approved: 05/21/2020 

  • Contract Review Approval and Management Policy (v2), #650 
    This policy sets forth requirements for:

    • memorializing such transactions in contracts and
    • the internal review and approval of such transactions.

    This policy involves the review and execution of Contracts, not payments made by Check Requests. Given the breadth of its contractual arrangements, AU Health seeks to improve its operational efficiency and reduce its financial and legal exposure by ensuring adequate oversight and management of Contracts. Approved: 05/21/2020 

  • Information Security Training Policy (v1), #4354 
    AU Health is committed to protecting Protected Health Information (PHI), electronic Protected Health Information (ePHI), and/or other sensitive information (SEI) by implementing physical security standards within facilities and within areas of a facility that contain or provide access to SEI, PHI, or ePHI. Approved: 05/21/2020 

  • Patient’s Right to Request a Restriction on Certain Uses and Disclosures of Protected Health Information Policy (v3), #195 
    AU Health permits patients to request restrictions of certain uses and disclosures of protected health information (PHI). Patients may request restrictions on AU Health’s use or disclosure of PHI as follows: to carry out treatment, payment, health care operations; to family members, friends or others involved in care, payment for care, and notification purposes. AU Health is not required to agree to the restriction request except in the case of ‘self-pay’ restrictions. Approved: 05/21/2020 

  • Protected Health Information in the Facility Directory Policy (v3), #198 
    AU Health maintains a facility directory, which is limited to the patient’s name, condition in general terms, location within the facility, and religious affiliation. This policy applies to all patient care areas within AU Health including inpatient and observation patients care areas that admit, see a patient and/or impact a patient’s admission. This policy does not apply to outpatient clinics. Approved: 05/21/2020 

  • Vulnerability and Patch Management Policy (v1), #5339 
    AU Health System’s Vulnerability and Patch Management Policy outlines necessary behaviors and actions to:

    1. Maintain the integrity of network systems and data by applying the latest operating system and

    application security updates/patches in a timely manner

    1. Establish a baseline methodology and timeframe for patching and confirming patch

    management compliance

    Information Security is charged with helping to protect AU Health System’s electronic information. To do so, Information Security conducts regular scans of the entire enterprise looking for misconfigured and/or unsecured electronic devices. Information Security then works with IT, IT Partners, and other units, to verify and remediate discovered vulnerabilities, especially when a new threat has been discovered. Approved: 05/21/2020

  • Physician Orders for Life-Sustaining Treatment (POLST) and Limitations of Care Policy (v2), #3262
    Patients have the right to make determinations about their medical treatment when competent and capable of doing so. A conscious patient who can communicate his/her wishes regarding medical treatment contemporaneously or in advance to their provider is preferred. A patient may express their medical preference in an advance directive for health care, Physicians Order for Life-Sustaining (POLST) or by a representative of the patient acting with legal authority. The POLST form was developed to enable seriously ill patients to designate which specific life sustaining treatments they want and to ensure that those wishes are honored by medical professionals. The POLST form should be used as a means of translating end-of-life discussions with patients into actual treatment decisions. Nothing in this policy should be understood to contradict an Allow Natural Death (DNR) Order or AU Medical Center’s policy on “Allow Natural Death/ (DNR).” This policy should be read in conjunction with the “Allow Natural Death (DNR)” Policy. Approved: 04/03/2020 
  • Vaccine Recommendations for Healthcare Workers Policy (v3), #298
    Because of likely contact with patients or infective material from patients, healthcare personnel are at risk for exposure to many vaccine preventable diseases such as influenza, varicella (chickenpox), measles, mumps, and rubella. Healthcare personnel can transmit these infections to patients and coworkers. Maintenance of immunity is an essential part of Employee Health & Wellness, Human Resources and is a responsibility of all healthcare personnel. Approved: 04/03/2020
  • Self-Administration of Medications Policy (v3), #2248
    This policy assures the safe and accurate administration of medications by a patient or non-hospital staff member. Approved: 04/03/2020
  • Performance Coaching Counseling and Discharge Policy (v3), #632
    It is the policy of AU Health to monitor performance for all employees and to assist employees to meet such performance standards through performance corrective counseling when non-compliance occurs. Our goal is to ensure AU Health’s coaching and counseling practices support a culture of high performance and accountability for employees. Approved: 04/03/2020
  • Workforce Reduction Policy (v2), #385
    It is the policy of AU Health System (AUHS) to avoid reductions in workforce whenever possible. However, changing economic circumstances and/or strategic initiatives may require a reduction in workforce levels. If a workforce reduction becomes necessary, AUHS will follow an orderly process to reduce its workforce while adhering to the organization’s commitment to deliver the highest quality patient care in the most cost effective ways. In addition, AUHS shall comply with all applicable laws and policies in carrying out any reduction in workforce. Approved: 04/03/2020
  • Observership Policy (v2), #643
    To provide a process that allows for supervised clinical observerships while maintaining patient confidentiality and patient safety, and in which the observer releases AU Health System from all liability. AU Health System allows for supervised, clinical observerships in clinical areas located throughout the healthcare system. Approved: 04/03/2020
  • Care of Substance Abuse Patients Policy (v3), #209
    AU Medical Center (AUMC) offers evaluative, diagnostic, treatment, and referral services for patients with alcoholism or other substance-related disorders. These services include but are not limited to psychiatric consultation regarding diagnostic evaluation, the treatment of withdrawal and other medical complications of substance-related disorders that may necessitate inpatient care, treatment of concomitant psychiatric disorders in the patient with a substance-related disorder (the “dual diagnosis” patient), and consultation regarding inpatient or outpatient treatment / referral recommendations for rehabilitative substance abuse or chemical dependency disorders. AUMC does not have an inpatient or outpatient substance abuse treatment program. These programs are available in the private and public sector. The Department of Psychiatry and Behavioral Health performs such referrals from the Inpatient Behavioral Health Units and the Outpatient Psychiatry and Behavioral Health Clinic, and is available to assist with such referrals through its Consultation Service for patients receiving care in other services. Approved: 04/15/2020
  • Diversion of Patient Transfer/Transport Policy (v4), #389
    AU Medical Center, Inc., (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 unique 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 area facilities. This policy applies to all patient care units that admit patients within AUMC and the Children’s Hospital of Georgia (CHOG). Approved: 04/15/2020
  • Focused Professional Practice Evaluation (FPPE) Policy (v5), #1088
    To enhance the quality and safety of patient care, each clinical department is responsible for the monitoring and evaluation of the professional practice of their privileged staff. Approved: 04/15/2020
  • Universal Protocol Policy (v4), #235
    The purpose of this policy is to ensure and improve patient safety and prevent procedural errors including wrong site, wrong procedure, and wrong person surgery. All patients undergoing a surgical or non-surgical invasive procedure, prior to the start of the procedure, will undergo the pre-procedure verification process, site marking, and time out processes consistently and in congruence with the Universal Protocol as defined by The Joint Commission. The Universal Protocol applies to all surgical and nonsurgical invasive procedures. Evidence indicates procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation, although other procedures may also affect patient safety. Approved: 04/15/2020
  • Alteplase (Activase®) Spoilage Replacement Program (v2), #3873
    The Department of Pharmacy is responsible for ensuring safe and appropriate use, disposal and replacement of medications. Alteplase (Activase®) is the recombinant drug form of tissue plasminogen activator. Genentech, the manufacturer for alteplase (Activase®), currently offers a Spoilage replacement Program to minimize the waste and financial loss that occurs when the clinical decision is made to not administer alteplase (Activase®) that has previously been reconstituted for use in specific circumstances. The purpose of this document is to outline the eligibility criteria, procedure and documentation for appropriately returning reconstituted, unused alteplase (Activase®) to the manufacturer for replacement product.  The procedure outlined in this document applies to all AUMC personnel involved in the ordering, stocking, dispensing and administration of alteplase (Activase®). Approved: 03/06/2020
  • Acute Care Restraints and Seclusion Policy (v4), #942
    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).

  • Adult High Risk Airway Response Team Policy (v1), #4626
    To provide process for a multidisciplinary high risk airway team (HRAT) composed of personnel who have specialized training in managing adult tracheostomy, laryngectomy, T-tube, post airway reconstruction and other high risk airway patients, and who can respond in an emergency with specialized equipment to assist with airway management.

  • Autopsy Policy (v3), #477
    It is the policy of AU Health to promote a compassionate and consistent approach to matters related to autopsies. This includes obtaining proper consent for autopsies, performance of autopsies and use of information gathered from autopsies. Results and information obtained will be provided to the family by Health Information Management Services (HIMS) and may be used for the education of medical students, residents, medical staff and other healthcare workers as necessary.

  • Bed Bug Prevention and Response Policy (v2), #1091
    Any suspicion of a bed bug activity is grounds for immediate action and notification of the appropriate team members. Vigorous action, treatment and re-inspection will continue until there is no further evidence or indication of bedbug activity or potential for infestation. Facilities services representative provides the official word that no activity is found and patient care space can be utilized. This policy provides requirements for establishing and maintaining protocol to promote safe, efficient, and environmentally-preferred strategies designed to prevent or control bedbug activity that may adversely affect health, impede operations, and/or damage property.

  • Charge Capture and System Testing Policy (v1), #4637
    Successful optimization of a hospital patient accounting system is defined early by minimal impact to gross revenue organization-wide and for each individual cost center. To achieve this success, significant efforts should focus on design, build, testing, and auditing of appropriate for both professional and facility.

  • Chlorhexidine Gluconate (CHG) Daily Bathing SOP (v2), #671
    This SOP provides direction on daily bathing with chlorhexidine gluconate (CHG). Bathing will be performed on patients greater than two months of gestational age in an intensive care unit and the Bone Marrow Transplant unit, except the Neonatal Intensive Care Unit. Patients with acute leukemia regardless of their bedded location will also receive daily CHG bathing provided they are greater than two months of age.

  • Clinical Laboratory Specimen Labeling Policy (v4), #312
    The policy applies to all specimens submitted to the Clinical Pathology Laboratory of the AU Health System, whether for testing in-house or by referral to a CLIA-approved reference laboratory. The policy also applies to specimens submitted to the Histocompatibility Immunology Laboratory except as noted. Adherence to the specimen labeling requirements contained herein is necessary to ensure that all testing and reporting is performed on specimens with unique and accurate patient identification and to meet the requirements of regulatory agencies.

  • Conflict Resolution Policy (v3), #112
    It is the policy of AU Health to give employees an outlet to voice suggestions, issues, or complaints to internally resolve employee conflicts, disagreements, and issues with work or working conditions fairly, promptly and at the lowest organizational level through the chain of command.

  • Consent and Authorization for Patient Photograph, Videotaping and other Imaging for Treatment and Operations Policy (v3), #179
    The purpose of this policy is to establish guidelines for the use of cameras and video recording devices and to protect the privacy and security of patients and their confidential information.

  • Credentialing and Privileging for Robotic Surgical Platforms Policy (v1), #4257
    This policy is intended to guide and regulate the process for credentialing of surgical staff for privileges for robotic surgical systems (e.g. Da Vinci Surgical Robot).

  • De-Identification of Protected Health Information and Limited Data Sets (v3), #180
    This policy outlines how AU Health may use protected health information (PHI) to create de-identified information, that is, information that has been stripped of any elements that may identify the patient, relatives, employers, and household members of the patient, such as name, birthdate, or Social Security number. AU Health may disclose properly de-identified information for any purpose.

  • Discharge Dispute Policy (v4), #830
    It is the policy of AU Health (AUHS) to allow employees recently discharged involuntarily the opportunity to internally dispute the discharge.

  • Electroconvulsive Therapy Policy (v2), #899
    The policy is intended to provide guidelines for delivery of care for patients receiving electroconvulsive therapy (ECT). The policy ensures responsible licensed personnel, who direct or provide patient care will comply with standards of care within their scope of practice for all patients that receive ECT. Specific practices will be integrated into the assessment, planning, prioritizing, delivery and documentation of patient care. ECT is provided for inpatients and outpatients for whom this treatment is indicated, as determined by the ECT Attending. These include, but are not limited to the following indications: Depressive Disorders, Bipolar and Related Disorders, Schizophrenia Spectrum and other Psychotic Disorders, Schizoaffective Disorder, Catatonia, Medication-Induced Movement Disorders and Other Adverse Effects of Medication, Parkinson’s disease, Status Epilepticus.

  • Employee Benefits Policy (v3), #140
    AU Health System (AUHS) provides comprehensive and cost-efficient benefits to eligible medical center employees and their dependents based on employment status, length of service, and other criteria, as part of their total compensation package. In addition to core benefits, such as health, dental, vision and life insurance, the Health System also offers family-friendly benefits and employee assistance unique to medical center employees.

  • Employee Care Program Policy (v3), #141
    This policy outlines the types of programs offered to health system employees in need of assistance who may be experiencing financial difficulties due to temporary unforeseen or emergent personal crises.

  • Employee Transfer Policy (v3), #133
    It is the policy of the health system to allow employees the opportunity to further their professional development by applying for open positions. The health system 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 wish to enhance their skills or develop new competencies to pursue different or greater responsibilities internally.

  • Enteral Feedings Policy (v2), #1167
    Infection prevention and control standards are followed to prevent contamination during the administration and maintenance of enteral tube feedings.

  • Environment of Care (EOC) Rounds Policy (v2), #655
    A multidisciplinary team conducts Environment of Care (EOC) rounds in patient care areas semi-annually and in non-patient care areas annually to identify environmental deficiencies, hazards and unsafe practices associated with infection prevention, safety and security, fire, hazardous materials and waste, medical equipment, and utility systems. Proactive interventions will be implemented to mitigate identified risks. Healthcare personnel will be educated regarding the elements of a safe environment during the rounds.

  • Equipment Pre Order-Pre Use Evaluations Policy (v2), #266
    AUHS will ensure that all equipment purchased and installed for use within the AUHS entities meets all applicable health and safety codes, and standards and licensure/ accreditation requirements for their effective and safe operation.

  • Formulary Management, Drug Selection, Drug Procurement and Drug Storage Policy (v2), #1052
    This policy exists to assure the safe use of medications, including selection, purchase, storage and maintenance of an adequate inventory of all pharmaceuticals, intravenous solutions and supplies for dispensing and administering to patients.

  • Hiring of Relatives (Nepotism) Policy (v3), #134
    It is the policy of AU Health System that relatives of persons currently employed by any entity within the health system may be hired as long as the hire does not result in the existence of a subordinate-superior relationship between such individual and any relative of such individual through any line of authority. Relationship by a family or marriage shall constitute neither an advantage nor a disadvantage.

  • Hours Worked Policy (v3), #333
    The Fair Labor Standards Act (FLSA) requires nonexempt employees be paid at least the minimum wage for “hours worked” and be paid overtime wages for “hours worked” in excess of forty(40) during any workweek. Broadly defined, “hours worked” includes any time an employee is required to be at work or on duty, is under the employer’s control, or is performing activities which are primarily of benefit to the employer.

  • Human Milk Misadministration Management Policy (v3), #1089
    All AU Medical Center (AUMC) employees administering human milk will follow the Human Milk Storage and Handling policy to prevent misadministration. The following provisions will be followed should an incident of misadministration occur.

  • Infection Prevention and Control for Cystic Fibrosis Patients Policy (v2), #656
    Based upon best practices for the care of cystic fibrosis patients, expanded infection prevention and control guidelines are to be implemented and used when caring for all cystic fibrosis (CF) patients to minimize the risk of transmitting pathogenic organisms.

  • Investigational Drug Services policy (v2), #2250
    This policy exists to ensure compliance with all regulations and standards governing investigational drug use in patients within AU Medical Center (AUMC). Investigational drug studies and other clinical trials conducted at AUMC facilities and campus buildings must contain adequate safeguards for the institution, its staff, the scientific integrity of the study and, especially, the patient. All studies involving drug use in humans at Augusta University (AU) must be reviewed and approved by a university recognized institutional review board (IRB). Hospital approval is also required when a study or research project plans to conduct research (and/or recruit patients) at an AUMC location or access any institutional patient information. The medical center has a procedure to review and accommodate patient’s continued participation in a protocol that is independent of the hospital.

    The Clinical Research Pharmacy is responsible for the receipt, storage, labeling, dispensing, accountability and record-keeping for all research medications used in research studies involving humans throughout AUMC, including the adult Medical Center, the Children’s Hospital of Georgia, Georgia Cancer Center, the Medical Office Building and the Georgia War Veterans’ Nursing Home (GWVNH). These services are also provided to other components of Augusta University or Augusta University Health upon request. The Clinical Research Pharmacist (Pharmacy Manager) is responsible for implementation of this policy.

  • Lactation Support Policy (v3), #324
    AU Health recognizes the well documented health advantages of breastfeeding for infants and mothers and the critical nature of workplace support for breastfeeding success, as well as the importance of setting a positive example in support of AU Health employees. The AU Health Lactation Support Policy contains the minimum standards needed for workplace support of the breastfeeding or expressing mother.

  • Management of Corrugated Cardboard policy (v1), #4345
    This policy applies to all AU Health workforce members working in the clinical areas of the hospital and clinics. Exceptions to this policy include kitchens and dining facilities, which are subject to the inspection by state and/or county health departments, and laboratory areas which are subject to the inspection by the College of American Pathologists.

    AU Health maintains processes to assure safe management of raw corrugated cardboard. The purpose of this policy is to mitigate infection risks related to medical equipment, devices, and supplies stored in raw corrugated cardboard boxes.

    It is the responsibility of the local leadership in clinical areas to apply this policy to their space. Unit staff are to dispose of the corrugated cardboard in the designated locations as assigned by EVS. For routinely ordered PAR items, Supply Chain personnel will remove all items from raw corrugated cardboard boxes prior to stocking the PAR location. Those items ordered on the bulk template must be signed for, dated, and time recorded at the time of delivery from Receiving. Bulk supplies delivered to nursing units in corrugated boxes must have said boxes broken down by unit staff and removed from the unit within 24 hours of delivery.

  • Management of Hand Dermatitis and Natural Rubber Latex Sensitivity Policy (v3), #292
    Out of concern for employee health and safety, AU Health System, Inc., has replaced almost all latex products in the hospital and clinics with non-latex alternatives and by minimizing latex exposure to a level as low as is reasonably achievable. This policy delineates the responsibility of Employee Health and Wellness, Human Resources in monitoring and managing of occupational-related hand dermatitis due to contact with irritants, including, but not limited to, soap/water hand hygiene, cleaning supplies, protective equipment, natural rubber and other workplace irritants.

  • Medical Product, Device & Recalls Policy (v3), #251
    AU Health System, to include AU Medical Center and AU Medical Associates (“AU Health”), will receive medical product and device safety alerts and recalls via multiple sources: letter, facsimile, telephone, email- or through subscription with independent services (i.e. ECRI Alerts Tracer Web-based system). Departmental end-users will take appropriate action to resolve these notifications by following this policy’s provisions concerning medical product device and recalls.

    All medical product and device safety alerts and recalls are distributed to appropriate individuals and departments, so that corrective action may be taken and monitored to ensure the safety of AU Health patients, visitors, and staff. A comprehensive, organization-wide process, which is in compliance with requirement for accreditation for regulatory agencies (i.e. Joint Commission, FDA, College of American Pathologists), has been established for receiving, reviewing, resolving and reporting on all medical product and device safety alerts and recalls.

  • Medical Record Forms Management Policy (v3), #242
    Only forms approved by the Medical Record Forms Committee should become part of the AU Medical Center patient’s permanent medical record.

    The Medical Record Forms Committee will ensure that every approved medical record form serves a desired purpose and is clearly identified as an AU Medical Center medical record form. The committee will reject unnecessary, non-standard, or poorly designed forms that interfere with the efficient administration of patient care and result in inadequate data collection, laxity in documentation, erroneous information, duplication of effort, and other mistakes. In addition, the Medical Record Forms Committee will ensure that only necessary forms are maintained, all forms are readily available to users and can be permanently archived electronically and/or in hard copy in compliance with hospital, state, and federal medical record retention policies.

  • Medication and Tubing Labeling in Patient Care Areas Policy (v5), #660
    All personnel must label any medication, medication container or other solution that is prepared on and off the sterile field with the name of the medication/solution, the concentration/strength, the amount (i.e., if not apparent from the container), expiration date when not used within 24 hours and expiration time when expiration occurs in less than 24 hours. Items prepared and immediately administered by the same person not to leave that individual’s hands (e.g., IV push, etc.) are exempt from the labeling requirement. Personnel must also label all access lines and drains with preprinted, color coded labels. Drain labels must have type of drain written on label. Labels must be placed at the distal port of the tubing or drain closest to the access site.

    Items prepared by the Department of Pharmacy are outside of the scope of this policy.

  • Medication Order Revisions Policy (v2), #2249
    This policy exists to assure the safe, effective and timely delivery of patient care by describing the revisions that may be made by a pharmacist to a medication order entered via computerized prescriber order entry. If the prescriber does not wish for the order to be modified, he or she may write “Do Not Modify,” and the order will be filled as prescribed.

  • Medication Reconciliation Policy (v1), #5163
    This policy defines the standardized process used by AU Health for development, reconciliation, and communication of an accurate medication list throughout the continuum of care. Medication reconciliation prevents medication errors such as omissions, duplications, contraindications, incorrect dosing, interactions, unclear information, and errors of transcription. This policy applies in all AU Health settings where medication-related patient care occurs (e.g., ambulatory, emergency and urgent, inpatient, and procedure areas).

  • Mitigation for Improper Use and Disclosure of Protected Health Information Policy (v3), #189
    AU Health must mitigate to the extent practicable any harmful effects that become known as a result from an improper and/or impermissible access, acquisition, use or disclosure of protected health information (PHI) or in violation of the AU Health privacy policies and procedures.

  • Non-Patient Invoicing Policy (v3), #722
    To provide AUHS employees guidance on having non-patient invoices prepared and adjusted. This policy focuses on invoicing and adjustments due to non-patient activity that results in a related party or external company owing payment to AUHS.

  • Nursing Documentation Policy (v2), #3299
    The nursing care documentation guidelines in this policy will be adhered to in order to assure care is provided to and documented for each patient based on a nursing assessment. The documentation of assessment, plan, intervention, and patient response shall occur as close to the real time of occurrence as possible. The goal of the assessment is to determine the care, treatment, and services that will meet the patient’s initial and continuing needs.

  • Patient Radiation Dose Management Policy (v2), #3850
    AU Medical Center (AUMC) is committed to the safe and effective use of diagnostic radiation. Medically necessary imaging procedures can give radiation exposure to the patient and, since excess radiation exposure carries risks, efforts are made to eliminate avoidable exposure.

    The purpose of this policy is to provide guidelines for radiation dose management and patient follow up related to imaging procedures at AUMC.

  • Patient Safety Event Reporting Policy (v4), #379
    *The Management of Sentinel Events Policy and Serious Reportable Events Policy have been combined with the Patient Safety Event Reporting Policy. These separate policies have been archived and are no longer viewable on PolicyTech.

    AU Health System is committed to improve the quality and safety of patient care through the following:

    1. Identification and evaluation of errors, near misses or hazardous/unsafe conditions that are a threat to patient safety or have the potential to result in patient harm
    2. To improve systems and processes
    3. To foster a culture of safety and learning across the organization by openly discussing patient safety at all levels.

    Within a culture of safety, there is continuous reporting of patient safety events, near misses and hazardous conditions so these occurrences can be analyzed and processes can be changed or systems improved.

    Reporting is essential to the identification and evaluation of errors for the purpose of identifying root causes and trends which leads to improving processes which is essential to reduce risk and prevent patient harm. All team members are required to participate in the detection and reporting of any error, medication error, near miss, hazardous/unsafe condition, process failure, injuries involving patients, visitors and staff or a sentinel event.

  • Patient Skin Antisepsis for Operative and Invasive Procedures Policy (v1), #4437
    The goal of skin antisepsis is to remove dirt, skin oil and transient organisms at the surgical site to reduce the risk of surgical site infection. This policy applies to all staff AUMC staff who perform skin preparations for surgical and/or invasive procedures.

  • Patient’s Right to Request Access to Protected Health information for Inspection and/or Copying Policy (v3), #1135
    Patients and their personal representatives have the right to access, inspect and obtain a copy of their protected health information (PHI) that is maintained in the designated record set unless an exception applies.

    PHI maintained electronically in the designated record set must be provided in the electronic form and format that the patient or personal representative requested if the PHI can be produced in the electronic form and format requested by the patient or personal presentative.

  • Pediatric High Risk Airway Response Team Policy (v1), #5125
    To provide process for a multidisciplinary high risk airway team (HRAT) composed of personnel who have specialized training in managing pediatric tracheostomy, laryngectomy, T-tube, post airway reconstruction and other high risk airway patients, and who can respond in an emergency with specialized equipment to assist with airway management.

  • Pest Prevention and Control Policy (v2), #1092
    For patient safety, and to increase compliance with environment of care standards, outside food and drink must not be allowed in patient care areas within the Intensive Care Units (ICUs). Food and drink brought from outside the medical center and stored in a patient’s room on a general inpatient unit should be done in a manner preventing the attraction of pests.

    The Centers for Disease Control (CDC) recommends well developed pest control strategies in high risk areas and areas prone to infestation, as infestation can be linked to infection. The Association for Professionals in Infection Control and Epidemiology (APIC) recommends educating staff, patients, and care partners/families to ensure no food is kept in drawers/closets of patient rooms to prevent pest related disease/infection.

  • Pharmaceutical Waste Management Policy (v1), #5192
    The purpose of this policy is to define the process of proper disposal for pharmaceutical waste in compliance with the Environmental Protection Agency, the Drug Enforcement Agency, and other regulatory bodies.

  • Pre-Admission Communicable Diseases Screening Policy (v2), #843
    This policy will establish mechanisms to readily identify patients who may be incubating a common, communicable disease, in order to promptly initiate Transmission-based Precautions, thereby preventing transmission to unknown, susceptible individuals. These diseases include, but are not limited to, varicella zoster (chickenpox), herpes zoster (shingles), rubella (German measles, three-day measles), rubeola (measles, red measles), infectious parotitis (mumps), Bordetella pertussis (whooping cough), and Mycobacterium tuberculosis (MTB, TB).

  • Pre-Cleaning and Transportation of Instrumentation Policy (v1), #4607
    To ensure infection prevention practices are followed during pre-cleaning and transport of reusable contaminated instruments or devices to the reprocessing area.

  • Prevention and Management of Clostridioides (Clostridium) Difficile Policy (v1), #4715
    Clostridium difficile (C. difficile) is a spore-forming, gram positive anaerobic bacillus that produces two exotoxins, toxin A and toxin B, which cause diarrhea and colitis in susceptible patients whose normal colonic bacterial flora has been disrupted by antimicrobial treatment. C. difficile infection may result in pseudomembranous colitis, toxic megacolon, perforation of the colon, or sepsis.

  • Surgical Attire Policy (v3), #909
    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.

  • Surveillance of Occupational Exposure to Hazardous Drugs and Chemicals Policy (v3), #294
    The medical surveillance of employees who are potentially exposed to chemical hazards is to be monitored systematically with the intention to prevent occupational injury and disease. The purpose of this surveillance program is to identify the earliest reversible biologic effects so that exposure can be reduced or eliminated before the employee sustains irreversible damage.

  • Transcranial Magnetic Stimulation policy (v2). #1137
    The policy is intended to provide guidelines for delivery of care for patients receiving transcranial magnetic stimulation therapy (TMS). The policy ensures responsible licensed personnel, who direct or provide patient care will comply with standards of care within their scope of practice for all patients that receive TMS. Specific practices will be integrated into the assessment, planning, prioritizing, delivery and documentation of patient care. TMS is provided for outpatients for whom this treatment is indicated, as determined by the TMS Attending. Acceptable indications for TMS include but are not limited to: poor response to antidepressant medications, contraindication for antidepressant medication use or ECT, and past positive response to TMS. Indications and exclusionary criteria for TMS are those generally consistent with FDA-approved TMS devices, in conjunction with clinical judgment and the published evidence base for this treatment modality.

  • Transporting Protected Health Information Policy (v2), #931
    All protected health information (PHI) on paper and electronic protected health information (ePHI) must be transported and stored in a secure manner to safeguard it against improper disclosure and/or loss. ePHI will be securely stored or transported outside secure network servers only when necessary and should not be printed or recorded for unapproved purposes. Workforce members must remotely access electronic ePHI via Citrix or approved virtual private network (VPN) instead of physically transporting PHI. Only the minimum amount of PHI necessary to accomplish the purpose of the use/disclosure should be transported.

  • Valuation of Inventory Policy (v2), #254
    The inventory of AU Health is valued in a consistent manner and accurately reflected in the AU Health Financial statements in accordance with Financial Accounting Standards Board (FASB) guidelines and Generally Accepted Accounting Principles (GAAP). Inventory is a valuable AU Health System asset and will be properly safeguarded. Consistent compliance with the provisions of this policy reduces costs and ensures that supplies are available when needed.

  • Vendor Access and Control Policy (v3), #164
    This intent of this policy is to establish a uniform process for the management of all vendor representatives doing or soliciting business with AU Health System entities; ensure that all Vendor Representatives will adhere to AU Health System policies and procedures, and will abide by the laws and regulations of the United States of America, the State of Georgia, applicable accrediting agencies, and other regulatory standards of practice. In addition, the policy provides guidance to control and monitor vendor activity and assure appropriate vendor access to AU Health System entities; provide guidance for appropriate vendor behavior throughout AU Health System entities; and to ensure that all equipment and supply purchases, including new technology and pharmaceuticals, are in compliance AU Health System’s Purchasing and Contracting practices.

  • Ventilator Initiation and Adjustments Policy (v1), #4048
    The intent of this policy is to identify best practices and safe initiation and management of mechanical ventilation.

  • Withholding or Withdrawing Medical Treatment Policy (v2), #425
    This policy serves as a reference for understanding the medical-ethical questions involved in decisions regarding withholding or withdrawing medical treatments. Whenever there are questions regarding difficult or complicated cases involving withholding or withdrawing medical treatments, the AU Medical Center Ethics Committee is available for support. An ethics consult may be initiated by any staff member by calling 721-7475 (1-RISK) to speak with an attorney in the AU Health System Legal Office. After consultation with the Legal Office, if an ethics consult is appropriate, the Legal Office will be responsible for coordinating a day and time for the consult.

  • Work Restrictions Policy (v3), #299
    Work restrictions for infectious diseases will be based upon the Centers for Disease Control and Prevention’s (CDC) recommendations for health care workers and are listed below. Return to work for these diseases is permissible when approved by the employee’s Primary Care Practitioner or Employee Health and Wellness, Human Resources (EH&W). When neither is available, the employee’s immediate Supervisor may approve their return. Other potentially infectious conditions or diseases should be reported to EH&W. Employee Health and Wellness may implement work restrictions based on the mode of transmission and epidemiology of the disease.

    The pregnant health care worker is not to be excluded from the care of patients with particular infections solely on the basis of the pregnancy or intent to become pregnant. Use of standard precautions is required by everyone regardless of pregnancy to reduce exposure risks.

  • Workplace Violence Prevention Policy (v4), #889
    AU Health System, Inc. (AUHS) is committed to keeping the workplace safe where employees, patients, families, and guests are free from the threat of workplace violence. The policy on workplace violence is a zero-tolerance policy. This policy defines behavior that constitutes workplace violence and defines procedures for responding to and resolving workplace violence.

  • Portable Medical Gas Policy (v3), #283 
    This policy establishes procedures to be followed when cylinders are required to be stored on a unit or smoke compartment for emergency or transport use. Approved: 11/21/2019

  • Petty Cash Reimbursement Policy (v2), #3703

    The petty cash fund allows for reimbursement of minor business expenses of AUHS entities in an efficient and cost effective manner.

  • Equal Employment Opportunity Policy (v3), #114

    AU Health believes a strong commitment to equal employment opportunity (EEO) is more than a legal and moral obligation. It is also a sound business practice to realize the potential of every individual. AU Health is committed to providing equal employment opportunities without regard to race, color, religion, sex/gender, national origin, age, disability, marital or family status, sexual orientation, gender identity, veteran status, or genetic information. This extends to all aspects of employment including, but not limited to recruiting, hiring, placement, promotion, demotion, transfer, disciplinary actions, termination, staff reductions, rate of pay and other forms of compensation, selection for training, and participation in system sponsored employee activities.

  • Employee Assistance Program Policy (v3), #139

    The Employee Assistance Program (EAP) provides employee short-term counseling, assessment and referral services for personal and work related problems, critical incident management, and assistance with the Employee Care Program Policy. The EAP can be accessed in three ways:

    1. Self-Referral
    2. Supervisory Referral
    3. Physician Referral

    Supervisors and managers are encouraged to consult EAP regarding employees who have persistent performance or attendance problems, because these are often associated with personal problems. The EAP counselor will determine whether EAP counseling could be helpful, but the ultimate decision to pursue counseling is made by the employee.

  • INS Compliance and Employment of Aliens Policy (v2), #169

    It is occasionally necessary to employ alien non-citizen personnel into certain positions which may be specialized in nature and/or challenging to recruit. The health system shall verify the employment eligibility of each person hired.

    For aliens requiring visas to work in the United States, the process, as defined by Department of Labor (DOL) and Immigration and Naturalization Services (INS), is followed to facilitate obtaining the appropriate visa.

  • Licensure and Certification Policy (v2), #943

    AU Health employees that are required by law, regulation or policy to be hired in a job classification requiring licensure or certification (other than Physicians (MD, DO or equivalent), dentists (DDS or DMD) and Allied Health providers (APRN, PA, CRNA, CNS, CNM, DA) including administrative officials who request medical staff membership or clinical privileges in the Medical Center) must furnish proof of licensure or certification to the Talent Acquisition & Management Section of the Human Resources Division prior to their employment by the organization. Subsequent proof of current license or certification in job classifications where this is required must be furnished to the Records Section of the Human Resources Division by the employee’s department as soon as the license or certification is renewed.

  • Management of Occupational Exposures to Blood Borne Pathogens Policy (v3), #127

    To provide guidance and services for all health care personnel whose activities involve contact with patients or with blood or other body fluids from patients in a health care setting, laboratory, public safety setting, or research facility. The provisions of such services are based on the regulatory guidelines set forth by the Centers for Disease Control (CDC) and the United States Public Service Health Guidelines for the Management of Occupational Exposures. Treatment for occupational exposures to HBV, HCV, and HIV following the recommendations for post- exposure prophylaxis are offered.

  • Military Leave USERRA Policy (v3), #128

    AU Health will grant a military leave of absence to employees who are absent from work because of service in the United States uniformed services, including the National Guard, in accordance with the Uniformed Services Employment and Reemployment Rights Act (USERRA).

  • Tobacco-Free Policy (v3), #1106

    Augusta University and AU Medical Center (AUMC) prohibits the use of tobacco products on any property owned, leased or controlled by Augusta University, AUMC or 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 healthy environment for all persons, including faculty, students, staff, visitors, and others who visit the campus.

  • Pre-Construction Risk Assessment Policy (v4), #284

    AU Health is committed to protecting the health and safety of patients, staff, and visitors at all times. During construction and renovation, facilities management staff and appropriate members of the AU Health staff assesses the potential impact of each construction, renovation or demolition project on the ability of AUMC to meet the needs of patients, staff and others. The risks identified are used to develop a plan designed to minimize disruption of AU Health patient care services and risks to AU Health staff and visitors. Every effort is made to minimize disruption of services and care related to the construction process. However, in all cases, patient care considerations have the highest priority. AU Health will not compromise patient care quality or patient safety.

  • Patient No Show Policy (v2), #418

    To ensure a consistent management of patient no shows. These guidelines apply to patients being rescheduled at AU Medical Center (AUMC) operated properties.

    It is the policy of AUMC that a patient’s appointment status will be appropriately assigned “no show” in IDX when a patient has failed to keep an appointment and has not contacted the office to cancel or reschedule. The responsible provider will be notified and asked to determine if the patient needs to be contacted for follow-up, based on service-specific clinical guidelines.

  • Personal Protective Equipment Policy (v2), #927

    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.

  •  Daily Testing of Disinfection Equipment SOP (v1), #5178

    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.

  • Intra Hospital Patient Transport Policy (v3), #219

    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.

  • 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 (v3), #188
    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), #714
    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 beevaluated dailyfor 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), #295 
    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.

  • Acceptance of Business Courtesies & Contributions Policy (v2), #174

    At AU Health System, we strive to maintain a culture marked by the highest standards of institutional and professional ethics; we expect all employees to assist in cultivating and maintaining these ethical standards. While there are situations when modest gifts are offered to convey a thoughtful “thank you” and courtesies are offered to strengthen a business relationship, in healthcare, business courtesies and contributions pose a risk for conflicts of interest or fraud and/or abuse related to anti-kickback laws and regulations. In recognition of these issues, this policy provides guidelines for acceptance or refusal of any business courtesies and contributions. Where federal health care programs are involved, it is a violation of the federal anti-kickback law to accept gifts from patient referral sources and from vendors, unless the gift is truly nominal, as defined in OIG policy statements, is clearly and completely unrelated to past or future referrals of patients or purchases, or is very unlikely to influence referrals or purchases.

  • Signage Policy (v2), #149

    AU Health ensures that the AU signage meets the quality standards of aesthetic appeal, uniformity, and simplicity, while being highly functional in providing necessary information.

  • Board Member Travel Policy (v3), #261

    This policy applies to all members of the Board of Directors of AU Health System (AUHS), AU Medical Associates (AUMA), AU Medical Center (AUMC), and Roosevelt Warm Springs Rehabilitation & Specialty Hospitals (RWSH) for use in regular travel to attend board meetings and/or board sub-committee meetings. This policy also pertains to Board member travel associated with special events such as conferences and workshops that pertain to the work of the Board.

  • Vacated Space Policy (v2), #150

    AU Health ensures that policies and procedures are in place for the proper handling of vacated space occupied by AU Health. When a space is vacated, the user department will ensure that the space is properly clean, secured, and cleaned. Additionally, the user department will properly notify other departments, as appropriate.

  • Self-Administrations of Medications Policy (v2), #2248

    This policy assures the safe and accurate administration of medications by a patient or non-hospital staff member. The administration of medications by patients and/or non-staff members is discouraged because of the difficulty in ensuring the proper use of the medication and in documenting medication administration.

    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.

  • Contracted Patient Care Services Policy (v3), #265

    AU Health System (AUHS) has a systematic process for developing agreements and contracts for any patient care related services. A review, approval and monitoring process is in place to assure the appropriate individuals have input into the development of the contract, as well as the ongoing administration of the agreement.

  • The Legal Health Record Policy (v3), #246

    A “Legal Health Record” (LHR) is maintained on every patient registered and seen by a healthcare professional in the AU Medical Center, Children’s Hospital of Georgia or AU Medical Center Clinic. The content of specific encounter records varies based on the level of services provided; however, each record must:

    • Contain sufficient information to justify the diagnosis, treatment and outcome of the patient.
    • Provide a record of the patient’s health status including observations, measurements, history, and prognosis.
    • Provide a method for clinical communication and care planning among the individual healthcare practitioners serving the patient; therefore, the information must be available at all times via an enterprise-wide medical record system.
    • Serve to document evidence of the quality of patient care, complying with state and federal rules of evidence. Specifically, the records must be made in the normal course of business, must be completed within a reasonable timeframe following the episode of care, must be legible, must be reproducible, and must be certifiable by the Medical Record Custodian.standards and state and federal rules an.Provide a method for clinical communication and care planning among the individual healthcare.
    • Serve as the legal business record for AU Medical Center, complying with accreditation standards and state and federal rules.
  • Fans for Patient Use Policy (v2), #915

    AU Medical Center (AUMC) hospitals and clinics safely uses fans when additional measures are needed in providing for patient comfort.

  • Notifiable Diseases Policy (v2), #3346

    AU Medical Center (AUMC) will comply with the Rules and Regulations for Notification of Diseases, Chapter 290-5-3, Georgia Department of Human Resources (GDHR), and the Official Code of Georgia Annotated (OCGA).

    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.

  • Phase I Post Anesthesia Recovery Outside of the PACU Policy (v2), #1040

    The intent of this policy is to ensure that all patients with comparable needs receive the same standard of care, treatment and services throughout AU Medical Center. Patients requiring Phase I post anesthesia recovery observation in any of the intensive care units (ICU), will receive the same standard of care, treatment, and services as patients receiving Phase I post anesthesia recovery observation in the Post Anesthesia Care Unit (PACU).

  • 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 forevery 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.
  • 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.'