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Policies Posted for Comment

Draft and recently signed policies are posted here for review and comment by The University of Toledo community for thirty days. Draft policies do not have official status as approved policies until the Approving Officer has signed the policies. Some policies may be signed in advance of the vetting period to comply with the requirement of federal or state laws or regulations or accrediting agencies.

Please direct any comments or questions regarding the policies posted for comment to policies@utoledo.edu or click on the icon under “comment on this policy.” Please state the name of the policy in the subject line. Comments received on the policy will be forwarded to the policy’s responsible agent or agent’s designee.

To join our mailing list for email notification of updates and additions to the Policies Posted for Comment, please send an email to policies@utoledo.edu with “policies posted for comment” in the subject line.

College of Medicine and Life Sciences (1 policy)
College of Pharmacy and Pharmaceutical Sciences(1 policy)
Human Resources (5 policies)
Legal Affairs ( 3 policies)
Student Life (1 policy)
UTMC (18 policies)

College of Medicine and Life Sciences

Policy Name: Recently Signed 3364-81-04-012-01 Curriculum for the College of Medicine
Description: (Minor/technical revision of existing policy) This policy provides information related to the four year curriculum of the COM. Students successfully completing this program will be granted an MD degree. This policy provides a framework for medical education in the four year curriculum.
Scope: All University of Toledo Campuses
Comment Period: October 1, 2013 – October 31, 2013
Comment on this policy: 3364-81-04-012-01

College of Pharmacy and Pharmaceutical Sciences (1 policy)

Policy Name: Recently Signed 3364-83-03 Academic Performance Policy College of Pharmacy and Pharmaceutical Sciences

Description: (New policy proposal) The College of Pharmacy and Pharmaceutical Science (CPPS) encourages adequate academic performance to meet the standards of the degree programs which it offers. The College’s Academic Performance Committee is authorized to review and adjudicate academic performance standards of the various degree programs. The College also recognizes a student’s right to due process. This policy addresses academic performance and student progression toward graduation, as well as an appeals process for decisions rendered by the Academic Performance Committee.

Scope: The policy applies to all students of the CPPS

Comment Period: September 26, 2013 – October 28, 2013

Comment on this policy: 3364-83-03

Human Resources (5 policies)

Policy Name: Recently Signed 3364-25-04 Personnel Records
Description: (Minor/technical revision of existing policy) The human resources and talent development office is responsible for maintaining the official employment records for each staff employee. Employee records for faculty are maintained the office of faculty affairs or office of the provost. Revisions include: employees are able to maintain select records via the University’s self-service system; and any changes in family status affecting insurance must be completed within 30 days of the event with the benefits department.
Scope: all campuses
Comment Period: September 16, 2013-October 16, 2013
Comment on this policy: 3364-25-04

Policy Name: Recently Signed 3364-25-118 Recruitment of Personnel
Description: (Minor/technical revision of existing policy) The policy was revised to incorporate the electronic personnel action form (EPAF) and University’s Employment Opportunity site located at http://jobs.utoledo.edu.
Scope: Main Campus
Comment Period: September 16, 2013-October 16, 2013
Comment on this policy: 3364-25-118

Policy Name: Recently Signed 3364-25-119 Personnel Actions
Description: (Minor/technical revision of existing policy) The policy was revised to incorporate the electronic personnel action form (EPAF) and be consistent with 3364-25-48 Separation from employment.
Scope: Main Campus
Comment Period: September 16, 2013-October 16, 2013
Comment on this policy: 3364-25-119

Policy Name: Recently Signed 3364-25-106 HSC Drug and alcohol testing policy
Description: (Major revision of existing policy) Use of substances which cause intoxication or impairment on-the-job poses risks to The University of Toledo, the affected employee, to co-workers and patients. Recognizing that drug and alcohol abuse are treatable illnesses which should be dealt with initially by treatment and education, no employee will be discharged without first having an opportunity to seek treatment, if treatment is needed. This policy is designed to create a procedure to detect and permit workers to rehabilitate if drug or alcohol dependent.
Scope: University Health Science Campus Employees – see section (C)
Comment Period: September 16, 2013 – October 16, 2013
Comment on this policy: 3364-25-106

Policy Name: Recently Signed 3364-25-62 Appointment and classification
Description: (Minor revision of existing policy) Section (E) (e) Postdoctoral was revised as follows: Postdoctoral - Are individuals who completed a Ph.D., MD or comparable degree and whose goal is to acquire additional training and experience in order to enter a career in academia and/or research. These are temporary appointments, and work under the supervision of a faculty mentor who is responsible for the fiscal and intellectual activities. Appointments shall not exceed six (6) years after receipt of a Ph.D., MD or comparable degree.
Scope: all campuses
Comment Period: September 16, 2013 – October 16, 2013
Comment on this policy: 3364-25-62

Legal Affairs ( 3 policies)

Policy Name: Draft 3364-10-04 Claims management committee
Description: (Minor/technical revision of existing policy) The University will create and maintain a claims management committee (“committee”), as part of its litigation management process, that will evaluate claims made against the university, faculty practice plans (“FPPs”), or other entities or individuals insured by the university insurance program to determine approximate economic severity, set reserves, develop defense and litigation strategy, coordinate claims, set allocations of responsibility and do all other things necessary for management of litigation. Proposed revisions are tracked in the posted draft policy.
Scope: The University of Toledo, all campuses
Comment Period: September 20, 2013 – October 21, 2013
Comment on this policy: 3364-10-04

Policy Name: Draft 3364-10-16 Professional Liability Claims Reporting and Management
Description: (Minor/technical revision of existing policy) The University of Toledo will promptly report all professional liability claims for UT and the University of Toledo Physicians that meet the criteria outlined in this policy, to The University of Toledo Insurance Program. UT and UTP will promptly provide information related to actual or potential claims as required by this policy to the Office of Legal Affairs, Health Science Campus. The purpose of this policy is to assure that all professional liability claims and anticipated potential professional liability claims of UT and UTP are appropriately managed to improve quality of care and reduce the financial impact to both UT and UTP and are properly reported to the Insurance Program for insurance coverage. Proposed revisions are tracked in the posted draft policy.
Scope: The University of Toledo (Health Science and Main Campus) and University of Toledo Physicians (see section (C) in policy)
Comment Period: September 20, 2013 – October 21, 2013
Comment on this policy: 3364-10-16

Policy Name: Draft 3364-10-03 Standard of care committee
Description: (Minor/technical revision of existing policy) The university will create and maintain a standard of care committee (“committee”), as part of its litigation management process that will review care for standard of care issues that lead to claims or potential claims. In order to improve patient safety and reduce future risk exposures to the university and the faculty practice plans (“FPPs”) or other entities or individuals insured by the university’s insurance program, the committee will communicate any standard of care, or patient safety concerns to the Quality and Patient Safety Council. The committee is established to evaluate litigation claims, improve patient safety and reduce future risk.
Scope: The University of Toledo
Comment Period: September 26, 2013 – October 28, 2013
Comment on this policy: 3364-10-03

Student Life (1 policy)

Policy Name: Draft 3364-30-52 Satisfactory academic progress for recipients of federal and state financial aid
Description: (Major revision of existing policy) The federal Department of Education and the state of Ohio regulations require that the University of Toledo review the academic progress of students. This regulation applies to all applicants whether or not financial aid was received for all terms evaluated. The University of Toledo reviews progress at the end of each grading period. The purpose of the policy is to clearly identify the three financial aid tests required by federal legislation, the minimum test results to remain eligible and the process, if eligible, for appeal and steps to regain eligibility.
Scope: all University of Toledo campuses
Comment Period: September 5, 2013 – October 7, 2013
Comment on this policy: 3364-30-52

UTMC (18 policies)

Policy Name: Draft 3364-100-50-23 Adjustment of University of Toledo Medical Center Charges

Description: (Major revision of existing policy) The adjustment of University of Toledo Medical Center charges related to negative customer relations or alleged billing errors must be approved by either Risk Management or Hospital Administration. The purpose of the policy is to provide a systematic method for adjusting bills for services rendered by the UTMC.
Scope: The University of Toledo Medical Center
Comment Period: September 23, 2013 – October 23, 2013
Comment on this policy: 3364-100-50-23

Policy Name: Draft 3364-100-60-11 Use of Electronic Devises (Cell Phones/Pagers/Mobile Devices) at UTMC

Description: (Major revision of existing policy) Like the use of any other computing resource, the use of electronic devices at the University of Toledo Medical Center (“UTMC”) is subject to the requirements of appropriate, legal and ethical behavior within and around the clinical care areas of UTMC keeping in mind that patients come first. Users of electronic devices in clinical areas are required to comply with the “Responsible Use Standards” identified in this policy. The purpose of the policy is to establish standards for the responsible use of Electronic Devices. This posted draft policy is a revision of the previously posted “Personal Cell Phones/Pagers.”
Scope: The University of Toledo Medical Center Clinical Facilities (see Article (C) Scope in the policy)
Comment Period: September 23, 2013 – October 23, 2013
Comment on this policy: 3364-100-60-11

Policy Name: Draft 3364-100-10-01 Consent to Treat and Informed Consent
Description: (Minor/technical revision of existing policy) Appropriate information must be provided and consent must be obtained from patients before providing care in non-emergency situations at the University of Toledo Medical Center inpatient units, clinics, outpatient departments or other facilities or locations, including those of University of Toledo Physicians, LLC.. The purpose of the policy is to obtain the general and informed consent of patients to treat by providing an explanation of the nature and process for obtaining an informed consent, how the informed consent is to be documented, where it must be stored and accessibility.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: September 26, 2013 – October 28, 2013
Comment on this policy: 3364-100-10-01

Policy Name: Draft 3364-100-45-01 Do Not Resuscitate Orders (DNRCC & DNRCC-Arrest) and Refusal of Life Sustaining Treatments
Description: (Minor/technical revision of existing policy) The policy of UTMC is to provide medically appropriate care and support, including life-sustaining treatment(s) and full resuscitative measures to any patient who develops cardiac and/or respiratory failure and/or arrest, consistent with the patient’s wishes. Life-sustaining treatments and/or resuscitative measures may be withheld or withdrawn only by order of a physician.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: September 26, 2013 – October 28, 2013
Comment on this policy: 3364-100-45-01

Policy Name: Draft 3364-100-45-06 Code Blue Policy and Procedure for Main Hospital, Heart and Vascular Center, Hospital Clinics, the George Isaac Outpatient Surgical Center
Description: (Minor/technical revision of existing policy) The Code Blue Team shall respond to all Code Blues that are called within the main hospital, Heart & Vascular Center, Hospital Clinics and the George Isaac Outpatient Surgical Center (including Endoscopy and the Pain Clinic) at the University of Toledo Medical Center (UTMC). The purpose of the Code Blue team is to assure the prompt and skilled cardiovascular and cerebral resuscitation of persons who suffer a cardiopulmonary arrest. The formation of a Code Blue team shall provide for trained personnel and relieve other hospital staff members of the responsibilities of attending Code Blue’s.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: September 26, 2013 – October 28, 2013
Comment on this policy: 3364-100-45-06

Policy Name: Draft 3364-100-53-03 Point of Care Testing
Description: (Minor/technical revision of existing policy) All Point of Care Testing procedures must be performed following compliance standards required by The Joint Commission, CAP and CLIA. All sites failing to comply will not be permitted to conduct Point of Care patient testing. The purpose the policy is to assure that all laboratory testing performed at the point of care (outside the organization’s central laboratory) conforms to good laboratory practice standards and complies with federal and other regulatory requirements.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: September 26, 2013 – October 28, 2013
Comment on this policy: 3364-100-53-03

Policy Name: Draft 3364-100-50-10 Ambulance-ambulette services
Description: (Minor/technical revision of existing policy) Ambulance and ambulette services for UTMC patients will be coordinated and managed in a consistent manner with all external transportation companies. The purpose of the policy is to ensure a consistent, equitable process with external transportation companies and to provide a cost effective, efficient transportation process for UTMC patients; and to ensure compliance with all state and federal regulations related to certification and to ensure equal opportunity for all external transportation companies.
Scope: The University of Toledo Medical Center
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-50-10

Policy Name: Draft 3364-100-50-33 Cardiopulmonary resuscitation competency
Description: (Major revision of existing policy) Effective resuscitation services are systematically available throughout the hospital. Designated personnel will demonstrate competency in resuscitation services as appropriate to their job duties and responsibilities. The purpose of the policy is to provide an organized response to needs for resuscitative services and assure staff maintain the necessary knowledge and skills to safety and effectively provide these services.
Scope: The University of Toledo Medical Center
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-50-33

Policy Name: Recently Signed 3364-100-01-08 Room Assignment for Patients Undergoing Administration or Implantation of Therapeutic Radioactive Material
Description: (Minor/technical revision of existing policy) Patients undergoing the administration of I-131 requiring admission or implantation of Cs137 or Ir192 therapeutic radioactive material shall be held in radiation isolation in a private room. This location may be changed upon the medical decision of the radiation oncologist and attending physician, if an alternative location is clinically more appropriate. The Radiation Safety Office must be notified immediately of the change. Any change in this policy must be submitted to the Radiation Safety and Radioisotope Committee. The purpose of the policy is to provide the safest environment possible for patients, health care workers and visitors.

Scope: The University of Toledo Medical Center
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-01-0

Policy Name: Recently Signed 3364-100-45-03 Organ, Tissue or Eye Donation after Death
Description: (Major revision of existing policy) All patients have the right to elect organ donation in the event of death. This policy permits patients and families to consider organ procurement following both brain and cardiac (circulatory) death. The purpose of this policy is to: outline the process for identification of potential donors and coordinate with the appropriate recovery agency; define a mechanism by which families of potential donors are offered the opportunity of organ, tissue or eye donation; and provide a formal mechanism by which UTMC may initiate the process of donation and to ensure the proper measures are taken and ethical issues are considered to protect the patient with regard to organ, tissue or eye donation and to carry out the wishes of the patient and the patient’s family.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-45-03

Policy Name: Recently Signed 3364-100-60-03 Notarization and Witnessing Services for Patients
Description: (Minor/technical revision of existing policy) The University of Toledo Medical Center (“UTMC”) may provide a notary public to patients who need such services. The notary public will serve as a witness to patients’ signatures on documents for personal affairs of the patients. The purpose of the policy is to provide a notary and witness service when possible to inpatients of UTMC who may need to execute personal legal documents in order to carry out their personal affairs while admitted.
Scope: The University of Toledo Medical Center
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-60-03

Policy Name: Recently Signed 3364-100-60-12 Patient Financial Support for Ambulatory and Outpatient Care
Description: (Minor/technical revision of existing policy) For all UTMC clinic care or outpatient units, patients will confirm payment arrangements prior to clinic care visits. Patients with insurance will be asked to pay their co-pay on the day of the clinic appointment. The purpose of the policy is to provide access to care while ensuring financial responsibility is met by the patient.
Scope: The University of Toledo Medical Center
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-60-12

Policy Name: Recently Signed 3364-100-60-13 Patient Financial Support for Scheduled Surgical Procedures and Diagnostic Testing
Description: (Minor/technical revision of existing policy) All patients to be scheduled for a surgical procedure or diagnostic testing at the University of Toledo Medical Center will be provided patient support services by a Financial Counselor prior to scheduling. All patients will be required to pay the applicable out of pocket percentage of estimated total charges prior to scheduling the procedure, unless otherwise approved. The purpose of the policy is to provide access to care while ensuring financial responsibility is met by the patient.
Scope: The University of Toledo Medical Center
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-60-13

Policy Name: Recently Signed 3364-100-90-07 Medical Record Availability, Access and Amendment
Description: (Major revision of existing policy) The University of Toledo’s Health Information Management Department (“HIM”) maintains a medical record for each inpatient and outpatient encounter. The medical record is made available upon request to individuals by the HIM Department. Patients may request access and amendments to their medical records (“PHI”) through processes established by the HIM Department.
Scope: The University of Toledo Medical Center and its other Health Care Components, Medical Staff
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-90-07

Policy Name: Recently Signed 3364-100-90-11 Accounting and Documentation of Disclosures of Protected Health Information other than Treatment, Payment or Healthcare Operations
Description: (Major revision of existing policy) The University of Toledo Medical Center (“UTMC”) is committed to ensuring the security and privacy of protected health information (“PHI”) of its patients. In line with this commitment, UTMC, through its Health Information Management (“HIM”) department, has developed and implemented a system of tracking, monitoring and documenting disclosures of PHI. This system of documentation will enable UTMC to respond to individual requests for accounting of disclosures in a timely and efficient manner as the law requires.
Scope: The University of Toledo Medical Center and its other Health Care Components, Medical Staff
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-90-11

Policy Name: Recently Signed 3364-100-90-15 Reporting of Security Breach of Protected Health Information including Personal Health Information
Description: (Major revision of existing policy) The University of Toledo Medical Center (“UTMC”) and its other healthcare components are committed to ensuring the privacy and security of protected health information (“PHI”) and are aware of the inherent vulnerabilities that exist in the maintenance of such information. UTMC recognizes the need for safeguards to protect PHI and the importance of notifying individuals when their unsecured PHI is subject to a breach. The purpose of the policy is to outline the processes and procedures to (1) determine whether the security or privacy of PHI has been compromised, (2) ensure compliance with notification and reporting requirements.
Scope: The University of Toledo Medical Center and its other Health Care Components
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-90-15

Policy Name: Recently Signed 3364-100-90-17 Medical Record Amendment
Description: (New policy proposal) Patients may request amendments to their medical records (“PHI”) through processes established by the Health Information Management (“HIM”) Department.
Scope: The University of Toledo Medical Center and its other Health Care Components
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-90-17

Policy Name: Recently Signed 3364-100-90-18 Patient Request for Confidential Communications
Description: (New policy proposal) The University of Toledo Medical Center (“UTMC”) and its healthcare components are committed to ensuring the safety and well-being of its patients and the protection of their health information. In accordance with federal regulations, reasonable requests for confidential communications to be made to alternative locations or through alternative means will be accommodated. The purpose of this policy is to provide guidance with respect to the documentation and processing of requests to receive confidential communications.
Scope: The University of Toledo Medical Center and its other Health Care Components, Human Resources, Information Technology
Comment Period: October 4, 2013 – November 4, 2013
Comment on this policy: 3364-100-90-18

Recommendations to Rescind a Policy

Policies recommended for rescission are posted here for comment by The University of Toledo community for thirty days. Please direct any comments or questions regarding the policies recommended for rescission to policies@utoledo.edu

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