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.
NOTE: The University’s policies ultimately become a part of the Ohio Administrative Code. The Administrative Code is written in lower case. As each UT policy comes due for review, it will be formatted according to the Ohio Legislative Service Commission Drafting Manual. Many words that normally would be capitalized will not be capitalized in the text of the policy. For example – university of Toledo, president of the United States, supreme court, holidays such as Christmas day (Christmas is capitalized but day is not). The Drafting Manual includes many other grammatical guidelines. The header box and the signature box do not need to comply with these rules. Please do not send comments asking to revise capitalization, outline format, grammar, etc.
Patient Financial Servicies (UTMC) – 1 policy – This policy has been signed and is effective immediately during the 30 day comment period.
Policy Name: 3364-142-13 Patient financial assistance
Description: Major revisions as noted by red-line in the proposed policy.
Scope: UTMC
Comment Period: May 3, 2024 through June 3, 2024
Comment on this policy: 3364-142-13
COLLEGE OF MEDICINE and LIFE SCIENCES – 2 policies
Policy Name: 3364-81-04-013-02 Academic promotion, grading criteria, remediation, dismissal in
the MD program
Description: Minor revisions. Remove option to appeal to the Dean; clarifying statement for what
a student in good standing reflects; remove communication of grades in the syllabus;
remove score requirements on the NBME since the NBME exams are now becoming part of
the end of system summative assessment; remove language on monitoring by APC since
this language is in another policy; revised failed examination language and remediation.
Throughout the policy, there are many grammatical and title revisions.
Scope: College of Medicine and Life Sciences
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-81-04-013-02
Policy Name: 3364-81-12 Curriculum modification
Description: Minor revisions. Revisions clarify that ECC must review and approve curriculum changes;
that ECC will provide formal updates to COMLS council; and any major changes made
will be discussed at council and ultimate authority lies with ECC.
Scope: College of Medicine and Life Sciences
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-81-12
GRADUATE MEDICAL EDUCATION – 5 policies
Policy Name: 3364-86-002-00 Implementation of new programs or instituting change in existing programs
Description: Minor revisions. The committee will consist of equal member representation as designated
by the Dean of the COMLS and ProMedica CEO. The DIO will serve as a member of the
committee.
Scope: UT College of Medicine Residency Programs
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-002-00
Policy Name: 3364-86-019-00 Resident eligibility for graduate medical education at the University
of Toledo
Description: Minor revision to wording in the procedure section.
Scope: UT College of Medicine Residents
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-019-00
Policy Name: 3364-86-021-00 Graduate medical education committee
Description: Minor revisions. The committee should include two peer selected program coordinators
who will serve a two-year term. Change to meeting frequency, notification of recording
of meetings for purposes of taking minutes only. Required meeting attendance listed.
Scope: UT College of Medicine Residency Programs
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-021-00
Policy Name: 3364-86-038-00 Educational rotations outside of the University of Toledo and affiliated
hospitals/clinical sites
Description: Minor revisions. Educational rotations required by a program’s RRC, that all residents/fellows
must have experience in and are not available at UT/affiliated hospitals are not considered
outside rotations and are not applicable to this policy.
Scope: UT College of Medicine Residents
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-038-00
Policy Name: 3364-86-041-00 Multidisciplinary pain medicine fellowship management
Description: Minor revision. The committee will regularly review the program’s resources and its
attainment of stated goals and objectives.
Scope: UT College of Medicine Residency Program
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-041-00
College of Medicine & Life Sciences - 4 policies
Policy Name: 3364-81-01-004-01 Individual conflict of interest in education and clinical care
Description: (Minor/technical revision of existing policy) Clarifying revisions.
Scope: College of Medicine & Life Sciences
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-81-01-004-01
Policy Name: 3364-81-04-012-04 Combined degree programs for medical students
Description: (Major revision of existing policy) Revisions include clinical training requirements and addition of MD/PhD-(BMSP) and
MD/PhD-(BME) degree programs
Scope: All University of Toledo Campuses
Comment Period: May 31, 2024 to July 1EQP-, 2024
Comment on this policy: 3364-81-04-012-04
Policy Name: 3364-81-15 Pre-clinical pathology student fellowship
Description: (Minor/technical revision of existing policy) Clarifying revisions.
Scope: Medical students in the pre-clinical portion of the MD program in the College of Medicine
& Life Sciences (certificate program)
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-81-15
Policy Name: 3364-81-25 Faculty review
Description: (Minor/technical revision of existing policy) Clarifying revisions.
Scope: Faculty in the College of Medicine & Life Sciences
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-81-25
UTMC - 5 policies
Policy Name: 3364-100-45-06 Code blue policy and procedure
Description: (Major revision of existing policy) The phrase “An ACLS qualified health care provider is available 24/7, 365 days a year” was added to ensure compliance with the standards of our bariatric accreditation,
as well as to reflect the current practice of how the team responsible for code blue
attendance is staffed.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-100-45-06
Policy Name: 3364-109EQP-306 Equipment cleaning
Description: (Major revision of existing policy) Added requirements for ultrasound probe and glucometer cleaning; revised language
for cleaning workstation on wheels and for room equipment cleaning during discharge
process.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-109EQP-306
Policy Name: 3364-139-1-03 High level disinfection
Description: (Minor/technical revision of existing policy) Added the requirement for ultrasound probes cleaning when coming into contact with
blood or body fluid.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-139-1-03
Policy Name: 3364-100-45-10 Code blue carts (contents and locations)
Description: The policy is recommended to be rescinded. The policy will be made a procedures in order to allow for practice changes to be made as needed, and in accordance with the R3 report which states guidelines and procedures are acceptable in lieu of a policy.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-100-45-10
Policy Name: 3364-100-45-25 Urgent and emergent inpatient intubation pathway
Description: The policy is recommended to be rescinded. The policy will be made a procedures in order to allow for practice changes to be made as needed, and in accordance with the R3 report which states guidelines and procedures are acceptable in lieu of a policy.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period: May 31, 2024 to July 1, 2024
Comment on this policy: 3364-100-45-25