University Policy

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.

Legal Affairs ( 1 policy)
Research (1 policy)
Student Life ( 1 policy)
UTMC (7policies)


 

Legal Affairs -  1 policy

Policy Name:   Draft 3364-10-06  Practice location approval
Description:  (Minor/technical revision of existing policy)   The University of Toledo professional liability insurance program provides coverage to physicians and certain clinical associates (“Insured(s)”) of The University of Toledo Physicians, LLC  who practice at practice locations that have been approved by the UT Dean, College of Medicine & Life Sciences.  Practice locations owned or controlled by UT or UTP (see Appendix A) have been pre-approved, however, Practice Location Fact Sheets and Procedure Checklists do need to be submitted to Risk Management for entry into the practice location database.  The purpose of the policy is to provide a procedure for approving the practice locations of Insureds for coverage under the UT professional liability insurance program.
Scope:  The University of Toledo and University of Toledo Physicians
Comment Period:   August 19, 2015 – September 18, 2015
Comment on this policy  3364-10-06


Research - 1 policy

Policy Name:   Draft 3364-70-26  Photography and videography in University of Toledo Department of Lab Animal Resources animal use areas
Description:  (New policy proposal)   The use of any recording device (e.g., film camera, digital camera, camera phones, digital recorder, sound recorder) is prohibited in animal use areas with the exceptions stated in section (A) of the policy. PIs who wish to allow filming in animal use areas for reasons described in the policy must involve facility managers and animal care supervisors in planning these activities prior to filming. This includes photography or filming by outside interests. This policy is intended to protect the confidentiality and integrity of UT animal use and related policies and procedures.
Scope:  UT and UT-DLAR animal use areas, with the exception of the Lake Erie Center
Comment Period:   August 17, 2015 – September 16, 2015
Comment on this policy  3364-70-26
Student Life - 1 policy

Policy Name:   Draft 3364-30-52  Policy on satisfactory academic progress of recipients of federal financial aid
Description:  (Major revision of existing policy)   The Higher Education Act of 1976, as amended, requires The University of Toledo to develop and apply a consistent and reasonable standard of academic progress for all students who receive federal financial aid in order for those students to continue to receive such assistance.  This standard much contain all elements specified in the regulations and must be at least as strict as the policy used for all students who do not receive federal financial aid.  “Satisfactory Academic Progress” is measured in terms of performance through grade point average, and in terms of degree or program completion.  The purpose of the policy is to provide the requirements for Satisfactory Academic Progress for recipients of federal financial aid.
Scope:  all University of Toledo campuses
Comment Period:   August 25, 2015 – September 24, 2015
Comment on this policy  3364-30-52


UTMC - 7 policies

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.  UTMC uses the American Heart Association as its required standard for certification.  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 safely and effectively provide these services.
Scope:  The University of Toledo Medical Center
Comment Period:   August 12, 2015 – September 11, 2015
Comment on this policy  3364-100-50-33
 
Policy Name:   Draft 3364-100-90-20  Use of electronic messaging containing protected health information
Description:  (New policy proposal)   UTMC desires to take all reasonable steps necessary to ensure the confidentiality and integrity of protected health information sent via electronic messaging.  The purpose of this policy is to require the use of approved encrypted electronic messaging software to improve UTMC communications and patient care, maintain integrity of the electronic health record, and to avoid patient confidentiality breaches under HIPAA.
Scope:  All University of Toledo Medical Center Workforce Members
Comment Period:   August 12, 2015 – September 11, 2015
Comment on this policy  3364-100-90-20
 
Policy Name:   Draft 3364-100-01-09  Admission and discharge criteria for special care units
Description:  (Minor/technical revision of existing policy)   The purpose of the policy is to maintain clinically appropriate and efficient intensive care bed utilization by providing mechanisms for:  admitting patients to the intensive care units based on clinically based criteria; assigning available beds to the most appropriate ICU patients; address overflow placement of ICU patients during times of maximum bed occupancy within the ICU’s; and coordinate appropriate patient discharge from the ICU.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   August 19, 2015 – September 18, 2015
Comment on this policy  3364-100-01-09
 

Policy Name:   Draft 3364-100-50-06  Accommodations for patients who are sensory impaired and/or who have limited English proficiency
Description:  (Reaffirmation of existing policy)   UTMC will provide services for effective communication with patients and others, as needed, who have hearing impairments, visual impairments, and/or are limited-English-proficient.  These services are free of charge to the patients while obtaining care at UTMC.
Scope:  The University of Toledo Medical Center
Comment Period:   August 19, 2015 – September 18, 2015
Comment on this policy  3364-100-50-06

Policy Name:   Draft 3364-100-50-26  Trauma alert system
Description:  (Major revision of existing policy)   The Trauma Alert Team shall respond to all trauma alerts that are called in the Emergency Department.  The purpose of the Trauma Alert Team is to assure the rapid institution of Advanced Trauma Life Support-ATLS protocol for the resuscitation and treatment of patients who have incurred life-threatening or multi-system trauma.  The formation of a Trauma Alert Team shall provide all trauma patients and their families with optimal care by skilled trauma providers, thereby insuring patients the best clinical outcomes achievable.
Scope:  The University of Toledo Medical Center and its medical staff
Comment Period:   August 19, 2015 – September 18, 2015
Comment on this policy  3364-100-50-26

Policy Name:   Draft 3364-100-50-46  Patient Complaint Monitoring
Description:  (New policy proposal)   UTMC strives to improve the human condition by providing patient-centered, university quality care.  This includes promoting teamwork and group responsibility in identifying and implementing opportunities for improvement.  Patient complaints are indicators of patient or family concerns about their healthcare experiences.  Dissatisfaction may be associated with patient non-adherence to medical treatment plans, unwillingness to stay with a practice, impaired outcomes of care, as well as increased risk for professional liability claims.  This policy outlines UTMC’s process for identifying and addressing professionals associated with high numbers of patient complaints.
Scope:  The University of Toledo Medical Center and Clinics
Comment Period:   August 19, 2015 – September 18, 2015
Comment on this policy  3364-100-50-46

Policy Name:   Draft 3364-100-53-27  Completion of reporting and reporting of critical and abnormal unexpected findings
Description:  (New policy proposal)   All UTMC and medical staff members must timely complete all exams, images or labs for radiologic, clinical pathology, neurodiagnostic, vascular and cardiologic reports within a reasonable period of time in the interest of patient safety.  Radiology will contact the ordering physician on all Critical Test Results and Unexpected Abnormal Findings and document such communications in accordance with this procedure.  The purpose of the policy is to ensure that all exams, images and labs are conducted, read and reported in a timely manner.
Scope:  The University of Toledo Medical Center
Comment Period:   August 19, 2015 – September 18, 2015
Comment on this policy  3364-100-53-27


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

Last Updated: 8/25/15