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.
The following policies have been posted for the 30-day comment period:
GME – 1 policy
Policy Name: 3364-86-046-00 Accommodations for residents with disabilities
Description: (Minor/technical revision of existing policy) Change from Program Director initiating resident’s request for ADA accommodations.
The resident must submit an ADA accommodation request form via the Workplace Accommodations
website.
Scope: UT College of Medicine Residents
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-86-046-00
College of Medicine & Life Sciences - 6 policies
Policy Name: 3364-81-04-012-08 Area Health Education
Description: (Minor/technical revision of existing policy) The revisions include in section (D) Procedure - housing is now provided if more
than 60 miles from the HSC in place of “a one-hour drive” and also minor grammatical
changes.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: April 22, 2025 through May 22, 2025 - POLICY TO BECOME EFFECTIVE MAY 5, 2025
Comment on this policy: 3364-81-04-012-08
Policy Name: 3364-81-17 Excused absences
Description: (Minor/technical revision of existing policy) The revisions include in section (D) Excused Absences –directs to 3364-81-04-013-05 Graduation Requirements for information about flex time.
Scope: Medical students in the pre-clerkship and clinical years, University of Toledo College
of Medicine and Life Sciences
Comment Period: April 22, 2025 through May 22, 2025 - POLICY TO BECOME EFFECTIVE MAY 5, 2025
Comment on this policy: 3364-81-17
Policy Name: 3364-81-04-013-02 Academic promotion
Description: (Minor/technical revision of existing policy) The revisions include in section (D) Procedure – Remediation of FAILED Clerkship
Grades – The failed clerkship must now be repeated before applying for graduation
instead of by August 31 of the M4 year.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: April 22, 2025 through May 22, 2025 - POLICY TO BECOME EFFECTIVE MAY 5, 2025
Comment on this policy: 3364-81-04-013-02
Policy Name: 3364-81-04-013-00 Student formative feedback
Description: (Minor/technical revision of existing policy) The revisions include title corrections.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: April 22, 2025 through May 22, 2025 - POLICY TO BECOME EFFECTIVE MAY 5, 2025
Comment on this policy: 3364-81-04-013-00
Policy Name: 3364-81-013-05 Graduation requirements
Description: (Minor/technical revision of existing policy) The revisions include section 4a-c – additional MD/JD elective to count towards
UTCOMLS elective requirements. Clarification of what 2/4 week electives and transition
courses count toward graduation.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: April 22, 2025 through May 22, 2025 - POLICY TO BECOME EFFECTIVE MAY 5, 2025
Comment on this policy: 3364-81-04-013-05
Policy Name: 3364-81-20 Continuous quality improvement
Description: (Minor/technical revision of existing policy) The revisions include Under Procedure it states that committees are also now able
to see the data collected, as well as title corrections.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: April 22, 2025 through May 22, 2025 - POLICY TO BECOME EFFECTIVE MAY 5, 2025
Comment on this policy: 3364-81-20
UTMC - 36 policies
Policy Name: 3364-100-50-02 Disaster responsibilities for volunteer health care professionals
Description: (Minor/technical revision of existing policy) Added chief nursing officer or assigned designee to the list of individuals responsible
for assigning disaster responsibilities to volunteer health care professionals.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-50-02
Policy Name: 3364-100-50-31 Approval of standard care arrangements for hospital-employed advanced
practice nurses
Description: (Minor/technical revision of existing policy) Removed APN and added APRN in reference to Advanced Practice Nurses. Added reference
to Clinical Nurse Specialist titles, including those in mental health, are required
to enter into a standard care agreement with one or more collaborating physicians;
whose practice is similar to the nurse’s specialty. The Clinical Nurse Specialist
will meet requirements as outlined in the Ohio State Board of Nursing.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-50-31
Policy Name: 3364-100-01-16 Patient identification
Description: (Minor/technical revision of existing policy) Removed reference to Kobacker policy 3364-122-39 and added reference to Kobacker
Identification Guidelines.
Scope: University of Toledo Medical Center
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-01-16
Policy Name: 3364-103-VS-20 Volunteer requirements at the University of Toledo Medical Center and
Patient Clinics
Description: (Minor/technical revision of existing policy) Change in location of the Volunteer Services Office from Dowling Hall to Mulford
Library Annex.
Scope: University of Toledo Medical Center
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-103-VS-20
Policy Name: 3364-103-VS-14 Benefits
Description: (Minor/technical revision of existing policy) Changes to benefits section – removing prescription benefit and access to Morse
Physical Fitness and Student Recreation Center.
Scope: University of Toledo Medical CenterComment Period: May 2, 2025 through
June 3, 2025
Comment on this policy: 3364-103-VS-14
Policy Name: 3364-100-01-12 EMS Bypass
Description: (Minor/technical revision of existing policy) Spelled out “EMS” – Emergency Medical System and “ED” – Emergency Department for
accessibility purposes. Under procedure added “or designee” after reference to the
Medical Director of the Emergency Department for initiation of EMS Bypass.
Scope: University of Toledo Medical Center and its Medical Staff
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-01-12
Policy Name: 3364-108-102 Personnel/Selection/Training/Competency/Education
Description: (Minor/technical revision of existing policy) Under annual competency, eliminated the review of policies and procedure manuals.
Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-102
Policy Name: 3364-108-103 Equipment Calibration, Validation, - Preventative Maintenance
Description: (Major revision of existing policy) Under procedure, Category/Tag Numbers, updated Frequency, Calibration/Validation
Technique, Acceptable Criteria and Corrective Procedure information. Other minor
grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-103
Policy Name: 3364-108-104 Process Control/Change Control
Description: (Minor revision of existing policy) Under procedure, added clarification to process control. Consolidated sections
and removed any unnecessary references. Other minor grammatical and/or formatting
changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-104
Policy Name: 3364-108-105 Documentation, Recordkeeping, Record Review
Description: (Minor revision of existing policy) Under Blood Transfusion Reviews, added physician designee. Other minor grammatical
and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-105
Policy Name: 3364-108-108 Supplier Qualification/Reagent Verification
Description: (Minor revision of existing policy) Under Procedure, updated approved suppliers. Updated reagent and supply graphs.
Updated blood, blood components and specialized services, updated supplier and blood
testing and component name. Updated licensing body names. Other minor grammatical
and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-108
Policy Name: 3364-108-111 Process and Equipment Validation Protocol
Description: (Minor revision of existing policy) Updated Records of validation are maintained in the Blood Transfusion Service Supervisor’s
office. Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-111
Policy Name: 3364-108-112 Blood Bank Emergency Operations Plan
Description: (Minor revision of existing policy) Under Procedure, updated number of units of red blood cells. Clarification of storage
and tagging process. Added clarification to which patient identifiers will be used.
Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-112
Policy Name: 3364-108-201 Storage Units for Blood and Blood Components
Description: (Minor revision of existing policy) Under Acceptable Temperature Limits, removed reference to Micro Freezer – Blood
Bank Freezer. Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-201
Policy Name: 3364-108-204 Blood and Component Label Verification
Description: (Minor revision of existing policy) Under procedure, changed pooled to thawed, removed UTMC assigned number and added
product code. Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-204
Policy Name: 3364-108-206 Blood Bank in the Emergency Department
Description: (Minor revision of existing policy) Under procedure, changed the amount of blood products stored in the ED refrigerator
from 4 units to 2 units. Added that 4 units will be stored if inventory permits.
Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-206
Policy Name: 3364-108-301 Collection and Identification of Specimens
Description: (Minor revision of existing policy) Updated policy statement to clarify specimen identification and labeling.
Under procedure, added criteria for labeling, documentation, and identification of
patient specimens. Clarification added regarding blood transfusion band system, blood
type, and retention of specimens. Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-301
Policy Name: 3364-108-302 Requisition and Selection of Blood and Blood Components
Description: (Minor revision of existing policy) Under procedure, added clarification of documentation, identification of patient
and patient specimen(s), turn-around-time, ordering, and platelets. Other minor grammatical
and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-302
Policy Name: 3364-108-303 Special Circumstances for Selection of Blood and Blood Components
Description: (Minor revision of existing policy) Under procedure, added clarification for sickle-cell patients related to units of
blood and type of blood for exchange transfusions. Other minor grammatical and/or
formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-303
Policy Name: 3364-108-304 Confirmation of Donor Blood Type
Description: (Minor revision of existing policy) Under procedure, added blood inspection criteria and documentation of any findings.
Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-304
Policy Name: 3364-108-307 Critical Test Limits in the Blood Transfusion Service
Description: (Minor revision of existing policy) Under procedure, added clarification to the notification and documentation process.
Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-307
Policy Name: 3364-108-401 Issue and Return of Blood and Blood Components
Description: (Minor revision of existing policy) Under Policy statement, added acronym for Blood Transfusion Service. Under procedure,
updated patient identification number to medical record number. Added clarification
for the OR for return of unused blood. Other minor grammatical and/or formatting
changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-401
Policy Name: 3364-108-402 Administration of Blood and Blood Components
Description: (Minor revision of existing policy) Under procedure, clarified documentation of blood products in the medical record.
Added specific post transfusion vital signs to be documented, when applicable. Added
clarification to blood storage requirements. Added review process by Nursing Administration,
Nursing Directors, and the Blood Utilization Committee.
Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-402
Policy Name: 3364-108-404 Urgent Request for Uncross-matched Blood
Description: (Minor revision of existing policy) Under procedure, provided clarification on blood type and amount of red blood cells
maintained for immediate release. Added attachment with sample Urgent Release of
Uncrossmatched Blood Products form. Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-404
Policy Name: 3364-108-405 Massive Transfusion Protocol
Description: (Minor revision of existing policy) Under procedure, added the blood transfusion service will be notified immediately
by phone call to X383-5212. Provided clarification on the blood type and amount of
red blood cells stored, reserved and immediately available for use. Other minor grammatical
and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-405
Policy Name: 3364-108-501 Laboratory Investigation of Adverse Reaction to Transfusion
Description: (Minor revision of existing policy) Under procedure, changed clinical investigation to clinical process. Added clarification
of a transfusion reaction documentation, physician notification and procedures to
follow. Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-501
Policy Name: 3364-108-503 Lookback Protocol
Description: (Minor revision of existing policy) Under policy statement wrote out ASBB - Association for the Advancement of Blood
and Biotherapies. Changed specific blood supplier names to blood supplier throughout
the document. Other minor grammatical and/or formatting changes.
Scope: Pathology/Laboratory – Blood Bank
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-108-503
Policy Name: 3364-135-090 Written Directives for Radiopharmaceutical Administration
Description: (Major revision of existing policy) Under policy statement, updated administrations and removed procedures. For clarification,
added identifying acronym for radioactive materials (RAM). Under procedure, clarification,
added identifying acronym to Radioisotope Committee (RSC) and Authorized Users (AU).
Added resource for questions in the Radiation Safety Office. Added requirements for
approval from authorized users, criteria, and documentation. Other minor grammatical
and formatting changes.
Scope: UTMC Radiology
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-135-090
Policy Name: 3364-146-01 Rate Setting
Description: (Minor revision of existing policy) Under procedure, removed charge calculations and added EPIC table from electronic
medical record. Removed reference particular medical services. Added clarification
and summary of annual rate increases. Other minor grammatical and/or formatting changes.
Scope: University of Toledo Medical Center
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-146-01
Policy Name: 3364-87-14 Institutional Ethics Committee
Description: (Minor revision of existing policy) Under Institutional Ethics Committee Review, added access to the IEC may be obtained
by placing an ethics consult order via the electronic medical record. The person
initiating the consultation will be kept confidential.
Scope: University of Toledo Medical Center and Medical Staff – All Campuses
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-87-14
Policy Name: 3364-100-05-05 Medicare Questionnaire
Description: (Minor revision of existing policy) Under policy statement, added applicability of the questionnaire to Traditional
Medicare recipients and removed reference to Medicare Replacement Plan. Under procedure,
updated the required frequency of the questionnaire. Updated those who can complete
a questionnaire on behalf of the patient. Updated storage location of the completed
questionnaires will be in the patient medical record. Removed reference to ADT system
storage.
Scope: University of Toledo Medical Center
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-100-05-05
Policy Name: 3364-87-46 CT Surgery Internal Review of Surgeons Based on Risk of Mortality and Surgical
Volume
Description: (New Policy) New policy created to ensure thorough internal reviews of any surgeon performing
adult open-heart procedures who demonstrates a combination of higher-than-expected
risk-adjusted mortality rates and low individual case volume. This internal review
is intended to maintain the highest standards of patient safety, surgical outcomes,
and regulatory compliance in accordance with ODH requirements. Policy includes compliance
with data monitoring and reporting, internal review process, follow-up and reassessment.
Scope: University of Toledo Medical Center Medical Staff performing Open-Heart Surgery
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-87-46
Policy Name: 3364-100-53-05 Universal Protocol Policy – Comprehensive Surgical Checklist
Description: (Major Revisions) Under policy purpose, added reference to Operating Room Surgical Services Policy.
Under procedure, updated the criteria for procedures with anesthesia, pre-procedure
verification, marking the procedure site and time-out. Added requirement when two
or more procedures are performed on the same patient, and the perform performing the
procedure changes, a time-out is required before each procedure is initiated. Added
time-out requirement criteria for Bedside and clinic procedures.
Scope: University of Toledo Medical Center Medical Staff
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-100-53-05
Policy Name: 3364-100-45-05 Rapid Response Team
Description: (Major Revisions) Under definitions, changed ICU trained nurse to Critical Care trained Nurse. Under
policy purpose, added ambulatory care areas on Health Science Campus as a covered
area. Under procedure, updated criteria for activating, roles, contact information,
documentation requirements, and follow-up. Changed Modified Early Warning System
to Deterioration Index. Updated tables. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-100-45-05
Policy Name: 3364-100-70-15 Medication Reconciliation
Description: (Minor Revisions) Under Policy Statement, spelled out University of Toledo Medical Center. Under procedure,
added Nurse Practitioners to list of qualified practitioners who can review and document
medications in the inpatient, outpatient, and procedural areas.
Scope: University of Toledo Medical Center Hospital Administration
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-100-70-15
Policy Name: 3364-100-01-23 Ordering and Management of Non-Invasive Ventilation and CPAP
Description: (New Policy) This policy was created to establish specific guidelines concerning the ordering and
management of non-invasive ventilation and CPAP devices.
Scope: University of Toledo Medical Center
Comment Period: April 25, 2025 through May 27, 2025
Comment on this policy: 3364-100-01-23