The University of Toledo

Policy Name:  Draft 3364-100-01-06  Inpatient Rehabilitation Admission to Coughlin Rehabilitation Center
Description:  (Minor/technical revision of existing policy)  Patients may be admitted to the Coghlin Rehabilitation Center inpatient program provided they meet the criteria established by the Medical Director and Administration of that hospital.  Each patient must be attended by a physician with Class I privileges in the Division of Physical Medicine and Rehabilitation.  The purpose of the policy is to allow for selective patient base which is appropriate and conducive to the rehabilitation philosophy of this hospital.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-01-06 

Policy Name:  Draft 3364-100-40-02  Management of the Health Care Worker Infected with Hepatitis B Virus, Hepatitis C Virus or Human Immunodeficiency Virus
Description:  (Minor/technical revision of existing policy)  Infected health care workers will be offered confidential counseling and guidance as to how to minimize the risk of infecting patients and/or their co-workers.  The purpose of the policy is to establish procedures to reduce the risk of transmission of HIV, HBV, and/or HCV from infected health care workers to patients or other health care workers.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-40-02

Policy Name:  Draft 3364-100-45-10  Code Blue Carts (Contents and Locations)
Description:  (Minor/technical revision of existing policy)  All code carts will be uniformly and fully equipped throughout the University of Toledo Medical Center in order to implement cardiorespiratory and cerebral resuscitation.  The purpose of the code cart policy is to standardize the appearance and contents of all code carts so that they are fully functional and easily recognizable to those persons attempting cardiorespiratory and cerebral resuscitation.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-45-10

Policy Name:  Draft 3364-100-45-14  Suspected Child Abuse/Neglect
Description:  (Minor/technical revision of existing policy)   It is the policy of UTMC, in accordance with the Ohio Revised Code, to report all instances of suspected child abuse and/or neglect to the appropriate authorities; to follow a protocol for interviews, examinations, data collection and documentation of those patients who you know or have reasonable cause to believe, have been a victim of child abuse, exploitation, or neglect.  This policy applied to all physicians, limited practitioners, nurses, or any employee giving aid to a sick or injured child. The purpose of this policy is to establish guidelines for reporting, examination, interview and documentation of suspected victims of child abuse, exploitation, or neglect.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-45-14

Policy Name:  Draft 3364-100-45-16  Adult-Elder Abuse, Neglect and Exploitation
Description:  (Minor/technical revision of existing policy)   It is the policy of UTMC to report all instances of suspected abuse, neglect or exploitation to the appropriate authorities.  Any physician, nurse, limited practitioner, or employee having reasonable case to believe that an elder Adult (see definition within policy) is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect or exploitation will immediately report this belief to the county authorities.  The purpose of this policy is to establish guidelines for reporting, examination, interview and documentation of suspected abuse, neglect or exploitation of the Adult patient that are in accordance with the Ohio Revised Code Section 5101.61.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-45-16

Policy Name:  Draft 3364-100-45-21  Domestic Violence
Description:  (Minor/technical revision of existing policy)   It is the policy of UTMC that health care providers must document or write an assessment in the patient’s medical record if they suspect or identify the patient as a victim of Domestic Violence.  The purpose of this policy is to establish guidelines for reporting, examination, interview and documentation of suspected Domestic Violence.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-45-21

Policy Name:  Draft 3364-100-50-28  The Joint Commission (TJC) Unannounced Survey Readiness Plan
Description:  (Minor/technical revision of existing policy)   Surveys by The Joint Commission will be on an unannounced basis.  The organization needs planned activities to operate optimally during an unannounced survey process.  The purpose of this Plan is to prepare the organization for a TJC unannounced survey.  The Plan is to provide direction and to facilitate the optimal performance of the organization during the survey process.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-50-28

Policy Name:  Draft 3364-100-53-19  Horizon Patient Folder Electronic Signature
Description:  (Minor/technical revision of existing policy)   UTMC medical staff, administration and the Health Information Management Committee have approved the use of electronic signatures and developed rules and regulations governing their use.  The purpose of the policy is to ensure that electronic signatures are used appropriately by physicians at UTMC.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-53-19

Policy Name:  Draft 3364-100-70-12  Medication Management
Description:  (Minor/technical revision of existing policy)   To delineate the licensed practitioner responsible for medication management within all areas of UTMC.  Medication management includes ordering procurement, dispensing, administration and patient safety.  The purpose of the policy is to establish responsibility for the safe, effective and efficient distribution of pharmaceuticals within UTMC.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-70-12

Policy Name:  Draft 3364-100-70-13  High Alert Medications
Description:  (Minor/technical revision of existing policy)   The Pharmacy and Therapeutics Committee has reviewed the hospital formulary and trend analysis of medication errors to determine a list of high-risk/high alert medications.  Additional input is incorporated from such organizations as the Institute for Safe Medications Practices, United States Pharmacopoeia and other national databases reporting information on the use of medications. The purpose of the policy is to provide the highest quality pharmaceutical care with the minimum number of medication errors and the lowest patient risk.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-70-13

Policy Name:  Draft 3364-100-50-21  Financial Policy for Organ Transplant Recipients
Description:  (Minor/technical revision of existing policy)  Financial coverage of all patients is evaluated on an individual basis.  Those patients deemed medically acceptable for organ transplantation by UTMC recipient transplant selection process may be provided the option of transplantation.  The purpose of the policy is to provide consistent information to patients pursuing organ transplantation by the transplant team regarding financial information, funding resources, and financial expectations.
Scope:  The University of Toledo Medical Center
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-50-21

Policy Name:  Draft 3364-100-50-22  Managing Staff Requests Not to Participate in Aspects of Patient Care
Description:  (Minor/technical revision of existing policy)  UTMC understands that situations may arise in which the prescribed care or course of treatment for a patient may be in conflict with the cultural values, ethics or religious beliefs of a staff member.  An employee may request to be relieved from participating in an aspect of a patient’s care or treatment in situations where the prescribed care or treatment presents a conflict with the employee’s cultural values, ethics or religious believes.  The purpose of this policy is to establish a mechanism by which an employee may request to be excused from participating in an aspect of a patient’s care or treatment in situations where the prescribed care or treatment presents a conflict with an employee’s cultural values, ethics or religious believes.
Scope:  The University of Toledo Medical Center
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-50-22

Policy Name:  Draft 3364-100-65-02  Licensure and/or Certification
Description:  (Reaffirmation of existing policy)  There shall be a system to assure that not-physician staff members, required to be licensed, have current/valid licenses before beginning employment and that the licensure/certification be validated at a frequency as indicated by regulation.  This purpose of the policy is to assure that non-physician staff members, required to be licensed, have current/valid licenses before beginning employment and on an ongoing basis.
Scope:  The University of Toledo Medical Center
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-65-02

Policy Name:  Draft 3364-100-65-04  Requirements for Education Records
Description:  (Reaffirmation of existing policy)  Documentation for education/in-service programs may include the learning need addressed by the program and the attendance records of participants.  The purpose of the policy is to document and validate records of education/in-service programs undertaken by UTMC departments.
Scope:  The University of Toledo Medical Center
Comment Period:   March 6, 2014 - April 7, 2014
Comment on this policy:  3364-100-65-04