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.
UTMC (2 Policies)
Compliance (6 Policies)
Research (1 Policy)
Recommendation to rescind a policy
UTMC (2 Policies)
- Policy Name: RECENTLY SIGNED 3364-100-10-1 Consent to Treat and Informed Consent
Description: (Major revision of existing policy) Purpose of the policy is to obtain general and informed consent of patients to treat by providing an explanation of the nature and purposes of the case along with alternatives and their benefits and reasonably known risks. Also outlines the process for obtaining an informed consent, how the informed consent is to be documented, where it must be stored and accessibility.
Scope: All UT Health Care Facilities and Programs.
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-100-10-1
- Policy Name: DRAFT 3364-100-60-10 Communication of unanticipated clinical outcomes
Description: (Major revision of existing policy) The title changed from "Disclosure of Unanticipated Outcomes" to "Communication of Unanticipated Clinical Outcomes"; revised policy expands and details the information that was briefly outlined in the previous policy and establishes guidelines for providing patients and their families with information with regard to results that differ significantly from what was anticipated (“Unanticipated Outcomes”) including who should communicate with the patient, what information must be communicated, when to communicate the information, and how to communicate with the patient. The revised policy establishes an "Event Management Team" who should be immediately notified about the Unanticipated Outcome. The revisions made in this policy will help to improve physician/patient relations, reduce the risk of medical errors, reduce non-meritorious litigation, and also reduce professional liability risk exposure.
Scope: UT Medical Center and UT Clinical Enterprises
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-100-60-10
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Compliance (6 Policies)
- Policy Name: RECENTLY SIGNED 3364-15-03 Compliance incident reporting (non-patient)
Description: (New Policy) This policy sets forth the procedures that the University of Toledo will use to respond to reports by institutional members or others regarding possible violations of university policies and procedures or a possible violation of applicable state and federal laws.
Scope: all UT campuses
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-15-03
- Policy Name: RECENTLY SIGNED 3364-15-04 Non-retaliation policy
Description: (New Policy) This policy is intended to protect any individual who engages in good faith disclosure of alleged wrongful conduct to a designated university official or public body.
Scope: all UT campuses
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-15-04
- Policy Name: RECENTLY SIGNED 3364-15-05 Anonymous reporting line
Description: (Major Revision of an Existing Policy) The purpose of the university anonymous reporting line (ethicspoint – 1-888-416-1308) is to provide an additional communication channel for employees to report any activity or conduct that they suspect violates university policies and procedures, and/or federal, state or local laws and regulations.
Scope: all UT campuses
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-15-05
- Policy Name: RECENTLY SIGNED 3364-15-07 Compliance with privacy and security of protected health information (PHI)
Description: (Minor Revision of an Existing Policy) The purpose of this policy is to assure compliance with The University of Toledo policies relating to the privacy and security of protected health information.
Scope: all UT campuses
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-15-07
- Policy Name: RECENTLY SIGNED 3364-15-08 Health Insurance Portability and Accountability Act (HIPAA) compliance training policy
Description: (Reaffirmation of an Existing Policy) To educate appropriate institutional members about privacy and security in compliance with all Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations.
Scope: all UT campuses
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-15-08
- Policy Name: RECENTLY SIGNED 3364-15-09 Disposal of protected health information (PHI)
Description: (Minor Revision of an Existing Policy) To establish guidelines to ensure that confidential information is destroyed and disposed in a manner consistent with the federal and state laws and ensure the confidentiality of protected health information (PHI).
Scope: all UT campuses
Comment period: 07/17/08-08/16/08
Comment on this policy: 3364-15-09
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Research (1 Policy)
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Recommendation 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
