UAMS.EDU

Administrative Guide – New or Recently Updated

 

January 2013    
Policy Number Policy Name/Link Synopsis of Changes
3.1.16 Standards and Best Practices for Pages on the UAMS Website          
3.1.27 HIPAA Research Policy Time for review: minor changes throughout policy. 
3.1.28 Use and Disclosure of PHI and Medical Records Time for review:  one change in section 9, page 16, #7 due to a change in Arkansas Code 
3.1.29 Request for Data Extracts   
3.1.40 Employees Authorized to Have Work Stations at Home Time for review: minor changes throughout policy.  
3.1.41 Information Access for Transfers and Terminations Time for review: minor changes throughout policy.  
3.1.42 Job Shadowing Time for review: minor changes throughout policy. 
3.1.44 Photographing Patients Time for review: minor changes throughout policy. 
4.4.09 Ethical Conduct/Gift Policy    Added letter H under Procedure #4 for appearances at events in official capacity for UAMS
4.4.18 Surreptitious Recordings  Edited to allow for UAMS Automatic recorded system recordings (police dispatch, clinical program call centers, etc.)  

 
11.2.10 Space Management and Inventory Policy    
12.4.01 Use of Conference Room Facilities    
February 2013 Policy Name Synopsis of Changes 
Administration Section      
3.1.30 HIPAA Education and Training   
12.3.01 Library Services   
3.1.01 General Administration, Smoking/Tobacco Use Policy Time to review: no changes made other than review date.  
3.1.17 General Administration, Mobile Device Safeguards Time to review:  added references to portable hard drives, Bluetooth, texting and Smartphones; added statements concerning immediate reports of lost or missing devices; specified encryption in policy statement.  
3.1.29 General Administration, Request for Data Extracts Definitions added.  
3.1.30 Administration, General Administration, HIPAA Education and Training Change made to address rehired employees to UAMS and the HIPAA training requirement for them.  Also added sanctions statement.  

 
Information Technology    
7.3.01 Information Technology, IT Security Incident Identification & Handling Policy Time to review policy; corrections include clarifications; grammar corrections; links updated; sanctions statement revised to match the current version of sanctions statement within the HIPAA policies. 
Campus Operations    
11.1.10 Campus Operations, Vehicle Driver Safety Program Periodic Review -Minor changes were made to clarify the policy  
11.1.12 Campus Operations, Travel Insurance One change to deductible for vehicle accidents increased from $500 to $1000 per insurance company. 
11.1.13 Campus Operations, Insurance Claims Time to review: no changes made other than review date  
11.2.10 Campus Operations, Guidelines for Space Committee and Assignment A new process was implemented to make space assignments and the Space Committee more efficient and effective.  The updated policy reflects the current process, has information that people need to know, and contains information about the form that is used to initiate space requests. 
11.4.02 Campus Operations, Hazard Communication Reviewed policy for accuracy and updated to correct format – added policy statement; added students to scope; corrected references to MSDS (Material Safety Data Sheet) to its new name SDS (Safety Data Sheet); corrected Joint Commission name; removed outdated reference and deleted sample sheet. 
11.4.03 Campus Operations, Holiday Decorations Reviewed policy for accuracy and updated to correct format – added policy statement 
11.4.04 Campus Operations, Occupational Exposure Assessment and Control  Time to review: no changes made other than review date 
11.4.07 Campus Operations, Electrical Safety for Personal Medical Devices and Appliances Time to review: no changes made other than review date  

 
11.4.08 Campus Operations, Laboratory Safety Reviewed policy for accuracy and updated to correct format – added policy statement. Removed the word “Material” in material safety data sheet. 
11.4.09 Campus Operations, Radioactive Substances Reviewed policy for accuracy and updated to correct format – added policy statement; added description of how radioactive materials are to be ordered; clarified when “call in” orders are to be made. 
11.4.11 Campus Operations, Abandoned Hazardous Chemicals  Reviewed policy for accuracy and updated to correct format – added policy statement and added students to scope  
11.4.13 Campus Operations, Handling Chemotherapy Drug Spills in Clinical & Research  Reviewed policy for accuracy and updated to correct format – added policy statement  

 
11.4.14 Campus Operations, Respiratory Protection Deleted “Pt 1” from policy name; reviewed policy for accuracy and updated to correct format – reworked policy, scope and purpose statements.  
11.4.15 Campus Operations, Unsafe Equipment and Furniture Reviewed policy for accuracy and updated to correct format – reworked policy and purpose statements 
11.4.16 Campus Operations, Microwave Oven Survey Policy Reviewed policy for accuracy and updated to correct format – added policy statement  
11.4.17 Campus Operations, Fire Retardant/Resistant Materials and Furnishings  Time to review: no changes made other than review date.  

 

 
11.4.18 Campus Operations, Exposure Control Plan (Part I)  Time to review: no changes made other than review date.  

 
11.4.19 Campus Operations, Occupational Exposure to Hazardous Chemicals in Laboratories (Pt. 1) Time to review: no changes made other than review date.  

 

 
11.4.21 Campus Operations, Use of Space Heaters on Campus  Time to review: no changes made other than review date.  

 
11.4.22 Campus Operations, Removal, Disposal, and/or Transfer of Equipment used with Radioactive Materials Reviewed policy for accuracy and updated to correct format – added policy statement  

 
11.4.24 Campus Operations, Hazardous Materials & Waste Management Reviewed policy for accuracy and updated to correct format -updated policy statement, removed outdated link; updated responsibilities and updated references  
11.4.25 Campus Operations, Fire Safety and Prevention Program Time to review: no changes made other than review date.  

 
11.4.26 Campus Operations, Employees with Latex Allergy Time to review: no changes made other than review date.  
Academic Affairs      
12.3.01 Academic Affairs, Library Services  The old Library Services policy was very outdated, so it has been rewritten to make it current.  
12.5.01 Academic Affairs, Faculty Grievance Policy   New Policy – currently there is no common grievance procedure for faculty.  Some of the colleges have their own or refer to a 1996 policy from the 1996 Faculty Handbook, which no longer exists.  The Council of Deans developed this common policy for all faculty in all colleges and with primary appointments in the AHEC Regional Programs and the Division of Academic Affairs.  It supplants all previous or college policies.  
March 2013    
Administration    
3.1.28 Administration, Use and Disclosure of PHI & Medical Records Edits due to new HIPAA ruling. 
Human Resources    
4.3.10 Employer Provided Cell Phones Will be deleted from the Admin Guide.  The policy was for accounting for the personal use of employer provided cell phones.  There was a change in tax laws, so the policy is no longer necessary.
4.4.11 Human Resources, Conflict of Interest for Non-Academic Staff Members  Edits made to comply with U of A System audit recommendations. 
4.4.17 Human Resources, Reductions in Force New policy – we currently have Reductions in Force regularly, usually due to grants ending, but have no policy for the process.  Was reviewed in Dec 2011 – resubmitted. 
4.4.19 Human Resources, Communications with Federal, State, and Local Government Officials Policy is new; it was concluded a written policy was needed to appropriately communicate guidelines to the faculty, staff and students in dealing with public officials.  
Finance    
8.7.03 Finance, Non-Patient Receivables New policy to improve procedures that will tighten internal controls on campus in relation to non-patient billing.  
General    
11.4.01 Pregnant Employees Working with Ionizing Radiation Reviewed policy for accuracy and updated to correct format – added policy statement; added title to declaration of pregnancy page. Note: Legal wanted HR to review, and HR recommending adding references to the Leave of Absence without pay and FMLA policies, which the department has now added. 
11.4.12 Campus Operations, Emergency Medical Response including Code Blue Updated to reflect changes in UAMS Medical Center policy PS 1.03; added new review date; expanded the name to reflect emergency response for campus; added responses of Code Team for visitors and staff for non-traditional areas, based on UAMS Medical Center PS 1.03; Updated reference to sections; II.B changed name of CARTI to Radiation Oncology Center; III listed Areas as A., B., C. instead of in paragraph form; V.(Q) updated name of College of Health Professions; VI. added per policy PS 1.03; VII added per Policy 1.03; added definition of Code Blue; removed the team composition list, felt that the Campus policy did not need all the team details; added statement on who comprised the team with reference to Policy PS 1.03; in Procedures removed team responsibilities and added a general statement with reference to policy PS 1.03; in II. Activation- A.2 there may be events on campus that do not involve a patient, but added “if patient is involved”; II.B added statement about pediatric code blue; F.2, added statement concerning PRI staff notification (PS 1.03); G.2made changes based on Hospital Policy PS 1.03 
11.4.23 Campus Operations, Indoor Environmental Quality (IEQ) Added policy statement, changed names of departments to reflect current name (Physical Plant now Engineering & Operations); added clarification of standards overseers; few other small edits. 
 11.4.27  Campus Operations, Compressed Gas   Added policy statement, changed names of departments to reflect current name (Physical Plant now Engineering & Operations); added clarification of standards overseers; few other small edits. 
Research    
16.1.14 Research Administration, Grant Proposal Review New policy
May 2013    
Administration    
3.1.05 Sexual Harassment Policy overdue for an updated, not revised since its creation in 1995.  The process has changed and now policy reflects current process. Added Scope, added disciplinary statement regarding non-employees, and clarified/corrected titles. 
3.1.30 HIPAA Education and Training One edit to change required HIPAA Privacy and Security training must be completed within 30 days not 60 days. 
3.1.46 Protected Health Information Breach Notification and Reporting Edits due to new Final HIPAA Omnibus Rule.  These edits included edits and additions to the definitions and some small grammatical and formatting corrections.