UTMB HANDBOOK OF OPERATING PROCEDURES

Section 1 Official Governance Subject 1.1 Official Governance Documents Policy 1.1.3 Institutional Handbook of Operating Procedures

05/01/88-Originated 08/01/08-Reviewed w changes -Reviewed w/o changes President's Office -Author

Institutional Handbook of Operating Procedures

Policy

As set forth by the Regents’ Rules, the President’s Office maintains the coordination of the Institutional Handbook of Operation Procedures (IHOP) for UTMB. Before official publication of UTMB policies in the Institutional Handbook of Operating Procedures on line manual, policies shall undergo review and approval at the following levels: Step One: Institutional Handbook of Operating Procedures Committee Step Two: Strategic Executive Council (SEC) Step Three: Office of the Executive Vice Chancellor for Health Affairs, UT System The IHOP committee reviews, recommends, denies and approves changes including the integration or deletion of existing policies. In the event that the recommendations of the IHOP committee are not adopted by the author, the policy will be sent forward to the SEC with an advisory that the content of the policy is not in alignment with UTMB core values or mission and has not been approved by the IHOP committee. The final decision will be that of the SEC. Should there be a conflict between the Handbook and the Regents’ Rules, the Regents’ Rules shall prevail, and the institutional Handbook shall be amended immediately to eliminate such conflict. Department policies can clarify but may not conflict or contradict the policies in the institutional Handbook. Department policies that are separate from IHOP are also compulsory. Policies are effective and published following approval by the SEC, however, recommendations received from the Office of General Council (OGC) are reviewed with the policy author. Any changes made to the policy resulting from the OGC recommendations will be communicated throughout UTMB.

Review and Approval

The Institutional Handbook Committee, appointed by the President, is responsible for the maintenance of the UTMB Institutional Handbook. This responsibility includes: • Ongoing coordination of the amendment and approval process of all institutional policies to be included in the Handbook. • The distribution of all policies in accordance with an appropriate mailing list maintained by the President's Office.

Review and Approval, continued

New policies or amendments to existing policies may be proposed by any individual, group or committee at UTMB by submitting the information or idea for the policy through the appropriate departments/committees to the UTMB Handbook Committee Chairperson or Coordinator. The IHOP committee may deny a new policy or amended language if the policy content: • puts UTMB at risk for non-compliance with regulatory requirements, • is unrealistic to monitor or achieve, • is addressed in another existing IHOP policy that could be edited to reflect the information, or • can be accommodated as a departmental policy • is not in alignment with UTMB core values Policies included at the IHOP level should have a global institutional effect, and interpret regulatory and legal requirements.

Procedure

The UTMB Institutional Handbook is comprised of ten (10) sections representing the following areas: I Official Governance II General Institutional Policies III Employee Related IV Fiscal Related V Faculty Related VI Compliance Related VII Student Related VIII Health, Safety and Security Related IX Clinical X Academic Policies are sent out for review every three years but may be reviewed more frequently in response to changes in regulatory requirements or changes within UTMB. All changes are reviewed by members of the IHOP committee and then discussed at regularly scheduled IHOP meetings. New policies go through the same review process. Additionally, all Section 9 (i.e., Clinical) policies undergo review and approval by the Clinical Policies and Procedures Committee (CAPP) prior to review by the IHOP committee.

Procedure, continued	Policies are shared with the Entity Leaders for additional input prior to being placed on an SEC agenda to ensure a thorough review. Authors are invited to IHOP meetings to explain revisions or the necessity for the policy. Authors must demonstrate that stakeholders have had an opportunity to review and comment on all revised policies Individuals requiring assistance in identifying the appropriate channel for processing a proposed policy may contact the Handbook Chair or Coordinator for assistance.
Communication	All policy updates will be published on the Web; and, notification of the approvals will be sent via the UTMB E-mail Broadcast Daily Announcements.
Reference	The UT System Rules and Regulations Series: 20201 IHOP 1.1.2 Rules and Regulations of the Board of Regents