Policies and Procedures
 
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Institutional Handbook of Operating Procedures (IHOP)

Table of Contents
Official Governance

General Administrative
Employee Related
Fiscal Related
Faculty Related
Compliance Related
Student Policies
Health, Safety and Security


About IHOP

Description of the IHOP Process
Committee Members
Goals of the IHOP Committee
Process Diagram


Policy Guidelines

Policy Definitions
Policy Template
Violation of Policy Paragraph
Understanding the CMS

Other Policies and Procedures

Departmental
Healthcare Epidemiology Policies

IHOP Table of Contents

 
 
 

Section 1 - Official Governance

 

IHOP - 1.1.1 - Institutional Mission Statement of the University of Texas Medical Branch (UTMB)

IHOP - 1.1.2 - Rules and Regulations of the Board of Regents

IHOP - 1.1.3 - Institutional Handbook of Operating Procedures

IHOP - 1.1.4 – Intellectual Property

 
 

Section 2 - General Administration

IHOP - 2.1.3 - Release of Information Under the Texas Public Information Act

IHOP - 2.1.4 - Records and Information Management and Retention

IHOP - 2.1.5 – Business Continuity Plan

IHOP - 2.6.1 - Use of UTMB Facilities

IHOP - 2.6.2 - Special Use Facilities

IHOP - 2.6.3 - Naming of Buildings, Other Facilities, and Entities

IHOP - 2.6.4 - Registering a Faculty or Staff Organization

IHOP - 2.6.5 - Acceptance and-or Solicitation of Gifts or Benefits from Vendors

IHOP - 2.6.6 - Posting of Notices on Institutional Bulletin Board

IHOP - 2.6.9 - Food Services Policy

IHOP - 2.6.10 - Food Services Contracting Policy

IHOP - 2.7.1 - Signage and Wayfinding Approval

IHOP - 2.9.1 - No Smoking Policy

IHOP- 2.19.3 – Mobile Communication Devices Policy

IHOP - 2.19.4 UTMB Web Accessibility

IHOP - 2.19.5 - Acceptable Use of Information Resources –deleted integrated into 2.19.6 (12/21/07)

IHOP - 2.19.6 - Information Resources Security

IHOP - 2.19.7 - Email Use - deleted integrated into 2.19.6 (12/21/07)

IHOP - 2.19.8 - Internet Use - deleted integrated into 2.19.6 (12/21/07)

IHOP - 2.19.9 - Using Microcomputing Software in Compliance with Copyright Laws

IHOP – 2.27.6 Outside Auditor Policy

 
 

Section 3 - Employee Related

IHOP - 3.1.1 - Staffing During Adverse Conditions

IHOP - 3.1.2 - Employee Files

IHOP - 3.2.1 - Equal Employment Opportunity and Affirmative Action

IHOP - 3.2.2 - Americans with Disabilities Act Policy

IHOP - 3.2.3 - Nondiscrimination Policy

IHOP - 3.2.4 - Sexual Harassment and Misconduct

IHOP - 3.3.1 - Verification of Selective Service Registration

IHOP - 3.3.2 - Security Clearance for New Employees

IHOP - 3.3.3 - Processing Non-Citizen Employees and Students

IHOP - 3.3.4 - Eligibility and Tax Requirements

IHOP - 3.3.6 - Verification of Excluded, Debarred, and Suspended Individual or Entity Lists

IHOP - 3.3.7 - Contract Workforce (deleted 08/01/08)

IHOP - 3.3.8 - Faculty and Administrative & Professional Recruitment

IHOP - 3.3.9 - Classified Staff Recruitment and Transfer

IHOP - 3.3.11 Eligibility for Re-employment Process

IHOP - 3.3.14 - Employment of Relatives (Nepotism)

IHOP - 3.3.16 - Dual State Employment

IHOP – 3.3.17 – Fitness for Duty

IHOP – 3.3.18 – Pre-Employment Drug Testing

IHOP - 3.4.1 - Compensation Policy for Professional and Classified Employees

IHOP- 3.4.2 Fair Labor Standards Act Regarding Deductions from Salary of UTMB Employees

IHOP - 3.4.8 - Compensatory Time

IHOP - 3.4.9 - Pay for On-Call Classifed Employees

IHOP - 3.4.10 Overtime

IHOP - 3.4.11 - Shift Differential

IHOP - 3.4.13 - Longevity Pay

IHOP - 3.5.1 - Sick Leave Pool

IHOP - 3.5.2 - Tuition Reimbursement for College Credit Coursework

IHOP - 3.5.3 - Long-Term Training (LTT)

IHOP - 3.5.4 - Telecommuting (Alternate Work Site)

IHOP - 3.6.4 - New Employee Orientation

IHOP - 3.6.5 - Performance Management Program

IHOP - 3.7.1. - Attendance

IHOP - 3.7.2 - Personal Appearance

IHOP - 3.7.3 - Jury Service and Witness Fees and Service

IHOP - 3.7.4 - New Employee Probationary Period

IHOP - 3.7.5 - Resignations deleted 07/02/09 incorporated into 3.7.12

IHOP - 3.7.8 - Time Off for Voting

IHOP - 3.7.10 Work Schedules and Work Week

IHOP - 3.7.11 - Meal and Break Periods deleted 02/16/09 incorporated into 3.7.10

IHOP - 3.7.12 - Employee Resignation and Exit Process

IHOP - 3.7.13 - Reduction in Force (RIF)

IHOP - 3.8.2 – Employee Assistance Program

IHOP - 3.8.5 - Temporary Job Modification

IHOP - 3.9.2 - Paid Military Leave

IHOP - 3.9.3 - Emergency Leave (Including Funeral Leave)

IHOP - 3.9.4 - Official Holidays

IHOP - 3.9.5 - Medical Leave of Absence (deleted 06/09/09)

IHOP - 3.9.6 - Leave Without Pay

IHOP - 3.9.7 - Parental Leave

IHOP - 3.9.8 - Sick Leave

IHOP - 3.9.9 - Vacation

IHOP - 3.9.10 - Family and Medical Leave

IHOP - 3.9.11 - Assistance Dog Training Leave for Employees with a Disability

IHOP - 3.9.12 - Leave for Employees Certified as Firefighter, Emergency Medical Service, and Disaster Service Volunteers

IHOP - 3.9.14 - Extended Unpaid Military Leave

IHOP - 3.9.15 - Service on Outside Boards

IHOP - 3.9.16 - Leave for Employees Donating an Organ, Bone Marrow, or Blood

IHOP - 3.10.1 - Discipline and Dismissal

IHOP - 3.10.2 - Appeal Policy (deleted 06/09/09)

IHOP - 3.10.3 - Grievance Policy

IHOP - 3.11.1 - Workers Compensation Insurance

 
 

Section 4 - Fiscal Related

IHOP - 4.1.4 - Time and Attendance Reporting

IHOP - 4.2.1 - Historically Underutilized Businesses (HUB)

IHOP - 4.3.1 - Travel Policy

IHOP - 4.4.2 - Official Function Expenditures

IHOP - 4.4.13 - Cash Handling and Reporting

IHOP – 4.4.17 – Membership Organization Dues

IHOP - 4.4.20 - Use of State Sales Tax Exemption Form

IHOP - 4.4.5 - Departmental Ledger Sheets

IHOP - 4.5.1 - Service Centers

IHOP - 4.5.2 - Consistent Treatment of Costs

IHOP - 4.5.3 - Fringe Benefit Costs

IHOP - 4.5.5.- Hiring Independent Contractors

IHOP - 4.5.6 - Procurement Policy

IHOP – 4.5.7 – Cost Sharing

IHOP – 4.5.8 – Effort Reporting

IHOP - 4.5.9 - Cost Transfer Policy

IHOP - 4.7.3 - Inventory Tags deleted 03/03/09 and integrated into 4.7.4

IHOP - 4.7.4 – Accountability and Responsibility for State Property

IHOP - 4.7.6 - Transfer of Surplus Property deleted 03/03/09 and integrated into 4.7.4

IHOP - 4.7.7 - Salvage Equipment deleted 03/03/09 and integrated into 4.7.4

 
 

Section 5 - Faculty Related

IHOP - 5.1.1 - Rights and Responsibilities of Faculty Members

IHOP - 5.1.2. - Faculty Governing Authority

IHOP – 5.1.3 – Evaluation of Academic Administrators (moved to Section 10, 10.2.1)

IHOP - 5.1.4 - New Faculty Teaching Physician Education

IHOP - 5.3.1 - System Policy on Faculty and Designated Appointments

IHOP - 5.3.2 - General Policies for Academic Titles

IHOP - 5.3.3 - Named Professorships and Endowed Chairs

IHOP - 5.3.4 - Retirement and Modified Service

IHOP - 5.3.5 - Faculty Recruitment Policy

IHOP - 5.3.6 - Procedures for Appointment, Promotion, or Membership in all Schools

IHOP - 5.3.7 - Joint Appointments

IHOP - 5.3.8 - Faculty Grievance Policy

IHOP - 5.3.9 - Tenure and Reappointments

IHOP - 5.3.10 - Termination

IHOP - 5.3.12 - Faculty Development Leave

IHOP – 5.3.14 –Faculty Ombudsperson Policy
IHOP – 5.5.1 – Faculty E
valuations

IHOP - 5.5.2 - Periodic Performance Evaluation of Tenured Faculty

IHOP - 5.5.3 - Faculty Input Into Evaluation of Academic Administrators deleted 07/06/07

IHOP - 5.5.4 - Consecutive Terms of Appointment and Periodic Review of Academic Unit Leadership del 07/06/07

IHOP - 5.5.5 - Administrative Component of Compensation for Academic Administrators

IHOP – 5.5.6 – Faculty Credentials

IHOP – 5.5.7 Faculty Compensation Policy

IHOP – 5.7.5 – Policy on Integrity in Research

 
 

Section 6 - Compliance Related

IHOP – 6.1.0 The Office of Institutional Compliance

IHOP – 6.1.1 Clinical Conflict of Interest

IHOP - 6.1.2 - Non-Retaliation Policy

IHOP - 6.1.3 - Appeal of a Determination by The Institutional Compliance Office

IHOP – 6.1.5 – Investigating Allegations of Non-Compliance

IHOP – 6.1.6 – Payment for Vendors for UTMB Employee Off Site Visit Expenses

IHOP – 6.1.7 – Preventing, Detecting and Reporting Actions Involving Fraud

IHOP – 6.1.8 – Response to Government Investigations and Inquiries

IHOP – 6.1.9 – Reporting Suspected Wrongdoing (UTMB Open Door Policy)

IHOP – 6.1.10- Self Reporting Overpayments to the Federal Government

IHOP - 6.1.11 - Code of Ethics

IHOP – 6.1.12 - Conflict of Interest and Commitment Policy

IHOP – 6.1.13 - Commitment to Compliance

IHOP - 6.1.14- UTMB Gift Acceptance Policy

IHOP – 6.1.15 – Good Laboratory Practice Standards

IHOP - 6.2.0 - General Policy on the Use and Disclosure of PHI

IHOP - 6.2.1 - Use and Disclosure of PHI Based on Patient Authorization

IHOP - 6.2.2 - Use and Disclosure of PHI to Family and Friends for Individual Care and Notification Purposes

IHOP - 6.2.3 - Use and Disclosure of PHI by and for Personal Representatives, Minors and Deceased Individuals

IHOP - 6.2.4 - Use and Disclosure of PHI for Patient Directories

IHOP - 6.2.5 - Mitigation after Improper Protected Health Information (PHI) Use or Disclosure

IHOP - 6.2.6 - Confidentiality of Substance Abuse Treatment Program Records

IHOP - 6.2.7 - Use and Disclosure of Protected Health Information for Disaster Relief Purposes

IHOP - 6.2.8 - Use and Disclosure of Psychotherapy Notes

IHOP - 6.2.9 - Fax Transmittal of Protected Health Information

IHOP - 6.2.9 - Fax Transmittal of Protected Health Information - Form 1

IHOP - 6.2.9 - Fax Transmittal of Protected Health Information - Form 2

IHOP - 6.2.10 - Printing and Copying of Protected Health Information

IHOP - 6.2.11 - Storage of Protected Health Information

IHOP - 6.2.12 - Disposal of Protected Health Information

IHOP - 6.2.13 - Use and Disclosure of Protected Health Information for Limited Data Sets

IHOP - 6.2.14 - Minimum Necessary Use & Disclosure of Protected Health Information

IHOP - 6.2.15 - Use of Notice of Privacy Practices of Protected Health Information

IHOP - 6.2.16 – Permitted Uses & Disclosures of Protected Health Information in Special Situations

IHOP - 6.2.17 - Use & Disclosure of Protected Health Information for Marketing

IHOP - 6.2.18 - Use & Disclosure of Protected Health Information for Fundraising

IHOP - 6.2.19 - Use & Disclosure of Protected Health Information to Health & Human Services (HHS) (del inc 6.2.16)

IHOP - 6.2.20 - Use & Disclosure of Protected Health Information for Judicial or Administrative Proceedings

IHOP - 6.2.21 - Use & Disclosure of Protected Health Information for Health Oversight Reporting (del inc 6.2.16)

IHOP - 6.2.22 - Use & Disclosure of Protected Health Information for Specialized Government Functions (del 6.2.16)

IHOP - 6.2.23 - Use & Disclosure of Protected Health Information (PHI) for Public Health & Safety (del inclu 6.2.16)

IHOP - 6.2.24 - Removal of Protected Health Information from UTMB Facilities

IHOP - 6.2.25 - Revocation of Authorization to Release Protected Health Information Deleted 07/06/07 (6.2.1)

IHOP - 6.2.26 – Patient Rights Related to Protected Health Information

IHOP - 6.2.27 - Requests for Restricting Use and Disclosure and Confidential Communication Deleted 07/06/07 (6.2.36)

IHOP - 6.2.28 - Accounting of Disclosures of Protected Health Information Deleted 07/06/07 (6.2.36)

IHOP - 6.2.29 - De-Identification of Protected Health Information

IHOP - 6.2.30 - Use & Disclosure of Protected Health Information for Research

IHOP - 6.2.31 - Access and Denial of a Patient Request for Protected Health Information Deleted 07/06/07 (6.2.36)

IHOP - 6.2.32 - Verifying Identity and Authority of Individuals Requesting Protected Health Information

IHOP - 6.2.33 - Research Documentation and Release of Information Upon Request by Research Subjects

IHOP – 6.2.34 – Use and Disclosure of Social Security Numbers (SSNs)

IHOP - 6.2.35 - Business Associates with Access to Protected Health Information

IHOP – 6.2.36 – Maintaining Patient Confidentiality

IHOP – 6.2.37 – Reporting and Investigating Allegations of Privacy Violations

IHOP – 6.2.38 - Access to Protected Health Information by External Facilities

IHOP – 6.3.0 – Clinical Billing Documentation and Coding

IHOP – 6.3.1 – Billing Compliance Monitoring

IHOP – 6.3.2 – Correction of Errors Related to Federal Healthcare Programs

IHOP – 6.4.0 – Standard Conduct Guide

IHOP – 6.4.1 - Mandatory Education and Training for UTMB's Workforce

 
 

Section 7 - Student Policies

IHOP - 7.1.1 - Students with Disabilities

IHOP - 7.1.3 - Student Conduct and Discipline

IHOP - 7.1.4 - Student Travel Policy

IHOP – 7.1.6 – Students’ Ombudsman Policy (deleted 10/08/07)

IHOP - 7.1.8 - Student Release During Adverse Conditions

IHOP - 7.1.10 - Student Accident & Injury Reporting

IHOP - 7.1.12 - Sexual Assault Policy

IHOP - 7.1.13 - Other Non-Academic Concerns

IHOP - 7.1.14 - Student Non-Academic Grievance Procedures

IHOP - 7.1.15 - GSBS - Course Content and Methodology

IHOP - 7.1.16 - GSBS - Grading and Evaluation

IHOP - 7.1.17 - GSBS - Academic Dismissal Appeals

IHOP - 7.1.18 - SOM - Appeal of Examination Score, Evaluation, or Course Grade

IHOP - 7.1.19 - SOM - Appeal of Grading and Promotion Committee Decisions

IHOP - 7.1.20 – SHP- Grading and Evaluation

IHOP - 7.1.21 - SHP - Grading and Promotion Committee Decision

IHOP - 7.1.22 - SON - Academic Appeal Grading and Evaluation

IHOP - 7.1.23 - SON - Academic Dismissal Appeal Procedures

IHOP - 7.1.24 - Tax-Free Sales By Registered Student Organizations

 
 

Section 8 - Health, Safety, and Security

IHOP - 8.1.1 - Policy and Guidelines on AIDS, HIV, and Hepatitis B

IHOP - 8.1.2 - Tuberculosis Surveillance Program for Healthcare Workers

IHOP - 8.1.4 - Workplace Violence

IHOP - 8.1.5 - Fire Alarm and Incident Response Policy

IHOP - 8.1.6 - Removal or Disposal of Hazardous Waste

IHOP - 8.1.7 - Evaluation and Treatment of Impaired Physicians

IHOP - 8.1.9 - Manufacture, Sale, Possession, Distribution, or Use of Alcohol, Controlled Substances or Illegal Drugs

IHOP - 8.1.11 - Environmental Policy Statement

IHOP - 8.1.12 - Safety Training

IHOP - 8.1.13 - Reproductive or Fertility Hazards in the Work Place

IHOP – 8.1.14 – Decorations Safety

IHOP - 8.1.15 - General Requirements for Use of Vehicles

IHOP - 8.1.15a - UTMB-Owned Motor Vehicle Safety

IHOP - 8.1.16 Drug and Alcohol testing for DOT Regulated Employees

IHOP- 8.1.19 Portable Heating Devices

IHOP- 8.1.20 Open Flames Prohibited

IHOP - 8.1.21 Guidelines for Safe Patient Handling and Movement

IHOP– 8.1.22 Public Access to Automated External Defibrillators

IHOP - 8.2.1 - Threatening Situations

IHOP - 8.2.2 - Campus Security Reporting

IHOP - 8.2.3 - Identification Badges or Smart Cards

IHOP - 8.2.4 - Possession of Weapons

IHOP – 8.2.5 – Security Management

IHOP –8.3.1- Resources Conservation Policy

 
 

Section 9 - Clinical

IHOP - 9.1.1 - Registration at UTMB Hospitals and Clinics

IHOP - 9.1.2 - Management of Patient Belongings

IHOP - 9.1.4 - Patient Transportation

IHOP – 9.1.6 – Inpatient Discharge and Transfer (Deleted 07/06/07)

IHOP - 9.1.8 - Passes for Inpatients

IHOP - 9.1.9 - Delayed Discharge of Newborns

IHOP - 9.1.10 - Observation Patient Beds

IHOP - 9.1.12 - Interfacility Transfer of Patients from UTMB

IHOP - 9.1.14 - Patient Discharge Planning

IHOP - 9.1.15 - Adoption from the Neonatal Nurseries

IHOP - 9.1.16 - Admission of Interfacility Transfer Patients

IHOP - 9.1.20 - Day Surgery Unit (DSU)

IHOP - 9.1.21 - Examination and Treatment for Emergency Medical Conditions and Women in Labor

IHOP - 9.2.1 – Obligations of Management of UTMB’s Protected Health Information (PHI)

IHOP - 9.2.2 - Release of Open Inpatient Medical Records (deleted 08/01/08)

IHOP - 9.2.3 - Retiring Incomplete Records

IHOP - 9.2.6 - Medical Record Access

IHOP – 9.2.7 – Use and Disclosure of Inpatient Protected Health Information (Access to Medical Records on Patient Care Units)

IHOP - 9.2.8 - Medical Record Forms Management

IHOP – 9.2.9 – Delinquent Medical Record Management

IHOP - 9.2.10 - Identifying Surnames and Recording Paternity on Birth Certificates

IHOP - 9.2.13 - UTMB Medical Record Policy

IHOP - 9.2.14 - Medical Record Retention

IHOP - 9.2.15 - Medical Record Documentation

IHOP- 9.2.16 – Creation and Retention of Electronically Scanned Documents

IHOP - 9.2.17 - Release of Information to External Organizations for Continued Stay Review (OnSite and Telephone)

IHOP - 9.2.18 - Processing Specimens Without a Medical Record

IHOP - 9.2.19 - Loose Medical Document Handling

IHOP - 9.2.20 - Physician-Patient Email Communication

IHOP – 9.2.21- Unit History Number Assignment

IHOP – 9.2.30 Epic MyChart Proxy Access

IHOP - 9.3.1 - Resources Available for Patients with Disabilities

IHOP - 9.3.2 - Consent to Photograph, Video or Audio Record and or Televise Patients

IHOP - 9.3.3 - Telephone Consent for Treatment or Procedures

IHOP - 9.3.4 - Patient or Family Education

IHOP - 9.3.8 - Identification of Abuse, Neglect, and Exploitation of Children, the Elderly, and Disabled Persons

IHOP - 9.3.9 - Reporting Suspected Abuse, Neglect, and Exploitation of Children, the Elderly and or Disabled Persons

IHOP - 9.3.10 - Consent for HIV Antibody Testing and for Disclosure of Results

IHOP - 9.3.11 - No Smoking Policy for Patients and Their Visitors

IHOP - 9.3.13 - Patient Rights

IHOP - 9.3.14 - Patients Responsibilities

IHOP - 9.3.16 - Refusal of Consent or Treatment

IHOP - 9.3.17 - Patient Consent - Overview and Basic Requirements

IHOP - 9.3.18 - Consent for Treatment of a Minor

IHOP - 9.3.20 - Universal Childhood and Adolescent Immunizations

IHOP - 9.3.21 - Consent for Sterilization

IHOP- 9.3.32- Abandoned Baby

IHOP – 9.3.33-Surgical Counts

IHOP - 9.7.1 - Hospital Visitation

IHOP - 9.7.2 - Vendor Visitation - UTMB Clinical Enterprise

IHOP - 9.8.1 - Financial Arrangements for UTMB Services deleted 10/17/08 (integrated into 9.8.2)

IHOP - 9.8.2 – Financial Responsibility of UTMB Patients including Financial and Medical Indigent Application Process

IHOP - 9.9.1 - Security Associated with Offender or Correctional Patients in non-TDCJ Areas

IHOP - 9.9.2 - Security Associated With The TDCJ Hospital

IHOP - 9.9.3 - Hostage Policy Involving Offender or Correctional Patients

IHOP - 9.11.1 - Licensure or Certification or Registration of Healthcare Professionals

IHOP - 9.11.2 - Employee Conflict with Prescribed Patient Treatment

IHOP - 9.11.5 - Physician Orders

IHOP - 9.11.6 - Criteria for Visitors from Agencies or Non-Affiliated Educational Institutions to Visit, Observe and or Participate in Patient Care at UTMB Hospitals

IHOP - 9.13.1 - Cardiopulmonary Resuscitation-Calling a Code 99

IHOP - 9.13.2 - Governance of Provider Performed Microscopy Procedures (PPMP)

IHOP - 9.13.3 - Patient-Owned Medical Equipment or Devices

IHOP - 9.13.4 - Governance of Point of Care Testing (POCT)

IHOP - 9.13.5 - Moderate Sedation (Conscious Sedation)

IHOP - 9.13.7 - Latex Allergy or Sensitivity Management

IHOP - 9.13.8 - Interdisciplinary Plan of Care

IHOP - 9.13.9 - Interdisciplinary Admission Assessment and Reassessment of Patients

IHOP - 9.13.10 – Changing Patient Identifiers (Name and Unit History Number)

IHOP - 9.13.11 - Medical Device Recall, Alert, Safety Hazard Notification and Response

IHOP - 9.13.12 - Problem Summary Lists and Medication Records for Ambulatory Patients

IHOP - 9.13.13 – Unusual Event Reporting

IHOP - 9.13.14 - Adverse Drug Events

IHOP - 9.13.15 - Serological Testing for Syphilis, Hepatitis B, and HIV During Pregnancy and Delivery

IHOP - 9.13.16 - Sentinel Events

IHOP - 9.13.17 - Use of Mobile Communication and or Wireless Devices on Patient Care Units

IHOP - 9.13.18 - Disclosure of Unanticipated Outcomes

IHOP - 9.13.19 - Patient Care Alarm Systems - Maintenance, Testing and Activation

IHOP - 9.13.20 - Family Presence during Procedures and Resuscitation

IHOP - 9.13.21 - Reporting of Devices and Supplies Involved in Patient Injury, Illness, or Death

IHOP - 9.13.22 - Handling of Malfunctioning or Defective Equipment, Devices, and Supplies

IHOP - 9.13.23 - Emergency Shut-Off of Oxygen Zone Valves in UTMB Hospitals

IHOP - 9.13.24 - Patient Identifiers

IHOP - 9.13.25 - Time Out Universal Protocol for Invasive and Surgical Procedures

IHOP - 9.13.26 - Liquid Oxygen

IHOP - 9.13.27 - Limbic System Surgery Eligibility and Review Process (deleted 07/06/07)

IHOP - 9.13.29 - Percutaneous Biopsies in the General Clinical Research Center (GCRC) (deleted 02/16/09)

IHOP - 9.13.30 - Medication Reconciliation

IHOP - 9.13.31- Activation of the Rapid Response Team (RRT)

IHOP – 9.13.32 – Infant and Child Abduction Response Policy

IHOP - 9.14.2 - Clinical Practice Guidelines or Critical Pathways

IHOP - 9.15.1 – Disposition of Deceased Patients

IHOP - 9.15.2 - Authorization for Postmortem Procedures

IHOP - 9.15.3 - Postmortem Anatomical Gifts
IHOP - 9.15.5 - Patients Initiating Advance Directives

IHOP - 9.15.6 –Making and Documenting Treatment Decisions including Withholding or Withdrawing Life-Sustaining Treatment

IHOP - 9.15.7 - Withholding or Withdrawing Life-Sustaining Treatment From a Patient Without an Advance Directive (deleted 10/17/08 integrated into 9.15.6)

IHOP - 9.15.8 - Out-of-Hospital Do Not Resuscitate (OOHDNR) Orders

IHOP - 9.15.9 - Determination of Death

IHOP – 9.15.10 Donation After Cardiac Death

Section 10 Academic Policies

IHOP – 10.1.1 – Academic Program Evaluations

IHOP – 10.1.2 – New Educational Program Approval Process

IHOP – 10-1-4 – Enrollment Reporting Policy

IHOP – 10.2.1 Evaluation of Academic Administrators