Policy Terms & Definitions

Term Definition
21 CFR Part 58 U.S. Food & Drug Administration (FDA) Code of Regulations for Good Laboratory Practice (GLP) for Nonclinical Laboratory Studies.
340B Covered Entity (CE)

340B covered entities are facilities/programs that are listed in the 340B statute as eligible to purchase drugs through the 340B Program and appear on 340B OPAIS.

340B Drug Pricing Program (340B Program)

Section 340B of the Public Health Service (PHS) Act (1992) requires drug manufacturers participating in the Medicaid Drug Rebate Program to sign a pharmaceutical pricing agreement (PPA) with the Secretary of Health and Human Services. This agreement limits the price that manufacturers may charge certain covered entities for covered outpatient drugs. The resulting program is the 340B Drug Pricing Program.

Abandoned Infant

according to the DFPS, an abandoned infant meets the criteria for a Baby Moses case if the infant:

  • is 60 days old or younger;
  • has not been harmed (does not appear to have been abused or neglected);
  • has been voluntarily delivered to a Designated Emergency Infant Care (DEIC) provider such as UTMB, at a specific location indicated by a sign that reads “Safe Baby Site” and
  • is delivered to a DEIC by a parent who does not express intent to return for the infant.
Abduction to illegally or secretly carry off an infant or child
Above Ceiling Work (ACW) includes the inspection, repair and installation of pipes, conduits, ducts, cables, wires, pneumatic tubes, and similar building services which take place above existing ceiling levels. It does not include construction activities which occur before the permanent ceiling is installed in areas that are being renovated or in buildings under construction. In the latter cases the above ceiling final inspection addresses the issues covered by this Policy.
Absence

time off from work that may be recorded as Scheduled or Unscheduled.

  • Scheduled - supervisor notified of absence 16 hours prior to time scheduled to return to work.
  • Unscheduled notification of an absence anytime less than 16 hours prior to time scheduled to return to work. Excessive unscheduled absences may result in disciplinary action including termination

Scheduled leave or non-illness related situations or elective medical procedures must be submitted for approval in advance and may be disapproved based on staffing needs, operational needs, or frequency of absences. Failure to report to work on a day for which approval of leave has been denied may result in disciplinary action

Abuse mental, emotional, physical, or sexual injury to a child, person 65 years or older, or adult with disabilities, or failure to prevent such injury.
Academic Administrators – For purposes of this policy, academic administrators are defined as: Chief Academic Officer, Deans, Department Chairs, Directors of Centers, Directors of Institutes, and Directors of all other academic units. Any additional title must be approved by the Chief Academic Officer and the Vice President for Human Resources and Employee Services.
Accessioning

The formal process used to accept and record an item as a collection object.

Act of violence any behavior, intentional or reckless which results in bodily harm to another person and/or damage to property or threatens the safety of another individual in the workplace
Active Shooter

An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated areas; in most cases, there is no pattern or method to the selection of victims.

Actual Adverse Drug Event An event in the medication use process that reached the patient and caused injury or potential injury (e.g., a medication error, or an adverse drug reaction).
Actual Effort The Effort that an employee estimates to have devoted to a particular Sponsored Project or other professional activity, even if no salary is paid by the project or activity, including Effort pledged to a sponsor as mandatory or voluntary committed Cost Sharing, expressed as a percentage of total Effort during the confirmation period.
Acute Treatment is inpatient medical care, outpatient medical care and other related services for surgery, acute medical conditions, or injuries, usually for a short-term illness or condition. Short-term rehabilitative services lasting no more than sixty (60) days associated with a research related injury may be covered under this definition on a case by case basis, as determined by Risk Management. This care would not encompass long-term rehabilitative services, long term nursing home care or Long Term Acute Care (LTAC) hospitalization care.
ACW Certified Staff personnel that has attended the necessary certification class(es) and has been assigned or contracted to perform work above the ceiling in a UTMB healthcare facility.
ADA Americans with Disabilities Act of 1990.
ADAAA

ADA Amendments Act of 2008

Administer

Give a medication to an individual, typically in a hospital or a clinic, based upon a health care provider's order.

Administrative and Professional (A&P) Employee

Exempt-level position that is either:

  • Executive/managerial administrative positions engaged in strategic, tactical or operational management that have primary responsibility for the management or a department, or
  • Specialized professional positions requiring advanced degrees such as attorney, veterinarian, engineer or librarian
Administrative and Professional Employee

Exempt-level position that may be:

  • Executive/managerial administrative positions engaged in strategic, tactical, or operational management that have primary responsibility for the management of a department; and/or
  • Specialized professional positions requiring advanced degrees such as attorney, veterinarian, engineer, or librarian
Administrative Data Data used for administrative, regulatory, operational and financial purposes (e.g. charge tickets, requisitions, death certificates, authorization forms for disclosure of information, event history and audit trails, patient identifiable claims, patient identifiable data for quality assurance and management purposes, protocols, clinical pathways, practice guidelines and other knowledge sources that do not imbed patient data).
Administrative Disposition

A document signed by the student and the Investigating Official which includes a statement of the disciplinary charges, findings, sanctions, waiver of the hearing process (and possibly a waiver of appeals), and institutional policies and rules regarding student discipline.

Administrative Systems The following applications are included: Hyperion, Tivoli, Kronos, PeopleSoft FMS modules and PeopleSoft HCM modules.
Adult a person 18 years of age or older or a person under 18 years of age who has had the disabilities of minority removed by a court for general purposes (i.e., has been legally emancipated by a court) or who is: legally married; serving in the armed forces; or at least 16 years old and living away from home and managing his/her own financial affairs.
Adult

A person 18 years of age or older or a person under 18 years of age who has had the disabilities of minority removed (i.e. has been legally emancipated by a court).

Advance Directive a written instruction such as living will or medical power of attorney for health care recognized under State law and relating to the provision of such care when the person is incapacitated.
Advance Directive

A directive, medical power of attorney (MPOA), or Out-of-Hospital Do-Not-Resuscitate (OOHDNR) Order

Adverse Action

a decision for employment or enrollment purposes that adversely affects any current or prospective employee or student. Examples include failure to hire, termination, decision not to promote, deny enrollment as a student.

Adverse condition inclement weather or other factors which have an actual or potential disruptive effect on institutional operations (e.g., hurricanes, utility interruptions, floods, etc.).
Adverse drug reaction (ADR) An unintended physical reaction to a drug used in the approved manner. An allergic reaction (immunologic hypersensitivity, occurring as the result of unusual sensitivity to a drug) and an idiosyncratic reaction (abnormal susceptibility to a drug that is peculiar to the individual) are also considered ADR’s. For the purpose of this policy, side effects (expected, well-known reactions resulting in little or no change in patient management) are not included in this definition.
Adverse Event

Serious incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided. Adverse events may result from acts of commission or omission (e.g. administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment, etc.). Some examples of adverse events include: patient falls, medication errors, procedural errors/complications, completed suicides, para-suicidal behaviors (attempts/gestures/threats), and missing patient events. An adverse event can also be categorized as either a sentinel event or near miss.

A distinction is made between an adverse outcome that is primarily related to the natural course of the patient’s illness or underlying condition (not reviewed under the Sentinel Event Policy) and a death or major permanent loss of function that is associated with the treatment (including “recognized complications”) or lack of treatment of that condition, or otherwise not clearly and primarily related to the natural course of the patient’s illness or underlying condition (reviewable). In determinate cases, the event will be presumed reviewable and the organization’s response will be reviewed under the Sentinel Event Policy according to the prescribed procedures and timeframes without delay for additional information such as autopsy results.

Affidavit of Voluntary Relinquishment of Parental Rights(“Affidavit of Voluntary Relinquishment”)

A document that can be signed by the parent(s), including minor parents, any time after a newborn child has turned 48 hours old, to voluntarily relinquish their respective parental rights.  The affidavit must be notarized and its signing must be witnessed by two credible adults.   (Note: UTMB employees may not serve as witnesses). The licensed adoption agency or attorney handling the adoption  is responsible for the witnesses and notary public.  The affidavit must designate a  managing conservator of the child.


 

Agency

means any person or company that regularly collects or evaluates consumer information and then provides the information as consumer reports to third parties for monetary fees, dues, or on a cooperative, nonprofit basis.

agent

An adult to whom authority to make health care decisions has been delegated under a medical power of attorney. An agent may exercise authority only if the patient’s attending physician certifies in writing in the patient’s medical records that the patient is incompetent.  A person may not act as an agent while the person serves as: (1) the patient’s health or residential care provider; or (2) an employee of the patient’s health or residential care provider unless the person is a relative of the patient.

Agent of the Chief Medical Staff Physicians requested to evaluate a physician or resident physician under this policy will act as the agent Chief of the Medical Staff. If there is a conflict in obligation, the responsibility to the Institution takes precedence over the responsibility to the impaired employee.
Alcohol Screening Test Commercial Vehicles (49 CFR part 382)

An analytic procedure to determine whether an employee may have a prohibited concentration of alcohol in a breath or saliva specimen.

  1. Has gross combination weight rating of 26,001 or more pounds (11,794 or more kilograms) inclusive of a towed unit with a gross weight rating of more than 10,000 pounds (4,536 kilograms); or
  2. Has a gross vehicle weight rating of 26,001 or more pounds (11,794 or more kilograms); or
  3. Is designed to transport 16 or more passengers, including driver; or
  4. Is of any size and is used in the transportation of materials found to be hazardous for the purposes of the Hazardous Materials Transportation Act (49 U.S.C.5103 (b)) and which requires the motor vehicle to be placarded under the Hazardous Materials Regulations, 49 CFR part 172, Subpart F.
Alias Name the name(s) previously used by or assigned to a patient (e.g. maiden name, nickname, misspelled name accidentally entered into the PIDX, or trauma name).
Alias name the name(s) previously used by or assigned to a patient (e.g., maiden name, nickname, misspelled name accidentally entered into the Patient Index System (PIDX).
ALL CLEAR A signal that indicates that the incident has been resolved and departments may return to normal operations. The signal may be given by: Environmental Health and Service – Occupational Safety and Fire Prevention (EHS-OS&FP), UTMB Campus Police or the Galveston Fire Department (GFD).
ANCILLARY HEALTHCARE

An area not connected to ithe direct care of patients located in a healthcare building.  Examples include administrative offices, cafeterias, coffee shops, chapels and gift shops.

Animal Research Areas Includes any laboratory, housing facility or other area located on UTMB property which maintains research animals or is engaged in research involving an animal protocol.
Anticoagulant

any agent used to prevent the formation of blood clots. This class of medications is used for the prophylaxis and/or treatment of thromboembolic disorders and for these clinical purposes include:

  • Injectable anticoagulants including unfractionated heparin, low molecular weight heparin (i.e. Lovenox), direct thromin inhibitors (i.e. Argatroban, Bivalirudin) ad Factor Xa inhibitors (i.e., Fondaparinux) and
  • Oral anticoagulants such as warfarin
Applicant

is an individual who applies for a position within UTMB whether the individual is an internal or external candidate.  This also includes without salary (WOS) positions and volunteers.

Applicant Any person who applies for employment with UTMB including without salary employees (WOS). Drug tests are not required for volunteers.
Applicant The person who applies for a charity discount. Generally, this is the patient unless the patient is a minor child or has a legal guardian, in which case the applicant is the parent or legal guardian of the patient. Generally, when a patient is a child or has a legal guardian, the evaluation will be based on the patient’s Texas residency and citizenship status, and the income/asset evaluation will be based on the Family Income as defined. If the patient is a child whose custodial parent is a Texas resident, then the child can be considered a Texas resident.
Application Enhancement A change in user actions and/or navigation within an application that is intended to improve functions, user efficiency and application compatibility.
Approval Authority

will be the Conflicts of Interest Office in conjunction with Supervisors and Department Chairs

 

 

ARC Animal Resource Center
Area Alarm Leader

A person assigned to be responsible for an area during a fire alarm.  In healthcare areas, the Area Alarm Leader will generally be the unit charge nurse.  In non-healthcare areas, the Area Alarm Leader may include supervisors, area administrators or any person likely to be in the area the majority of the time.  An Alternate Area Alarm Leader should be assigned to stand in during the absence of the primary leader.  Any one department may have multiple Area Alarm Leaders.

Art

Works of art include objects of every description, includingbut not limited to paintings, etchings, drawings, photographs, rugs, tapestries, antiques, sculpture, statuary, ceramics, pottery, porcelain, memorabilia, natural history objects or historical artifacts, archeological objects, video artwork, plaques, mixed media and other forms of artistic expression.

Artificial Nutrition and Hydration The provision of nutrients or fluids by a tube inserted in a vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).
Assets

Resources including but not limited to:

  1. Cash
  2. Checking and Savings Accounts
  3. Certificates of Deposits
  4. Stocks
  5. Bonds
  6. Other Securities
  7. The equity value of real proerty (excluding Primary Residence and vehicle). This includes income producing property.
  8. Retirement accounts.
Assignable Square Feet

space assigned to a department measured from the inside face of the wall

Assistance animal

An animal that is specially trained or equipped to help a person with a disability and (A) is used by a person with a disability who has satisfactorily completed a specific course or training in the use of the animal; and (B) has been trained by an organization generally recognized by agencies involved in the rehabilitation of persons with disabilities as reputable and competent to provide animals with training of this type.

Attendance includes, but is not limited to, attendance in person, by paper correspondence, videoconference, satellite, Internet, or other electronic information and telecommunications technologies for students who are not physically present in the classroom, and the period during which a person is working under a work-study program.
Attending Physician

A physician selected by or assigned to a patient who has primary responsibility for a patient’s treatment and care.  For purposes of this policy, the designations faculty and house officer will have the same meaning as attending physician.  House officers are expected to be involved in discussions, certification, documentation and orders concerning treatment decisions and advance directives.  House officers must also ensure that faculty are made aware of all of these actions. 

Attending Physician The physician with primary responsibility for a patient's treatment or care.
Authorization An "authorization" allows for the use and disclosure of PHI for purposes other than Treatment, Payment, and Healthcare Operations (TPO).
Authorization Allows for the use and disclosure of PHI for purposes other than Treatment, Payment, and Healthcare Operations (TPO).
Authorized form An authorized form is a form that has been approved through the Health Information Management Department..
Authorized Use For the purposes of this policy “authorized use” means prior written consent from ARC or IACUC or any additional written consent required from management in certain UTMB facilities, including but not limited to the Galveston National Laboratory.
Authorized User

An individual that is granted access to Protected Health Information (PHI) through an authorization or IRB waiver or an individual who is performing an activity related to health care operations.

Authorizing Official

An Authorizing Official is someone who represents and confirms that he/she is fully authorized to legally bind a 340B covered entity into a relationship with the federal government and has knowledge of the practices and eligible programs at that site. This is the person responsible for and to whom the federal government would contact concerning compliance issues, integrity evaluations, and audits. Covered entities are required to provide HRSA with their Authorizing Official’s name and contact information upon enrollment, and to update this information when any changes are made. The Authorizing Official is also responsible for completing OPA’s online registration process for 340B covered entities and outpatient facilities as well as the annual recertification process. The Authorizing Official must also approve contract pharmacy registrations.

Authorizing Representative UTMB representative that has responsibility for obtaining the ACW Permit and overseeing work performed by ACW Certified Staff. Authorizing Representative signs ‘Final Inspection’ on permit to signify that all work has been completed to meet applicable codes/standards and that there has not been any damage caused to the ceiling.
Automated Clearing House

transactions governed by the National Automated Clearing House Association (NACHA) and controlled through UTMB banking services agreement.

Automatic External Defibrillator (AED) a device that can be used by any 1st Responder to deliver a shock. It uses a patented Shock Advisory System. This software algorithm analyzes the patient’s electrocardiographic (EKG) rhythm and indicates whether or not it detects a shockable rhythm. The AED requires operator interaction in order to defibrillate the patient.
Auxiliary Aids and Services Examples include qualified interpreter, qualified reader, note-taker, taped text, transcription service, modification of equipment, relay service, Telephone Text Devices (TDD's) which are telecommunication devices for deaf or hearing impaired, large print, Braille or written, telephone amplifier, listening system, open and closed captioning, audio recording, computer terminal, speech synthesizer, communication board. Note: The type of service needed will vary from case to case.
Behavioral Restraints use of restraints for violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others.
Benefit Anything reasonably regarded as monetary gain or monetary advantage, including benefits to any other person in whose welfare the beneficiary has a direct and substantial interest.
Benefit eligible employee for purposes of this policy, employees who are appointed to work at least twenty (20) hours per week for a period of at least four and one-half (4 1/2) months, and are not employed in a position for which the employee is required to be a student as a condition of employment.
Best Practice Advisories

system alerts built upon pre-established criteria that prompt the user for additional action, often in the form of orders or additional documentation.

Birth or Adoption Leave

FMLA leave may be used for birth or placement for adoption and can be taken prior to the actual birth or adoption. An employee’s entitlement to leave for the birth or placement (An employee may not use FMLA to care for an adult child after the birth of a grandchild.)

Biweekly Employees

An employee who is paid every two weeks based on UTMB's published Payroll Calendar.

Blood Bank Division Primary Request Form

Document(s) with the requesting physician’s signature for the emergency release of uncrossmatched blood and/or other blood components. It also serves as the requisition slip for the retrospective compatibility testing sample.

Blood Transfusion Record Tag

Attached to the unit of blood and provides information about the unit’s blood type, expiration date and the unit ID number.  This form becomes part of the patient’s medical record.

Brain death is the irreversible cessation of the function of the whole brain
Breach The unauthorized acquisition, access, use or disclosure of Protected Health Information (PHI) or other sensitive personal information that compromises the security or privacy of such information and poses a significant risk of financial, reputational, or other harm to the individual. If information is disclosed and then retrieved from an unauthorized individual so that the unauthorized individual would not reasonably have been able to retain the information, such event will not be deemed a breach. For example, an employee hands a patient discharge papers belonging to another patient, but realizes the mistake and quickly recovers the PHI from the patient.
Brief Off Unit Absence An inpatient leaving the unit for personal reasons an anticipated time of one hour or less
Building Owner the entity which is responsible for all aspects of the space, including utilities, security, safety, and delegation of the use of space.
Business Associate

is a person other than a member of UTMB's workforce, or entity who on behalf of UTMB:

  1. creates, receives, maintains, or transmits PHI for a function or activity regulated by HIPAA, including claims processing or administration, data analysis, processing or administration, utilization review, quality assurance, patient safety activities, billing, benefit management, and repricing, or
  2. provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services to or for UTMB, where the provision of the service involves the disclosure of PHI from UTMB, or from another business associate of UTMB to the person.

A covered entity may be a business associate of another covered entity.

Business Continuity Plan

The documentation of a predetermined set of instructions or procedures that describe how an organizations business functions will be sustained during and after a significant disruption.

Business Continuity Planning (BCP)

The process of developing advance arrangements and procedures that enables UTMB to respond to an interruption in such a manner that critical business functions continue with planned levels of interruption or essential change.  In simpler terms, BCP is the strategic act of planning a method to prevent, if possible, and to minimize and manage the consequences of an event that interrupts critical business processes.

Business Day

Monday through Friday, excluding any day that is an official UTMB holiday or when regularly scheduled classes are suspended due to emergent situations.

Business Entity

any entity recognized by law through which business for profit is conducted, including a sole proprietorship, partnership, firm, corporation, holding company, joint stock company, receivership, or trust.

 

Business Impact Analysis (BIA)

Involves the identification of critical business functions and workflows, identifies critical information resources, determining the qualitative and quantitative impact of a disruption, and prioritizing recovery objectives.

Business Meals and Employee Functions Events sponsored by the University that would include University employees engaged in the discussion of University business matters. In some instances individuals engaged in business with the University may be involved.
Campus all real property, buildings, or facilities owned or controlled by UTMB
Campus the physical area immediately adjacent to the UTMB’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider’s campus.
Campus Any building or property owned or controlled by UTMB within the same reasonably contiguous geographic area and used by UTMB in direct support of, or in a manner related to, UTMB’s educational purposes, including a residence hall; and any building or property that is within or reasonably contiguous to this area that is owned by UTMB but controlled by another person, that is frequently used by students, and that supports UTMB’s purposes (such as a food or other retail vendor).
Campus Security Authorities Members of the UTMB Police Department and the non-law enforcement personnel designated by UTMB as an individual or organization to which students and employees should report criminal offenses and  UTMB officials who have significant responsibility for student and campus activities.
Canister (Air-Purifying)

A container filled with sorbents and catalysts that removes gases, vapors, and/or particulates from air drawn through the unit. Canisters rely on a variety of mechanisms for contaminant removal such as chemical absorption, adsorption, catalytic action, neutralization, and mechanical filtration.

Capital Budget a budget approved annually by UTMB’s executive leadership to provide capital funding to projects identified and approved at the UTMB Facilities Steering Committee.
Cardiac death is the irreversible cessation of spontaneous respiratory and circulatory functions.
Cartridge

A container filled with sorbents and catalysts that removes gases, vapors, and/or particulates from air drawn through the unit. Cartridges are smaller than canisters but are designed to work on the same principles.

Case Management File/Shadow Medical Record (CMR) A medical record maintained by a specific physician or department that only includes copies of original patient care information  already in the UMR.  Commonly referred to as “shadow records,” CMRs are considered convenience copies only and have no record retention schedule.  CMRs should never contain original medical records.
Cash Under this policy, cash refers to currency, checks, credit cards, web payment, and electronic payments (ie: Automated Clearing House (ACH) and wire transfers).
Catastrophic illness or injury a severe condition or combination of conditions affecting the mental or physical health of an employee or the employee’s immediate family that requires the services of a licensed practitioner for a prolonged period of time and that requires the employee to exhaust accrued leave and to lose compensation from the State.
Census Date Also known as the Official Reporting Date, it is the official day of record for determining the enrollments that qualify to be reported to the Texas Higher Education Coordinating Board for funding.  While it can vary by the length of the semester, at UTMB it is normally the 12th class day for the fall and spring semesters and the 4th class day for summer semesters.
Certification/ Licensure is defined as recognition of completion of specialized training and/or examination by an accredited, certifying body, which enables an employee to demonstrate excellence in a particular area. To be accepted, certification tests must be written before a certifying body that is nationally recognized by the profession.
Chair of the hearing panel the faculty member from the student’s component school will serve as chair and a voting member of the panel. The primary responsibility of the chair shall be to administer impartially the disciplinary hearing
Change Fund

Funds maintained by individual departments authorized to handle cash to be utilized for the sole purpose of carrying on their cashiering operation and not for the purpose of obtaining miscellaneous items, paying for minor unanticipated operating expenses, cashing employee checks, or making loans for any reason.

Chemical Restraints a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Medications used as restraints are used in addition to or in replacement of the patient’s regular medication regime to control extreme behavior during an emergency. Medications that comprise the patient’s regular medication regime (including PRN medications) are not considered chemical restraints, even if their purpose is to control behavior.
Chemical substance abuse is the personal use of any chemical substance that is specifically proscribed by law or by regulation pursuant to legal authority (e.g., Schedule 1 drugs); the personal misuse of any legally controlled substance; or the personal misuse of any normally legal chemical substance (e.g., alcohol) in a manner that produces the likelihood of the development of impairment.
Chemical substance misuse is the self-administration of any chemical substance for any reason other than its intended use.
Child unmarried, under 18 years of age.
Civil Investigation

An extraordinary, detailed assessment of a regulated entity’s compliance status, which requires significantly more time to complete than a typical compliance inspection (i.e., several weeks, as compared with one or a few days). Investigations may be warranted when an inspection or record review suggests the potential for serious, widespread, and/or continuing civil or criminal violations, from a continuing pattern of citizen complaints, referrals from another agency, or from studies conducted by the regulating agency inferring a potential compliance problem.

Class Days consecutive days of the week during a semester on which classes routinely occur; not specific to a particular course schedule; excludes any day that is an official UTMB holiday or when regularly scheduled classes are suspended due to emergent situations.
Classified Employee A combination of degreed/non-degreed, exempt/non-exempt position in various Job Families such as Business, Clinical, Information Technology, Police, Research, etc.
Clinical Electronic Health Record (EHR) The following applications are included: EpicCare Inpatient, EpicCare Ambulatory, MyChart, ASAP, Optime, Epic RX and all Epic Specialty modules.
Clinical Research(aka Clinical Investigation) a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge that uses either data (1) obtained through intervention or interaction with a living individual or (2) by accessing identifiable private information.
Clinical Trial is a research study involving human subjects that is designed to seek basic biological knowledge or assess the safety, efficacy or both of drugs, devices, diagnostics, treatments, or preventive measures.
Clinical Trial Agreement A legally binding contract between the sponsor of a clinical trial and the investigational site.
Clinicians

includes faculty members, employees, and trainees at all levels (students, interns, residents, fellows, post-doctoral trainees) in any patient care discipline, including specialties of medicine, dentistry, nursing, and allied health sciences.

 

Clinicians and Staff Means faculty members and trainees at all levels (students, interns, residents, fellows, post-doctoral trainees) in any patient care discipline, including specialties of medicine, dentistry, nursing, and health professions, also includes volunteers and persons hired by the UTMB to perform work at or on UTMB’s behalf.
Code of Federal Regulations (CFR) The codified regulations of the Federal government based on the final agency regulations published in the Federal Register.
Collaborators, Contractors and Sub-recipients

A. If research is to be carried out in cooperation with or through a subcontractor, contractor, or collaborator, including a person identified under federal regulations as a “sub-recipient,” UTMB must enter into a written agreement with the contracting party that provides legally enforceable terms that establish whether this policy or the financial conflicts of interest policy of the contracting party applies to the research being performed.

B. If the policy of the contracting party applies to its researchers, the contracting party must certify that its policy is consistent with the requirements of any applicable federal regulations. If the contracting party cannot so certify, the agreement must state that the researchers are subject to this policy as covered individuals for disclosing significant financial interests that are directly related to the researcher’s work at UTMB.

C. If the policy of the contracting party applies to its researchers, the agreement must specify the time periods for the contracting party to report identified financial conflicts of interest to this institution. The time periods must be sufficient for this institution to make any reports required by federal regulation.

D. If the policy of this institution applies to the researchers of the contracting party, the agreement must specify the time periods for the researchers to submit a financial interest disclosure statement to this institution. The time periods must be sufficient for this institution to comply with its review, management, and reporting obligations under federal regulation

Collection Site The designated Substance Abuse and Mental Health Service Administration (SAMHSA) prepared facility utilized to collect blood and/or urine samples from applicants. The Employee Health Center (EHC) will be the collection site for campus-based employees. Remote collection site locations will be coordinated by the EHC.
Colposcope A lighted magnifying instrument used to examine the tissues of the hymen, vagina, cervix, and anal area, and which has the capability of taking and recording forensic photographs.
Commercial Motor Vehicle (CMV)

The U.S. Department of Transportation – Federal Motor Carrier Safety Administration defines a CMV as a motor vehicle or combination of motor vehicles used in commerce to transport passengers or property if the motor vehicle

  1. Has a gross combination weight rating of 11,794 kilograms or more (26,001 lbs. or more) inclusive of a towed unit with a gross vehicle weight rating of more than 4,536 kilograms (10,000 lbs.); or
  2. Has a gross vehicle weight rating of 11,794 or more kilograms (26,001 lbs. or more); or
  3. Is designed to transport 16 or more passengers (including the driver) or
  4. Is of any size and is used in the transportation of materials found to be hazardous for the purposes of the Hazardous Materials Transportation Act and which require the motor vehicle to be placarded under the Hazardous Materials Regulations (49 CFR part 172, subpart F).
Commissioned Art

Original art produced by a particular artist under contract to the university.

Committed Effort The amount of effort proposed in a grant or other project application and accepted by the sponsor, regardless of whether salary support is requested for the effort.
Committed Effort

The amount of Effort proposed in a grant or other project application and accepted by a sponsor, regardless of whether salary support is requested for the Effort.

OMB Circular A-21 Section J10b(1)(c) states “in an academic setting, teaching, research, service and administration are often inextricably intermingled. A precise assessment of factors that contribute to costs is not always feasible, nor is it expected. Reliance, therefore, is placed on estimates in which a degree of tolerance is appropriate” Moreover, OMB Circular A-21 Section J10(2)(a) states, “The payroll distribution system will… (ii) reasonably reflect the activity for which the employee is compensated by the institution.”

Community Based Physician for purposes of this policy, a physician who hosts UTMB students in their non-UTMB offices as a community-based educator, has a “without salary” (WOS) appointment and is not eligible for tenure. Faculty appointments of this type are a dual responsibility of an academic department and the Dean of Medicine
Community Teaching Physician

as used in this policy only, includes a physician who hosts UTMB students in their non-UTMB offices as a community-based educator, has a "without salary" (WOS) appointment and is not eligible for tenure.  Faculty appointments of this type are a dual responsibility of an academic department and the Dean of Medicine.

Community-wide Fund Raising Effort An institutional fund raising event sponsored and organized through the Office of University Advancement. Solicitations must be made to all vendors in the community and not only to vendors currently serving UTMB.
Compensable Injury An injury arising out of, and in the course and scope of employment for which compensation is payable according to law.
Compensation

any form of benefit, including but not limited to salary, retainer, honoraria, intellectual property rights or royalties, or promised, deferred, or contingent interest. It also includes sponsored travel or reimbursement unless paid for by a Federal, state, or local agency, an institution of higher education, an academic teaching hospital, a medical center, or a research institute that is affiliated with an institution of higher education.

 

Competent Possessing the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.
Computer Teaching Space

specialized space used for teaching supported by computer stations for each student.

Conditional Documentation

based on documentation entered, additional information or detail is prompted in the EHR, using pre-established criteria

Conditioning of Authorization

to require an individual to sign an authorization in order to provide treatment, payment, enrollment in a health plan, or eligibility for benefits to the individual.

Confidential Information

Information (or data) is classified as confidential if it must be protected from unauthorized disclosure or public release based on state or federal law or regulation, and by applicable legal agreement to the extent permitted by law.  Examples of confidential information include, but are not limited to: patient billing information, protected health information subject to HIPAA, and an individual's social security number.

Confidential Information the classification of data that is exempt from disclosure under provisions of the Texas Public Information Act or other applicable state or federal law, regulation, or court order. The controlling factor for confidential information is prevention of dissemination.
Confirmation of Drug Test Results The retesting of a urine or blood sample using gas chromatography/mass spectrometry to confirm the screening results.
Conflict of Commitment (COC)

a state in which the time or effort that a UTMB employee devotes to an outside activity directly or significantly interferes with the employee’s fulfillment of his or her institutional responsibilities or when the employee uses State property without authority in connection with the employee’s outside employment, board service, or other activity. Exceeding the amount of total time permitted by U.T. System or UTMB policy for outside activities creates the appearance of a conflict of commitment.

 

 

Conflict of Interest (COI)

a significant outside interest of a UTMB employee or one of the employee’s immediate family members that could directly or significantly affect the employee’s performance of his or her institutional responsibilities. The proper discharge of an employee’s institutional responsibilities could be directly or significantly affected if the employment, service, activity, or interest: (1) might tend to influence the employee’s conduct or decisions; (2) could reasonably be expected to impair the employee’s judgment in performing his or her institutional responsibilities; or (3) might require or induce the employee to disclose confidential or proprietary information acquired through the performance of institutional responsibilities.

 

 

Consensual Relationship

A romantic, dating, or sexual relationship agreed to by the parties involved.

Consistent Treatment Charging all costs incurred for the same purpose, in like circumstances, as either direct costs only or indirect costs only. Any cost charged as a direct cost to federal contracts must also be direct charged to other institutional activities. If a cost is identified as an indirect cost, it may be charged as a direct cost only in certain specific circumstances where the characteristics of the cost would unfairly burden the indirect costs. Direct costs that are allocated to sponsored projects or activities must be allocated using a reasonable method that is consistently followed. All departments must treat like costs in the same way.
Construction Cost

cost of construction of the project only.  This excludes professional design fees, equipment costs, furniture costs, make-ready costs, move costs, and any miscellaneous cost directly associated with the project.

Consumer Information

name, date of birth, physical and mailing addresses, and taxpayer number or other identifying numbers which may be contained in applications, change of address notifications, correspondence, or other documentation maintained by UTMB about a consumer. This includes information received about a consumer from a third-party source.

Consumer Report

any communication of information by a consumer reporting agency reflecting a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected to make business decisions regarding the consumer.  This includes but is not limited to:  background checks, criminal history checks, credit reports, educational background checks, and driving record checks.

Consumer Reporting Agency

means any person or company that regularly collects or evaluates consumer information and then provides the information as consumer reports to third parties for monetary fees, dues, or on a cooperative, nonprofit basis.

Continuing Professional Education (CPE)

educational activities intended for practicing clinicians, including those in medical, dental, nursing, and allied health specialties.

Continuum of Care Means the provision of comprehensive care from the hospital to the home, which advocates the pooling together of medical and social services within the community and the creation of linkages between community care initiatives at all levels of the health care system.
Contract Pharmacy

340B covered entities may contract with a pharmacy or pharmacies to provide services to the covered entity’s patients, including the service of dispensing the entity-owned 340B drugs. To engage in a contract pharmacy arrangement, the entity and pharmacy (or pharmacies) must have a written contract that aligns with the compliance elements listed in guidance and must list the contract pharmacy on 340B OPAIS during a quarterly registration period.

Contractor Means, any representative of a company contracted to perform long term service related work requiring frequent and routine visits to UTMB Campus.
Controlled Substance has the meaning assigned in Texas Health and Safety Code § 481.002, as that section may be amended from time to time.
Convenience Copy a copy of an original medical record, case management record or source data that was printed for a one time use. Convenience copies may be items like lab reports or other information found in an electronic system that are used for convenience but not required to be maintained in storage or in files.
Coordinator of Services for Students with Disabilities (CSSD) The Vice President for Student Services of UTMB or his/her designee will serve as the CSSD.
Cost Sharing

The mandatory or voluntary commitment of institutional resources contained in the proposal or award. The concept of cost matching is synonymous with Cost Sharing. Cost Sharing may be made up of either labor or non-labor costs. This policy only pertains to Cost Sharing as it relates to Effort commitments made by Individuals listed in the proposal or award. There are different types of Cost Sharing:

  • Mandatory Committed Cost Sharing refers to costs in excess of what the sponsor is going to fund where a requirement for the grantee to fund some portion of the cost is required by the sponsor as a condition of obtaining an award. It must be included in the contract or grant proposal to receive consideration from the sponsor.
  • Salary-cap Cost Sharing results when an Individual’s Institutional Base Salary exceeds a sponsor’s salary cap. The prorated excess is a form of mandatory Cost Sharing that must be funded by an appropriate and allowable source.
  • Voluntary Committed Cost Sharing refers to costs in excess of what we are asking the sponsor to fund that are included in the proposal budget where cost sharing was not required by the sponsor.
  • Voluntary Uncommitted Cost Sharing refers to costs of a project not funded by the sponsor and which were not committed in the proposal or award.

For both mandatory and voluntary committed Cost Sharing, when a notice of grant award is received in which Cost Sharing was proposed, the Cost Sharing becomes a binding commitment that must be provided and tracked in a consistent manner across The University of Texas Medical Branch at Galveston (UTMB). Budget reductions and scope changes recommended by the sponsor may be a basis for renegotiation of any proposed Cost Sharing. Additionally, these forms of Cost Sharing must be included in the appropriate direct cost base in the facilities and administrative rate proposal.

Cost Sharing

The mandatory or voluntary commitment of institutional resources contained in the proposal or award. The concept of cost matching is synonymous with Cost Sharing. Cost Sharing may be made up of either labor or non-labor costs. There are different types of Cost Sharing:

  • Mandatory Committed Cost Sharing refers to costs in excess of what the sponsor is going to fund where a requirement for the grantee to fund some portion of the cost is required by the sponsor as a condition of obtaining an award. It must be included in the contract or grant proposal to receive consideration from the sponsor.
  • Salary-Cap Cost Sharing results when an individual’s Institutional Base Salary exceeds a sponsor’s salary cap. The prorated excess is a form of mandatory Cost Sharing that must be funded by an appropriate and allowable source.
  • Voluntary Committed Cost Sharing refers to costs in excess of what we are asking the sponsor to fund that are included in the proposal budget where cost sharing was not required by the sponsor.
  • Voluntary Uncommitted Cost Sharing refers to costs of a project not funded by the sponsor and which were not committed in the proposal or award.
  • Non-salary Cost Sharing refers to non-labor costs, e.g. supplies, materials, equipment, that benefit a project but that are not financially supported by the project.

For both mandatory and voluntary committed Cost Sharing, when a notice of grant award is received in which Cost Sharing was proposed, the Cost Sharing becomes a binding commitment that must be provided and tracked in a consistent manner across UTMB. Budget reductions and scope changes recommended by the sponsor may be a basis for re- negotiation of any proposed Cost Sharing. Additionally, these forms of Cost Sharing must be included in the appropriate direct cost base in the facilities and administrative rate proposal.

Cost Transfer

A Cost Transfer occurs when an expense is transferred from one PeopleSoft project, class or chart field value to another when an error has occurred. Transfers between PeopleSoft accounts are considered coding corrections, not Cost Transfers, under this policy.

Cost Transfers for purposes of this policy include all costs, e.g. salaries, benefits, M&O (maintenance and operation) etc. Labor transfers typically occur via payroll transfer where non-labor transfers generally are done with a journal entry and may be initiated within the records of UTMB by Financial Accounting and Reporting, UTMB Hospitals or other authorized units.

Covered Active Duty
  • Members of the Regular Armed Forcesduty during deployment of the member with the Armed Forces to a foreign country; or
  • Members of the Reserve components of the Armed Forcesduty during deployment of the member with the Armed Forces to a foreign country under a call or order to active duty in support of a contingency operation.
Covered Family Member

for purposes of disclosure, a Covered Family Member includes (1) a spouse; (2) a dependent child or stepchild; (3) any other person financially dependent on the Covered Individual; and (4) any other person with whom the Covered Individual has joint financial interests such that an objective third party could reasonably conclude that the Covered Individual’s decisions or other exercise of professional responsibilities at the institution could be influenced by the effect of that action on the person’s financial interest. Any Individual may be identified as a Covered Family Member without regard to whether a legal or biological family relationship exists with the Covered Individual. If the Covered Individual is in doubt, the Covered Individual should resolve the doubt in favor of disclosure. In disclosing financial interests, the interest of any legal entity, including a foundation or a trust that is controlled or directed by the Individual or by the Individual and Covered Family Members is considered to be the interest of the Covered Individual or Covered Family Member as if the separate legal entity did not exist.

Covered Individual

An Individual who is required to complete a financial disclosure conflicts of interest form. UTMB requires the following to submit a financial conflicts of interest disclosure form: (1) all faculty engaged in organized research activities; (2) members of institutional research review-related committees; (3) staff members who negotiate or execute research agreements on behalf of UTMB; and (4) any Individual who, regardless of title or position, is responsible for the design, conduct or reporting of research, including a principal investigator, co-investigator, faculty agent, research tech, research nurse, staff, fellow or administrator who participates in research.

 

Covered individuals

health care workers and other individuals who provide care, enter a patient’s room, or meet patients face to face within 6 feet in the course of their duties.  This may be volunteers, students, pastoral care clergy, or contractors.

 

Creator

defined as a person who generates intellectual property, including but not limited to an inventor or an author of intellectual property.

Credentialed Monitoring Assistant

An MD, DO, DDS, RN, NP, PA, Respiratory Therapist, or Radiological Technician responsible for providing  sedation monitoring during the procedure.

Credit Hour

Federal Regulation 34 CFR 600.2: “Except as provided in 34 CFR 668.8(k) and (l), a credit hour is an amount of work represented in intended learning outcomes and verified by evidence of student achievement that is an institutionally established equivalency that reasonably approximates not less than

(1) One hour of classroom or direct faculty instruction and a minimum of two hours of out of class student work each week for approximately fifteen weeks for one semester or trimester hour of credit, or ten to twelve weeks for one quarter hour of credit, or the equivalent amount of work over a different amount of time; or

(2) At least an equivalent amount of work as required in paragraph (1) of this definition for other academic activities as established by the institution including laboratory work, internships, practica, studio work, and other academic work leading to the award of credit hours.”

Criminal Conviction Record Information refers to the public information maintained by the Department of Public Safety, as provided in Texas Government Code §411.135.
Criminal History Record Information is the information collected about a person by a criminal justice agency that consists of identifiable descriptions and notations of arrests, detentions, indictments, information, and other formal criminal charges and their dispositions, as more fully described in Texas Government Code §411.082.
Criminal Investigation

 A criminal investigation is the process of legally gathering evidence of a crime that has been, or is being, committed.

Critical Result

A test or diagnostic procedure finding that falls significantly outside the normal range and may indicate a life threatening situation. See IHOP - 09.13.36 - Reporting of Critical Results to Providers Appendices.

Current for purposes of this policy, within the most recent 12 months; or for professional licenses, the most recent and unexpired.
Current Good Manufacturing Practice (CGMP) The CGMP regulations for drugs contain minimum requirements for the methods, facilities, and controls used in manufacturing, processing, and packing of a drug product.  The regulations make sure that a product is safe for use, and that it has the ingredients and strength it claims to have. (Title 21, Food and Drug Administration.)
Custodian guardian or caretaker; the holder of data, the agent charged with implementing the controls specified by the owner. The custodian is responsible for the processing and storage of information. For mainframe applications, Information Services is the custodian; for micro and mini applications, the owner or user may retain custodial responsibilities. The custodian is normally provider of services.
Date of Discovery The date on which the need for a Cost Transfer is acknowledged.
Day a calendar day except for days on which the University is officially closed or when regularly scheduled classes are suspended due to emergent situations
Day Surgery Unit is the service that provides patient teaching, anesthesia screening, pre- and post-operative care, and discharge planning for Same Day Admit and Same Day Surgery patients.
De-accession

The removal of art from the UTMB inventory, whether sold or returned to its original owner/lender.

De-acession

The removal of art from the UTMB inventory, whether sold or returned to its original owner/lender.

De-identification

Data or information aggregated or summarized from patient records so that no means exist to identify the patient (e.g. management and quality management reports, case studies that do not identify the patient, statistical reports, anonymous data used for research purposes). See IHOP policy 6.2.29, De-Identification of PHI, for more information.

 

De-identified Data

Data or information aggregated or summarized from patient records so that no means exist to identify the patient (e.g. management and quality management reports, case studies that do not identify the patient, statistical reports, anonymous data used for research purposes). See IHOP policy 6.2.29, De-Identification of PHI, for more information.

Dean the Dean, or the Dean’s delegate, of a component school within UTMB.
Decision-making Capacity the ability to understand and appreciate the nature and consequences of a decision regarding medical treatment and the ability to reach an informed decision in the matter.
Declarant A person who has executed or issued an Advance Directive.
Deemed Export the providing, transferring or disclosing certain technology or information to a foreign national within the United States is “deemed” an export to the foreign national’s home country.
Deep sedation A drug-induced depression of consciousness during which a patient cannot be easily aroused but responds purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. A patient may require assistance with maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. A non-anesthesiologist must be privileged to administer deep sedation by the Department of Anesthesiology.
Degree Program Any grouping of subject matter courses which, when satisfactorily completed by a student, shall entitle him or her to a degree from a public university or health-related institution.
Demographic Information

 Name, address, other contact information, date of birth, age, and gender.

Departmental Art

Art that is procured with departmental funds and displayed within departmental assigned spaces.

Departmental Business Operation The department, center or hospital office that is responsible for the stewardship of institutional resources within the policies, practices and procedures of the institution.
Departmental Recharge Activities

such as department copiers, fax machines, scientific equipment, or services provided to users within the department or to fewer than five (5) UTMB Departments or Centers are not considered a University Service Center or a University Core.  The charge must be reasonable and is intended to only recover the costs of supplies.   The services of a Departmental Recharge Activity are intended as a convenience to faculty, staff, and students in the conduct of mission-based activities.  It is the responsibility of the department to maintain all records regarding costs used to determine recharge rates and the subsequent charges distributed to users.

Dependents A spouse, minor child, or parent whose Family member is responsible for his/her support (see definition of Family)
Deposits

To include all payments of coin, currency, checks, electronic media and all negotiable instruments.

Designated Building

Primary Care Pavilion (PCP), UTMB Health Clinics (UHC), Victory Lakes Specialty Care and Victory Lakes Multispecialty Center.

Designated Emergency Infant Care Provider (DEIC)

any operation where an infant can be left without fear of criminal prosecution for abandonment of a child; a child-placing agency (CPA) licensed by Department of Family and Protective Services (DFPS) can be a designated emergency infant care provider if the CPA:

  • Agrees to act as a designated emergency infant care provider;
  • Has on staff a person who is licensed as a registered nurse, or who provides emergency medical services, and who will examine and provide emergency medical services to a child taken into possession by the agency;
  • Examples include: hospitals, fire rescue stations or EMS stations
Designated Managing Conservator

A prospective adoptive parent(s) or licensed adoption agency that has been designated in an Affidavit of Voluntary Relinquishment of Parental Rights.  The designated person/agency then has the right to possession of the child and the right to consent to medical, surgical, dental, and psychological treatment of the child until such time as those duties and rights are modified, made permanent or terminated by a court order or, if the Affidavit of Voluntary Relinquishment of Parental Rights is revocable, until such time as the Affidavit of Voluntary Relinquishment of Parental Rights is revoked.

Designated Record Set

  A group of records maintained by or for UTMB that are:

  1. The medical records and billing records about patients maintained by or for UTMB;
  2. The enrollment, payments, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
  3. Used, in whole or in part, by or for UTMB to make decisions about patients.
Designated Record Set The Designated Record Set includes the Unit Medical Record (UMR) and billing records of patients. The Designated Record Set also includes medical records from non-UTMB sources used to make health care decisions.
Designated Responsible Party The Designated Responsible Party (DRP) is the senior administrative executive for the research operation who will manage and be responsible for the Effort reporting compliance program. This individual possesses exclusive responsibility for managing the risk, including the appropriate knowledge and necessary authority to manage the risk. The Associate Dean for Research Administration is the DRP at UTMB. It is acknowledged the DRP will work closely with the Provost, chief business officer and the institutional compliance officer to ensure all specific risks are adequately mitigated and effectively monitored.
Designated Shuttle Pick-up Locations

 Shuttle pick-up schedules and locations are available online at http:utmbhealth.com/transportation.

Direct Authority

The authority vested in an individual as a result of his/her immediate position of power over another. Examples include, but are not limited to: supervisor - supervised employee; faculty - enrolled student; faculty committee member - student submitting thesis; faculty mentor – student mentee; coach - coached athlete; Dean - supervised faculty.

Direct Costs Costs that can be identified specifically with a particular sponsored project, and instructional activity, patient care activity, or any other institutional activity, or that can be assigned to such activities relatively easily with a high degree of accuracy. For a cost to be charged directly to an activity there must be a direct benefit to the activity.
Direct Threat A direct threat is a significant risk of substantial harm to the health or safety of the individual or others that cannot be eliminated or reduced by reasonable accommodation. For example, an employee with a communicable disease may constitute a direct threat. UTMB has the burden of establishing whether a direct threat exists. Approval of the ADA Coordinator must be obtained in order to use "direct threat" as the basis for an employment or program action.
Directive

An instruction to administer, withhold, or withdraw life-sustaining treatment in the event of a terminal or irreversible condition.  The term includes a written directive executed by a competent adult, a non-written directive issued by a competent adult qualified patient, and a directive executed on behalf of a patient younger than 18 years of age

Director, Regulatory & Scientific Affairs Regulatory & Scientific Affairs (RSA) provides regulatory guidance for nonclinical studies which include infectious disease related projects to develop vaccines, therapeutics and diagnostics. The incumbent advises the university administration and principal investigators (PI) on scientific and regulatory policy involving strategy in the design and conduct of regulated and non-regulated studies to support development of products designed for the treatment and prevention of human disease for study in clinical trials and may be candidates for licensure. Involved is the design and conduct of both in vitro and in vivo GLP studies that meet scientific and regulatory requirements. The studies are designed to demonstrate vaccine potency, efficacy and safety to prevent disease, implementation of therapeutics to treat infectious disease, definition of antigens that stimulate protective immunity, diagnostic tests to improve clinical medicine, and translation of scientific discovery in the regulatory pathway to product development. Effort is focused on collaborative and programmatic research involving the cooperation of multiple scientific disciplines working together in an environment disciplined by regulatory principles and compliance. (UTMB JD A0401)
Director, Regulatory Operations The incumbent provides strategic, regulatory, and educational support and expert advice regarding compliance with federal and state requirements related to regulated nonclinical studies at UTMB; provides oversight for regulatory operations of the Institutional Office of Regulated Nonclinical Studies including the Quality Assurance Unit and Good Laboratory Practices (GLP) archive; approves institutional policies and Standard Operating Procedures (SOPs) governing regulatory operations for nonclinical studies. (UTMB JD A0946)
Directory Information means information in a student’s education record that would not generally be considered harmful or an invasion of privacy if disclosed.
Disability The inability because of a compensable injury to obtain and retain employment at wages equivalent to the pre-injury average weekly wage.
Disability A physical or mental impairment that substantially limits one or more major life activities, a record of such impairment, or being regarded as having such impairment.
Disability

For the purpose of IHOP - 03.06.13, a disability is defined as a mental or physical disability, an intellectual or developmental disability, hearing impairment, deafness, speech impairment, a visual impairment, post-traumatic stress disorder or any health impairment that requires special ambulatory devices or services.

Disability

According to the Americans with Disabilities Act of 1990 (ADA) and the Americans with Disabilities Act Amendments Act of 2008 (ADAAA), an individual has a disability if she/he has a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment. Although some disabilities (e.g., spinal cord injury or blindness) are readily observable, other disabilities are not as obvious. In the case of disabilities that are not as obvious, a qualified professional must perform a specialized assessment to identify the disability.

Disabled a person with a mental, physical, or developmental disability that substantially impairs the person’s ability to provide adequately for the person’s care or protection, and who is either 18 years of age or older, or under 18 years of age but who has had the disabilities of minority removed.
Disaster Conditions

a “disaster” might necessitate the transfer of patients when a hurricane is imminent.  A state of disaster may be declared before a hurricane makes landfall by a municipal executive, county judge, or the governor.   A declaration by the governor would allow for the use of state assets to transport patients by ground and air.

Disclosure

The release or, transfer of, providing access, or divulging in any other manner protected information (PHI) outside of UTMB.

Disclosure means to permit access to, release, transfer, or otherwise communicate personally identifiable information contained in education records by any method (including oral, written, or electronic) to anyone except the party that provided or created the record.
Disclosure The initiation of a discussion with a patient or the patient’s representative regarding an unanticipated outcome
Dispense

Provide a medication, typically in a hospital or a clinic, based upon a health care provider's order to be administered to a patient.

Disproportionate Share Hospital (DSH)

Disproportionate share hospitals serve a significantly disproportionate number of low-income patients; as such, they receive adjustment payments to provide additional help. The primary method of qualification is based on the sum of the percentage of Medicare inpatient days and the percentage of total patient days attributable to patients eligible for Medicaid but not eligible for Medicare Part A. Among other requirements, DSHs must have a DSH adjustment percentage >11.75% to be 340B eligible.

DNR Identification Device

An identification device worn for the purpose of identifying a person who has executed or issued an OOHDNR order or on whose behalf an OOHDNR order has been executed or issued.  The Texas Board of Health has specified a distinctive standard design for necklace and bracelet DNR identification devices.

Doctoral Graduation Rate The percent of students in an entering fall cohort for a specific degree program who graduate within 10 years. Doctoral graduation rates do not include students who received a master's degree.
Document owner

the department initiating a new or revised medical record form.

Doffing

The process of removing personal protective equipment (a respirator) from the individual.

Donning

The process of putting personal protective equipment (a respirator) on the individual.

DOT Agency an agency (or “operating administration”) of the United States Department of Transportation administering regulations requiring alcohol and /or drug testing (in accordance with 49 CFR part 40.
Drug Screening/Drug Testing Testing for presence of controlled substances. The drugs for which tests will be performed are marijuana, cocaine, amphetamines, phencyclidine (PCP), and opiates. All drug testing will be performed using urine samples collected according to the guidelines set forth by SAMHSA
Drug Testing Testing for presence of controlled substances. The drugs for which tests will be performed are marijuana, cocaine, amphetamines, phencyclidine (PCP), opiates and methylenedioxymethamphetamine (MDMA - a.k.a. Ecstasy). All drug testing will be performed using urine samples collected according to the guidelines set forth by 49 CFR.
Dual State Employment This includes employment by UTMB and/or another State agency.
Dual Use items or technologies that have commercial applications and also can be of military or terrorist use.
Duplicate Discount

A duplicate discount, prohibited by the 340B statute, occurs when manufacturers both provide a 340B discount on a drug AND pay a Medicaid rebate to the state on the same drug.

Education and Training

A. Each Covered Individual must acknowledge annually that the individual is aware of and has read this policy and is aware of the Covered Individual’s responsibilities regarding disclosure of Significant Financial Interests and of applicable federal and state regulations and institutional and UT System policies.

B. A Covered Individual must complete training in regard to this policy and applicable policies, regulations, and laws before engaging in research at the institution and at least once every four (4) years thereafter. A Covered Individual who is new to UTMB must complete the training before engaging in research at the institution or provide evidence of having completed the training at another institution of The University of Texas System within the last four (4) years. A Covered Individual must complete the training immediately if the institution finds that the individual is not in compliance with this policy or the individual’s management plan, or if the institution revises this policy in a manner that affects the individual’s duties. Failure to complete the required training may result in the withholding of access to funds related to federally-funded or other sponsored research activities until such time as the Covered Individual completes the required disclosure.

C. The Conflicts of Interest Office within Research Services, in conjunction with the Office of Institutional Compliance, is responsible for ensuring that appropriate faculty, staff, trainees, and other persons participate in training in regard to this policy and applicable laws.

Education Records

includes records maintained by UTMB that are directly related to a student. Education records do not include:

  1. records of instructional, administrative, and educational personnel for their own use and not shown to others;
  2. records of the UTMB campus police;
  3. student medical and counseling records created, maintained, and used only in connectin with providing medical treatment or counseling to the student that are not disclosed to anyone other than the individuals providing the treatment;
  4. records created or received by UTMB post-attendance that are not directly related to the person's attendance as a student;
  5. grades on peer-graded papers before they are collected and recorded by an instructor;
  6. employment records unrelated to the student's status as a student; or
  7. alumni records
Effective Date The admitting date of the encounter, determined after a patient has qualified for charity or discounted care.
Effective Period A period less than or equal to one year during which the charity discount is in effect.
Effort Sometimes referred to as Level of Effort, Effort is the amount of time spent by an Individual on any activity expressed as a percentage of Total Professional Effort for which an Individual is compensated by a UTMB. It is extremely important to understand that Effort is not calculated on a 40-hour workweek or any other standard workweek. In addition, Total Effort must equal 100%. For example, if an Individual with a full-time appointment averages working 60 hours per week during the Effort Reporting Period and estimates that he/she spends an average of 15 hours each week on a Sponsored Program, 25% of that Individual’s Effort is spent on the Sponsored Program and the other 45 hours, allocated to other institutional activities, represents 75% Effort.
Effort Confirmation (Also, referred to as Effort Certification): A Primary Individual’s representation that the Effort supported by the sponsor has been performed and/or Effort expended in support of a project (but not paid by the sponsor) has been performed. It is important to note that payroll distributions and Effort Confirmations are not the same thing. Payroll distributions describe the allocation of an Individual’s salary; whereas, Effort Confirmation describes the allocation of an Individual’s Effort.
Effort Confirmation (also referred to as Effort Certification) A Primary Individual’s representation that the Effort supported by the sponsor has been performed and/or Effort expended in support of a project (but not paid by the sponsor) has been performed. It is important to note that payroll distributions and Effort Confirmations are not the same thing. Payroll distributions describe the allocation of an Individual’s salary; whereas, Effort Confirmation describes the allocation of an Individual’s Effort.
Effort Confirmation Period The designated period of time for Individuals to enter and for Primary Individuals to confirm, estimates of actual Effort in the official UTMB Effort system. The end of the Effort Confirmation Period is deemed to be the initializing transaction date as referenced in the Cost Transfer vis-à-vis timeliness.
Effort Coordinator The individual at the department level that manages and oversees the Effort reporting process for a particular department or group departments. This individual is responsible for monitoring whether Effort has been reported and that the necessary salary adjustments resulting from Effort reporting (or lack thereof) are made.
Effort Reconciliation Period The designated period of time, after the Effort Confirmation Period, in which salary paid should be reconciled to the Effort confirmed and any adjustments submitted.
Effort Report

This is also known as the effort card. A form used by UTMB to document the proportion of total Effort devoted by an employee to each activity with which he or she is involved, including Sponsored Projects, administration, teaching and service. This document becomes UTMB’s official verification that the IBS charged to a Sponsored Project is consistent with the Actual Effort expended on the project. The sum of all reported Actual Effort percentages on the Effort Report represents the employee’s total Effort. By definition, total Effort must always equal 100%.

An Effort Report must be completed for all Individuals with Effort on a Sponsored Project by someone with suitable means of verification of the Effort expended on a project. This may be the Individual or it may be the direct supervisor. Confirmation of the Effort expended must be made in accordance with this policy. A Supporting Individual may not confirm the Effort expended on the Effort Report.

Effort Reporting Period The designated period of time over which the Effort is to be reported. UTMB reports Effort semi-annually.
Effort Reporting Period The designated period of time over which the Effort is to be reported. UTMB reports Effort semi-annually or according to other timetables established and published by Research Services.
Effort Reporting Procedure Manual A UTMB document that contains all the implementation and operational guidelines for Effort reporting at UTMB.
Elderly 65 years of age or older.
Electric Personal Assistive Mobility Device (EPAMD)

Commonly known as Segway.  EPAMDs are a two non-tandem wheeled device designed for transporting one person that is 1) self-balancing and 2) propelled by an electric propulsion system with an average power of 750 watts or one horsepower (Texas Transportation Code 551.201). Consumer-grade hoverhoard intended for recreational use are not considered EPAMDs. 

 

Electronic Health Record (EHR) The electronic recording of patient medical and medical history information in a software package designed to securely record, report on, and store such information.
Electronic mail (email) any message, image, form, attachment, data or other communication sent, received, or stored within an electronic mail system.
Electronic mail system any computer software application that allows electronic mail to be communicated from one computing system to another.
Eligible Employee 1) Director level or above. 2) Staff who work outside their main office at least 50 percent of the time. 3) Staff required to be accessible 24/7.
Eligible for Leave

For the purpose of FMLA, an employee’s spouse, children, and parents are considered next of kin. Spouse is defined in accordance with the applicable State Law including common law marriages when recognized by the State. Unmarried domestic partners do not qualify for family leave. The term ‘parent’ does not include parent “in law.” Persons who have day to day responsibilities to care for and financially support a child or, in the case of an employee, had such responsibility for the employee when the employee was a child are covered by FMLA (loco parentis). In this case, a biological or legal relationship is not necessary. Son or daughter is defined under the FMLA to include a child under 18 years or one who is 18 years or older who is incapable of self-care because of a mental or physical disability. For purposes of confirmation of family relationship, UTMB may require the employee giving notice of the need for leave to provide reasonable documentation or statement of family relationship.

Documentation may take the form of a simple statement from the employee, or a child’s birth certificate, a court document, etc. UTMB is entitled to examine documentation such as birth certificate, etc., but the employee is entitled to the return of the official document submitted for this purpose.

Emancipated Minor A person under the age of 18 who is legally emancipated by the courts and able to provide their own consent for treatment.
Emergency Blood Release Form

Provides information to the Blood Bank to assist in tracking the unit(s) of blood transfused.  This tracking form becomes a permanent part of the Blood Bank records.

Emergency Conditions

an “emergency” might necessitate the evacuation of patients (e.g., after a tornado, fire, explosion, etc.) due to a condition that has compromised UTMB’s ability to render care.  A state of emergency may be declared if the President of UTMB activates the Emergency Operations Plan.

Emergency Medical Condition

(A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:

(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,

(ii) serious impairment to bodily functions, or

(iii) serious dysfunction of any bodily organ or part; or

 

(B) with respect to a pregnant woman who is having contractions:

(i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or

(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

Emergency situation is one in which there may be a potential adverse effect on a UTMB patient or employee.
Emergency Work work that is required to be performed in the event of an emergency where it is not feasible to apply for a permit in a timely manner. This work will need to be recorded on a Utility interruption report.
Employee Every person in the service of UTMB under any appointment or contract of employment whose name appears on the payroll of UTMB.
Employment at will An employment relationship in which either party can terminate the relationship without prior notice and for any reason permitted by law.
Empowered Official (EO) means a U.S. citizen who is legally empowered in writing by UTMB to sign export license applications or other requests for approval on behalf of UTMB. The EO has the independent authority to inquire about any aspect of a proposed export, to verify the legality of the transaction and the accuracy of the information to be submitted, and to refuse to sign a license application or other request for approval without prejudice or other adverse recourse.
Encryption

process of encoding messages (or information) in such a way that eavesdroppers or hackers cannot read it, but that authorized parties can. In an encryption scheme, the message or information (referred to as a plaintext) is encrypted using an encryption algorithm, turning it into an unreadable ciphertext (ibid).  This is usually done with the use of an encryption key, which specifies how the message is to be encoded.  Any adversary that can see the ciphertext, should not be able to determine anything about the original message.  An authorized party, however, is able to decode the ciphertext using a decryption algorithm that usually requires a secret decryption key that adversaries do not have access to.  For technical reasons, an encryption scheme usually needs a key-generation algorithm, to randomly produce keys.

Enterprise ID (EID)

A number that is generated in Epic when a patient is added to the system without a MRN.

Enterprise Master Patient Index (EMPI)

An electronic demographic database, residing in Epic, with information on all patients who have received services at UTMB Health. It contains basic patient demographic information and the patient's MRN and is a key to locating patient's medical record information. It is not an index of legal identities, but is an index of all identities used by patients.

Entity Business Operations Entity Business Operations is charged with the oversight of policies and procedures for the Departmental Business Operations that report to them. Entity leaders and CFO’s will ensure that each department has an appropriate review process in place.
ESSENTIAL (“E”)

employees with specific responsibilities before, during or after a declared emergency. All employees can be classified essential depending on the needs of the University. These responsibilities may include but are not limited to the following:

  • Remain at worksite during the emergency
  • Accompany patients to another location and provide care at that location until notified to return to UTMB Galveston
  • Return immediately after the emergency to relieve those who were assigned to stay
  • Work at an alternate location if assigned during or after the emergency
  • Come to work during scheduled time off if requested
Essential Functions

fundamental job duties of the employment position that an individual holds or desires.  The term essential function does not include marginal functions of the position.

Essential Functions Committee (EFC) The EFC works closely with the ADA Coordinator and the CSSD with respect to the institution's overall compliance with the ADA.
Exchange Count Method is a method of counting needles used in cardiothoracic surgery to reduce the time a patient is on cardiopulmonary bypass.
Executive Committee (EC)

Consists of:

  • President of the UTMB
  • Executive Vice President and Provost Dean of Medicine
  • Executive Vice President and Chief Business and Finance Officer
  • Executive Vice President and Chief Executive Officer, UTMB Health System
  • Vice President and Dean, Graduate School of Biomedical Sciences
  • Vice President for Education, Dean, School of Nursing
  • Vice President and Dean, School of Health Professions
  • Senior Vice President for Health Policy and Legislative Affairs
  • Senior Vice President and General Counsel
  • Vice President and Chief of Staff
Exempt Employee

an employee who is salaried and exempt from the overtime provisions of the Fair Labor Standard Act.

Exit Access Corridor

As defined by the NFPA, an Exit Access Corridor is that portion of the exit path that leads to an exit (e.g. corridor leading to a stair or horizontal) and is typically separated from the rest of the building by rated walls.  This does not include aisles within suites. Contact Environmental Health and Safety, Occupational Safety and Fire Prevention (ext.70515) with questions regarding your area and whether or not a particular corridor meets this definition.

Expert Testimony

Any Compensated Outside Activity that involves providing evidence—in the form of a deposition, written document, in-person testimony, or otherwise—based on the employee’s scientific, technical, or professional expertise or training in the relevant field.  This includes evidence provided for judicial, legislative, or executive agency proceedings on either a State or Federal level.

Exploitation misusing the resources of a person 65 years or older or an adult with disabilities for personal or monetary benefit. This includes taking Social Security or SSI (Supplemental Security Income) checks, abusing a joint checking account, and taking property and other resources.
Export is the actual shipment or transmission of items or technology subject to the EAR out of the United States.
Export Administration Regulations (EAR) The Department of Commerce implements the EAR, which bars the export of items, technology, and technical information found on the Commerce Control List to foreign countries without appropriate export license. EAR covers the transfer of dual-use items.
Export Controls Officer (ECO) means a person who is identified formally at UTMB for purposes of institutional compliance with export control regulations.
Exposure-prone procedure A procedure involving the contact of a Health Care Worker’s finger with a needle tip in a body cavity or the simultaneous presence of the Health Care Worker’s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined area of the body. Such procedures pose a recognized risk of injury to the Health Care Worker that is likely to result in the Health Care Worker’s blood contacting the patient’s body cavity, subcutaneous tissues, or mucous membranes.
Express Consent

Oral or written consent given by a competent person or authorized representative for an  incapacitated patient:

Facility Building or site owned, leased, used, or controlled by UTMB.
Faculty member

an employee who has any type of faculty appointment, and receives any compensation or benefits from UTMB, regardless of the source of funds or assignment during the year.

Faculty Publications Discipline-related refereed publications, books or book chapters, juried creative or performance accomplishments, and notices of discoveries filed and patents issued.
Faculty Teaching Load Total number of semester credit hours taught per academic year by faculty divided by the number of faculty.
Fair Market Value

is the price at which the property would change hands between a willing buyer and a willing seller, neither having to buy or sell, and both having reasonable knowledge of the relevant facts.

Fall An unplanned descent to the floor with or without injury to the patient. Include falls when a patient lands on a surface where you wouldn’t expect to find a patient. All types of falls are included, whether they result from physiological reasons (fainting) or environmental reasons (slippery floor), or assisted falls, when another person attempts to minimize the impact of the fall by assisting the patient’s descent to the floor. Also report patient that roll off a low bed onto a mat as a fall.” (NDNQI February 2012)
Fall Enrollment Commonly used benchmark measure of enrollment headcount, taken on the census date of the fall semester.
Family As used in this policy, family is defined to include a spouse, a domestic partner (including a same-sex domestic partner), siblings, children, other family members, or a friend. This definition should not be confused with the definition of “family” as contained in other IHOP policies; for example, for issues regarding consent or refusal to treatment, please refer to the appropriate IHOP policies.
Family

All persons who are legally responsible for the financial obligations of the patient or for whom the patient is legally responsible. The Family may or may not live in the same home as the patient (e.g. custodial parent living away). Legal guardians, anyone who has claimed the patient as a Dependent on his/her most recent Federal Income Tax return, and/or anyone who takes the Federal Elderly Income Tax Credit for the patient on his/her most recent Federal Income Tax Return are included in this designation. Spouses are included in this definition. Spouses who live apart, but are not divorced are included, unless it can be demonstrated that they have lived apart for at least two years, with separate addresses, separate financial accounts, and separate income tax returns. Common Law or Informal Marriages are included in the Family definition if either A or B is met:

A. The couple has filed a Declaration of Informal Marriage, or

B. The couple meets all of the following conditions:

  1. they agree that they are married
  2. they live together in Texas, and
  3. they represent themselves or hold out to others that they are married to one another.

For purposes of this policy, Family does not include non-custodial parents who are not legally obligated to support the applicant and/or who do not claim the applicant as a Dependent; adult (age 19 or over) children or siblings with no financial responsibility for the applicant.

Family Income Money or its equivalent received by those who are legally responsible for the support of the patient, who claim the patient as a dependent or tax credit, and/or who are defined as Family in this Policy in the form of but not limited to items in the Approved Document List. If an applicant has received voluntary support from someone who is not legally obligated to provide support, the amount of that support should be considered as part of the applicant’s total income and documented, but the total income of the person providing that support is not considered. The value of anticipated or future voluntary income or gifts cannot be considered.
Family Violence any act or serious threat by one member of a family or household intended to physically harm, bodily injure, or sexually assault another family member. The term also includes child abuse.
FDA Reportable Event

an event where a device has the potential to cause or contribute to a serious injury, serious illness or death of a patient or employee. This event may include equipment malfunctions and/or user errors. Reporting to the FDA is required within ten working days. These same reportable events may also fall within the Adverse Event or Sentinel Event policies. A serious event is defined as one in which the patient outcome is:

  • Death – the patient’s death is suspected as being a direct outcome of the adverse event.
  • Life-threatening – the patient was at substantial risk of dying at the time of the adverse event or it is suspected that the continued use of the product would result in the patient’s death.
  • Hospitalization (initial or prolonged) – if admission to the hospital or prolongation of a hospital stay results because of the adverse event.
  • Disability – if the adverse event resulted in a significant, persistent, or permanent change, impairment, damage or disruption in the patient’s body function/structure, physical activities or quality of life.
  • Congenital anomaly – if there are suspicions that exposure to a medical product prior to conception or during pregnancy resulted in an adverse outcome in the child.
  • Requires intervention to prevent permanent impairment or damage – if the use of a medical product results in a condition which requires medical or surgical intervention to preclude permanent impairment or damage to a patient.
Federal healthcare programs

Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or part, by the United States Government (other than the health insurance program under Chapter 89 of Title 5 of the United Sates Code – the Federal Employees Health Benefit Program); or any state healthcare program, as defined in 42 U.S.C 1320a-7(h).

Federal healthcare programs include, at a minimum, the following:

  • Medicare Program, Parts A & B (Title XVIII of the Social Security Act); (but not Medicare managed care plans)
  • Medicaid (Title XIX of the Social Security Act); (but not Medicaid managed care plans)
  • Federal Prison Hospitals (prisoners);
  • Indian Health Service;
  • OWCP (workers’ compensation for federal employees);
  • Public Health Service;
  • Railroad Retirement Board;
  • The Black Lung Program;
  • TRICARE/CHAMPUS/Department of Defense healthcare programs (Chapter 55 of Title 10, United States Code); and
  • Veterans Administration (VA).
Federal Motor Carrier Safety Administration FMCSA A separate administration within the U.S. DOT dedicated to improving the safety of commercial motor vehicles
Federal Poverty Guidelines (FDG) Guidelines are issued each year in the Federal Register by the Department of Health and Human Services (HHS); they are a simplification of the poverty thresholds for use for administrative purposes— for instance, determining financial eligibility for certain federal programs (from U.S. HHS website: http://aspe.hhs.gov/poverty/05poverty.shtml).
Fiduciary Position

a position the UTMB employee held in a for-profit or non-profit entity in the preceding twelve (12) months, including a position as a member of the board of directors, an officer, or other executive or management position, for which the Individual received any form of payment or reimbursement for expenses.

 

Filter

A fibrous medium used in respirators to remove solid or liquid particulates from the air before it enters the facepiece (this term may be used interchangeably with cartridge).

Financial Accounting and Reporting Financial Accounting and Reporting (FAR) is charged with the responsibility of maintaining the official financial records of the institution. FAR is responsible for ensuring that policies and procedures are in place to assure the proper stewardship of externally funded projects, including the Cost Transfer policy.
Financial indigence Financially indigent persons include uninsured and underinsured persons who meet an institution’s eligibility for discounted care up to and including a 100% discount. Eligible patients whose household income level and calculated assets are below 400 of the FPG are eligible for this discount. Approved applicants are still responsible for any deposits or amounts indicated in any financial agreements and may receive a bill for any balances due. The eligibility for financial assistance or charity care at UTMB is based on a patient’s household income, number of dependents, Texas residency and calculated assets. Demographics information such as race/ethnicity, gender, and age are not considered.
Financial Remuneration

Direct or indirect payment from or on behalf of a third party who product or service is being described. Does not include non-financial benefits, such as in-kind benefits, provided to UTMB in exchange for making a communication about a product or service.

Fine Art

Any art that is maintained in the inventory of the Office of University Conferences and Events. Fine Art can be an original work, antique, bonafide rarity or other item that is likely to appreciate in value as determined by the Office of University Conferences and Events.

FIRE ALARM

Any fire alarm system activation to which all personnel respond. This may include fire drills, system malfunction, system maintenance/testing or accidental activation.

FIRE DRILL Any scheduled fire alarm activation to practice the appropriate response to a fire alarm, including any other scheduled activation of the fire alarm system as approved by Environmental Health and Service – Occupational Safety and Fire Prevention (EHS-OS&FP).
FIRE INCIDENT

Any unscheduled activation of the fire alarm system upon detection of smoke, fire, and smell of gas, electrical fire, or other burning odors.  May include, but is not limited to, accidental activation, system malfunction and activation of devices linked to other building protective systems.

Fiscal Year The financial accounting period from September 1st through August 31st.
Fitness for Duty Whether an employee is physically and mentally capable of safely performing the essential functions of his/her job with or without reasonable accommodation.
Fitness for Duty Evaluation- Evaluation by an impartial, independent health care professional with appropriate expertise in one or more of the following: medical conditions, psychological conditions, and/or conditions related to the use or abuse of alcohol or other substances.
FMAL Qualified Employee

An employee is eligible for leave if he or she has worked for UTMB at least 12 months and worked at least 1,250 hours during the 12 month period immediately preceding the leave.

FMLA Qualified Employee

An employee is eligible for leave if he or she has worked for UTMB at least 12 months and worked at least 1,250 hours during the 12 month period immediately preceding the leave.

Foreign National

means any natural person who is not a lawful permanent resident in the U.S and is not a “protected individual.”

For the purpose of export controls, foreign nationals who are protected individuals are the following:

  1. foreign nationals granted U.S. Citizenship,
  2. “green card” holders,
  3. foreign nationals granted status as a “protected individual” under 8 U.S.C. §1342b(a)(3) which includes political refugees and political asylum holders.
Forensic Photographs Photographs that are taken during a sexual assault/abuse forensic/medical exam and/or forensic evidence collection process.
Full-Time Employee

any individual employed by UTMB on a twelve (12) month or nine (9) month basis.

Full-Time Faculty Member

an employee who has a nine (9) or 12 (twelve) month faculty appointment and receives any compensation or benefits from UTMB regardless of the source of funds or assignment during the year.

Fundamental Research means basic or applied research in science and engineering performed or conducted at an accredited institution of higher learning in the U.S.
Fundamental Research Exclusion means research that is not subject to export control regulations due to the research being the result of scientific or engineering research at an accredited university in the U.S. to which no publication restrictions apply, (other than a short period in which to seek patent protection or remove sponsor proprietary data under EAR and probably ITAR) and is not proprietary and is ordinarily published (for EAR-or is intended to be published) and broadly shared in the scientific community.
Fundraising Projects

pertains to projects and events sponsored/coordinated by departments internal to UTMB other than the Development Office.

General Teacher Space

general, non-specialized space used for teaching and related activity.

General Teaching Space

general, non-specialized space used for teaching and related activity.

Gift

anything of value, including, but not limited to cash, securities, bequest/trust distributions, life insurance, real estate, loans, gift cards, tickets to entertainment or sporting events, and food given to UTMB, a department/institute, and/or a UTMB employee by a third party.  NOTE: salary, honoraria, expense reimbursements, and other such payments for services are not considered gifts.  These payments are considered compensation for disclosure purposes.

Gift A benefit which may include, but are not limited to, the following: cash, checks, securities, subsidies, real property, personal property, referrals, offerings, goods, honoraria, favors, prizes, services, employment, business or professional activities, membership, travel expenses, and compensation.
Gift - For the purposes of this policy, “Gift” is defined as a commitment in the form of cash, pledge, securities, bequest/trust distributions, life insurance, real estate, in-kind and other transferable assets received by UTMB from an individual, corporation, foundation or other entity that is given with the charitable intent of supporting UTMB’s mission and programs, with no expectation of benefit other than UTMB expending the contribution for any mutually agreed upon purposes.
Good Laboratory Practices (GLP): As stated in 21 CFR Part 58 Subpart A58.1(a), Nonclinical laboratory studies that support or are intended to support applications for research or marketing permits for products regulated by the FDA, including food and color additives, animal food additives, human and animal drugs, medical devices for human use, biological products, and electronic products. Compliance with this part is intended to assure the quality and integrity of the safety data filed. Procedures for regulated studies follow GLP guidelines.
Good Standing employee’s most recent performance evaluation “meets standard” and no disciplinary actions greater than written warning have occurred since last evaluation.
Government Agent

A government official, representative, investigator, or other individual acting on behalf of a government or a non-institutional legal entity, including contractors.

Government Investigation

A government investigation is the process of legally gathering information related to an allegation of fraud, waste, abuse, or a violation of federal or state law.

GPO Prohibition

The GPO Prohibition, per 340B statute, prohibits 340B participating disproportionate share hospitals (DSH), children’s hospitals (PED), and free-standing cancer hospitals (CAN) from obtaining covered outpatient drugs through group purchasing organizations (GPOs). Upon enrollment, an entity official signs a form attesting that the hospital will comply with the GPO Prohibition. This applies to the hospital as of the date of listing in 340B OPAIS. Upon recertification of information from 340B OPAIS, the hospital official attests to compliance with the GPO Prohibition.

Graduate Placement The number and percent of graduates employed or engaged in further education or training, those still seeking employment, and unknown.
Gross Square Feet (GSF) space measured to the outside face of the building.
Group Purchasing Organization (GPO)

A Group Purchasing Organization is an organization created to leverage the purchasing power of entities to obtain discounts from vendors based on the collective buying power of the GPO members. GPOs are common in the drug industry; the GPO may set mandatory purchasing participation levels from its members or be completely voluntary. Disproportionate share hospitals are prohibited from purchasing covered outpatient drugs from a GPO.  However, drugs used for inpatients may be purchased from a GPO.

Hazardous Chemical

any chemical that:

  • Poses a physical and/or health hazard. 
  • Is a physical hazard has scientifically valid evidence that it is a combustible liquid, a compressed gas, explosive, flammable, an organic peroxide, an oxidizer, pyrophoric, unstable (reactive), or water-reactive. 
  • Is a health hazard has statistically significant evidence (based on at least one study conducted in accordance with established scientific principles) that acute or chronic health effects may occur in exposed persons.  This includes chemicals that are:
    • carcinogens or known to cause neoplastic effects
    • highly toxic agents
    • moderately toxic agents
    • reproductive system toxins
    • teratogens
    • mutagens
    • sensitizers or allergens (immunologic system effects)
    • substances causing target organ effects (hepatotoxins, nephrotoxins, neurotoxins, hematopoietic system toxins, and agents which damage the lungs, skin, eyes, or mucous membranes)
    • corrosives
    • irritants
  • Is a substance listed in 29 CFR 1910.1200, parts (c) or (d), or any chemicals listed in the most current American Conference of Governmental Industrial Hygienists booklet “Threshold Limit Values and Biological Exposure Indices.”
Hazing

Hazing is defined by the Texas Education Code, Section 37.151(6) as any intentional, knowing, or reckless act, occurring on or off the campus of an educational institution, by one person alone or acting with others, directed against a student for the purpose of pledging, being initiated into, affiliating with, holding office in, or maintaining membership in an organization if the act:

(A) is any type of physical brutality, such as whipping, beating, striking, branding, electronic shocking, placing of a harmful substance on the body, or similar activity;

(B) involves sleep deprivation, exposure to the elements, confinement in a small space, calisthenics, or other similar activity that subjects the student to an unreasonable risk of harm or that adversely affects the mental or physical health or safety of the student;

(C) involves consumption of a food, liquid, alcoholic beverage, liquor, drug, or other substance, other than as described by Paragraph (E),  that subjects the student to an unreasonable risk of harm or that adversely affects the mental or physical health or safety of the student;

(D) is any activity that induces, causes, or requires the student to perform a duty or task that involves a violation of the Penal Code; or

(E) involves coercing, as defined by Section 1.07, Penal Code, the student to consume:

(i) a drug; or

(ii) an alcoholic beverage or liquor in an amount that would lead a reasonable person to believe that the student is     intoxicated, as defined by Section 49.01, Penal Code.

HBeAg That portion of the hepatitis B virus, whose presence in the blood of a person correlates with higher levels of circulating virus and therefore with greater infectivity of that person’s blood; the presence of HBeAg in blood can be detected by appropriate testing.
Health care facility all settings in which patient care is provided at UTMB Health, including all hospitals, ambulatory care centers, and clinics.
Health care operations

 

Any one of the following activities to the extent the activities are related to providing health care:

  1. Conducting quality assessment and improvement activities including outcomes, evaluation and development of clinical guidelines, provided that the obtaining of generalizable knowledge is not the primary purpose of any studies resulting from such activities; patient safety activities (as defined in 42 CFR 3.20); population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting of health care providers and patients with information about treatment alternatives, and related functions that do not involve treatment
  2. Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals, accreditation, certification, licensing, or credentialing activities
  3. Underwriting, enrollment, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to claims for health care
  4. Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs
  5. Business planning and development, such as conducting cost management and planning related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or covered policies
  6. Business management and general administrative activities:
  • Management activities related to HIPAA compliance
  • Customer Service
  • Resolution of internal grievances
  • Sale, transfer, merger, or consolidation of covered entities, creating de-identified health information or limited data set, and fundraising for the benefit of UTMB

 

Health care or treatment decision

Consent, refusal to consent, or withdrawal of consent to health care, treatment, service, or a procedure to maintain, diagnose, or treat an individual's physical or mental condition, including decisions made on behalf of a minor.

Health Care Worker A person who provides direct patient health care services pursuant to authorization of a license, certificate, or registration, or in the course of a training or education program.
Health Care Workers

Individuals, who may present a risk for transmission of vaccine-preventable diseases because they provide direct patient care, enter a patient’s room or meet patients face-to-face within six feet in the course of their duties.

Health Resources and Services Administration (HRSA)

An agency of the U.S. Department of Health and Human Services, HRSA is the primary federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable. Comprising five bureaus and ten offices, HRSA provides leadership and financial support to health care providers in every state and U.S. territory. The Office of Pharmacy Affairs (OPA), the office responsible for administering the 340B Program, falls under the Healthcare Systems Bureau within HRSA.

Healthcare Occupancies

Occupancies used for purposes such as medical or other treatment and care of persons of all ages suffering from physical or mental illness, disease, infirmity or convalescents

Hearing as used in this policy is an administrative process where conduct and discipline charges and evidence are presented to a Hearing Panel in order to determine a student’s responsibility related to an alleged violation of institutional policy or local, state, federal or System regulations when a student has contested the facts upon which the charges are based
Hearing officer the hearing officer is the chair of the hearing panel
Hearing Panel

A panel of three faculty members, composed of one faculty member from the accused student’s school and two faculty members from the other UTMB schools, appointed by the Investigating Official to hear disciplinary charges, make findings of fact, and, upon a finding of responsibility, impose an appropriate sanction(s).

High Risk Patient Care Areas

Inpatient hospital units with a high proportion of dependent patients, requiring full assistance with patient handling tasks and activities of daily living. A high risk patient care area is based on the dependency level of patients and the frequency with which patients are encouraged to be out of bed.

High Risk Patient Handling Tasks

Patient handling tasks that have a high risk of musculoskeletal injury for staff performing the tasks. These include but are not limited to transferring tasks, lifting tasks, repositioning tasks, bathing patients in bed, making occupied beds, dressing patients, turning patients in bed, and tasks with long durations.

High-Efficiency Particulate Arresting (HEPA) Filter

a type of air filter designed to remove 99.97% of airborne particles measuring 0.3 micrometers or greater in diameter passing through it.

HIM Satellite Operations HIM may delegate or appoint management of the SMRs to individuals approved by HIM.  Original medical records managed by HIM satellite operations will be considered part of the UMR.  HIM must be consulted before a department other than HIM plans to maintain original medical records.
Historical Edits (Payroll)

A time correction that occurs after the payroll period has closed and been locked from editing.

Home Dialysis

Dialysis performed at home, including a nursing home, by an ESRD patient or caregiver who has completed an appropriate course of training.

Honoraria

a payment provided to a UTMB employee from an academic entity, professional service organization, non-profit organization, federal or state agency, foundation, or other similar entity outside UTMB for service provided to the entity, speaking engagement or other public appearance that is beyond the employee’s normal responsibilities to UTMB. Payments from private, for-profit, health-care related Industry shall not be considered honoraria.

Hornoraria

a payment provided to a UTMB employee from an academic entity, professional service organization, non-profit organization, federal or state agency, foundation, or other similar entity outside UTMB for service provided to the entity, speaking engagement or other public appearance that is beyond the employee’s normal responsibilities to UTMB. Payments from private, for-profit, health-care related Industry shall not be considered honoraria.

Hospital and Clinical Enterprise Sites and/or Clinical Enterprise Means, the buildings used by UTMB for inpatient or outpatient care including physician and administrative offices
Hoteling Space

space that is not assigned to any one department, but used by UTMB employees when there is a business need to work remotely from their primary office location.  Hoteling space will have workspace, access to internet and electrical service. 

HR Business Center The administrative team within each entity business operation responsible for approving and processing salary transactions.
HRSA 340B OPAIS

The 340B Office of Pharmacy Affairs Information System (OPAIS) provides access to covered entity and manufacturer records, user accounts, change requests, recertification, and registrations. This system increases the integrity and effectiveness of 340B stakeholder information and focuses on three key priorities: security, user accessibility, and accuracy.

Human Resources

UTMB Human Resources (HR) department includes all areas of HR in Galveston and the Correctional Managed Care District Offices. 

Human Subject is a living individual about whom an investigator (whether professional or student) conducting research obtains (1) data through intervention or interaction with the individual, or (2) identifiable private information.
Human Subject is defined as any living individual about whom an investigator conducting research obtains: (1) data through intervention or interaction with the individual; or (2) identifiable private information. Research involving a human subject requires panel review and approval by a UTMB Institutional Review Board (IRB).
Humpty Dumpty Fall Assessment (HDFA) is a tool that can help to predict the likelihood of a pediatric patient fall.
IACUC Institutional Animal Care and Use Committee
IHOP Committee The Committee appointed by the President to review, approve and make recommendations regarding the IHOP to the President and Executive Committee. The IHOP committee membership includes the President or his or her designee, representatives from each of the institutional policy sections; representation from the Faculty Senate; representation from Student Government and other individuals as appointed by the President.
Immediate family individuals who reside in the same household with the employee and are related by kinship, adoption, or marriage, as well as foster children certified by the Texas Department of Protective and Regulatory Services, or if not living in the same household, are totally dependent upon the employee for personal care or services on a continuing basis.
Immediate Family For the purposes of this policy, immediate family is defined as the employee's spouse, the employee's and spouse's children, parents, brothers, sisters, grandparents, and grandchildren
Immediate Family Members

include:

a) a spouse;
b) a dependent child or stepchild or other dependent, for purposes of  determining federal income tax liability during the period covered by the disclosure statement; and
c) a related or non-related, unmarried adult who resides in the same household as the individual and with whom the individual is financially interdependent as evidenced, for example, by the maintenance of a joint bank account, mortgage, or investments.  
 

Immediately Dangerous to Life or Health (IDLH)

an atmosphere that poses an immediate threat to life, would cause irreversible adverse health effects, or would impair an individual's ability to escape from a dangerous atmosphere.

Impaired Physician Committee is a medical peer review committee, as defined in the Texas Medical Practice Act, Occupations Code, Section 151 et.seq., to assist physicians with physical handicaps, chemical or substance abuse problems, or mental and emotional difficulties that may affect clinical skill and judgment. The committee members will be appointed by, and report to, the Chief of the Medical Staff
Impairment by substance abuse refers to any condition, resulting from substance abuse that interferes with the individual’s ability to function at work as normally expected.
Impairment for other reasons refers to other categories of impairment including major debilitating illnesses, depression, dementia, or other psychopathology that may interfere with the individual’s ability to function at work as normally expected.
Implied Consent

Consent may be inferred from the patient's actions or behavior (e.g.,extending their arm for a blood draw).  Implied consent is rarely documented and may be relied upon for care, treatment or service that is routine and does not involve significant risk(s).  Implied consent may not be used for HIV testing except as expressly stated in IHOP Policy 9.3.10, Consent for HIV Antibody Testing and for Disclosure of Results.

IN-PATIENT HEALTHCARE

Occupancies that provide sleeping facilities and are occupied by persons who are mostly incapable of self preservation due to age, physical or mental disability, or due to security measures not under the control of the occupants. In-patient healthcare occupancies are located in John Sealy Annex, John Sealy Hospital, TDCJ Hospital, Waverly Smith Pavilion and Trauma Center.

Incapacitated

Lacking the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits, risks, complications and reasonable alternatives to any proposed treatment.

Incompetent

Lacking the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.

Independent Contractor An individual who provides services to UTMB with whom UTMB does not have an employee/employer relationship.
Indirect Authority

Authority derived from an informal or indirect relationship which allows for determinations or evaluations affecting the terms and conditions of employment or student status. Examples include, but are not limited to: a student majoring in a particular field who would still be indirectly under the control or influence of a senior professor or individual in the department or school; an employee in the same organizational unit who is under the indirect control of all more senior individuals in the department; a graduate teaching assistant and a non-supervising department faculty member.

Indirect Costs Costs that are ordinary and routine and incurred for common or joint objectives and cannot be readily and specifically identified with a specific activity. These costs are allocated to the direct activities through the use of the indirect cost rate.
Individual

An Individual is anyone who has committed and/or reported Effort on a Sponsored Project regardless of whether salary was charged to the project or not. Where appropriate in this policy the following subcategories will be utilized:

  • A Primary Individual is a person listed as principal investigator (PI), project director, co-investigator, co-project director, or those with comparable responsibilities on a Sponsored Project application. A Primary Individual typically, but not always, carries an academic (i.e. faculty) appointment.
  • Supporting Individual is an employee other than a Primary Individual who has expended Effort on a sponsored program. The Supporting Individual may or may not have been identified on the funded application and typically does not have Committed Effort greater than the amount paid on a specific Sponsored Program.

An Individual designated as Key Personnel may be either a Primary Individual or a Supporting Individual based on the unique circumstances of a specific Sponsored Project.

Individual

a student, prospective student, employee, prospective employee, contractor, volunteer, patient or other individual about whom a consumer report is requested by UTMB.

Industry any for-profit entity or representative of such entity that develops, produces, markets, sells, or distributes drugs, biomaterials, herbal/nutritional products, devices (including durable medical devices), services (including home health care services), hospice care, or equipment intended for use in the practice of clinical specialties.
Industry Vendor any sales representative or account executive and includes, but is not limited to, any sales representative, pharmaceutical representative, clinical educator, scientific liaison, or equipment or device manufacturer representative.
Industry Vendor Means any sales representative or account executive and includes, but is not limited to, any sales representative, pharmaceutical representative, or equipment or device manufacturer representative
Information any and all data, regardless of form, that is created, contained in, or processed by, UTMB Information Resources facilities, communications networks, or storage media.
Information Resources (IR) any and all computer printouts, online display devices, magnetic storage media, and all computer-related activities involving any device capable of receiving email, browsing Web sites, or otherwise capable of receiving, storing, managing, or transmitting electronic data including, but not limited to, mainframes, servers, personal computers, notebook computers, hand-held computers, personal digital assistants (PDA), smart phones, pagers, distributed processing systems, network attached and computer controlled medical and laboratory equipment (i.e. embedded technology), telecommunication resources, network environments, telephones, fax machines, printers and service bureaus. Additionally, it is the procedures, equipment, facilities, software, and data that are designed, built, operated, and maintained to create, collect, record, process, store, retrieve, display, and transmit information.
Information Resources Manager (IRM) responsible to the CAO and the State of Texas for management of UTMB’s information resources. UTMB’s IRM is the Chief Information Officer. The designation of an agency information resources manager is intended to establish clear accountability for setting policy for information resources management activities, provide for greater coordination of the state agency's information activities, and ensure greater visibility of such activities within and between state agencies. The IRM has been given the authority and the accountability by the UTMB President, the Strategic Executive Council, and the State of Texas to implement Security Policies, Procedures, Practice Standards and Guidelines to protect the Information Resources of UTMB.
Information Security Officer (ISO) responsible to the Information Resources Manager (IRM), i.e. Administration Chief Information Officer (CIO) for administering the information security functions within UTMB. The ISO is UTMB’s internal and external point of contact for all information security matters.
Information Services (IS) the name of the UTMB department responsible for computers, networking and data management.
Informed Consent

Adult patients (or when appropriate, their decision makers) must receive from their physician informtion regarding the risks and hazards of a proposed treatment and/or procedure.

Informed Consent

Adult patients (or, when appropriate, their surrogate decision-makers) must receive from their physician information regarding the risks and benefits of a proposed treatment and/or procedure.  Obtaining informed consent also allows the patient to fully participate in their care.  Except in emergencies, this information may include, but is not limited to: 

  1. the patient's diagnosis, if known;
  2. the general nature and purpose of the procedure or treatment, including its risks and benefits and whether it is experimental;
  3. the name(s) of the person(s) performing the procedure or administering the treatment;
  4. the benefits, risks, discomforts, side effects, complications, and potential problems related to recuperation associated with the procedure or treatment;
  5. the likelihood of success;
  6. the patient's prognosis and risks and benefits of not receiving or undergoing a treatment or procedure; and
  7. reasonable alternatives (regardless of their cost or the extent to which treatment options are covered by health insurance).
Injury Damage or harm to the physical structure of the body and those diseases or infections naturally resulting from the damage or harm. The term also includes occupational diseases.
Inpatient Status

Patient status, including inpatient status, is tracked in EPIC. Examples of inpatient statuses include, but are not limited to: inpatient, newborn, and pre-admit.

Inspection (ACW)

routine visual or investigative inspections in which no work is performed or where the possibility of disturbing dust or debris above the ceiling is minimal. Inspections where only one ceiling tile is removed and no work is being performed do not require an ACW permit.

Institutional ADA Officer (IADAO)

The IADAO is appointed by the Associate Vice-President of Human Resources and Employee Relations and coordinates the ADA Panel for the UTMB Enterprise.

Institutional Base Salary (IBS) The total guaranteed annual compensation an individual receives from UTMB, whether the individual’s time is spent on research, instruction and teaching, patient care, public service or other activities. The IBS shall be used to compute salaries charged to sponsored programs unless sponsor’s policies further limit salary charges. IBS excludes: fringe benefit payments; non-recurring merit payments; incentive payments; reimbursed expenses; temporary, supplemental compensation for incidental work; income earned outside of duties to the institution; and any portion of compensation deemed to be at-risk. IBS may or may not include additional payment, in special circumstances, by prior approval of Research Services.
Institutional communications venues are defined as print or electronic venues for mass dissemination of information. They include, but are not limited to, the main internal and external web pages, the employee newsletter, TV monitors and bulletin boards maintained by the Office of Public Affairs.
Institutional Conflict of Interest Committee (ICOI)

a situation in which the purchasing activities, research, teaching, outreach, or other activities of UTMB may be compromised because of an external financial or business relationship held by the institution or by an institutional leader or his or her family members that may bring financial gain to UTMB, any of its divisions, departments, or Institutional Officials.

Institutional Officials

those individuals, including those in a temporary or interim position, who have direct authority over faculty appointments, salaries, promotions, and/or allocation of institutional resources, such as assignment of graduate students or other trainees, funding or space, or faculty who are conducting human subjects research. Such individuals include, but are not limited to, members of UTMB’s Executive Committee, School Deans, Department Chairs, and Vice Chairs/Administrators. Financial interests of the President are disclosed through a process conducted by the Texas Ethics Commission.   

Institutional Responsibilities

any professional responsibility performed by a Covered Individual on behalf of UTMB, including conducting research activities, teaching, professional practice, research consultation, institutional committee membership, and service on an institutional research committee or panel including, but not limited to, an Institutional Review Board (IRB), Data and Safety Monitoring Board (DSMB), or Pharmacy and Therapeutics Committee.

Institutional Review Board (IRB) A committee group comprised of UTMB personnel and community representatives with varying backgrounds and professional experience that review and approve the research protocol involving human subjects.
Institutional Review Board (IRB) An administrative body established to protect the rights and welfare of human research subjects recruited to participate in research activities conducted under the auspices of the organization with which it is affiliated. The Institutional Review Board has the authority to approve, require modifications in, or disapprove all research activities that fall within its jurisdiction.
Instruments are surgical tools or devices designed to perform a specific function, such as cutting, dissecting, grasping, holding, retracting, or suturing.
Intellectual Property

defined as, but not limited to, any invention, discovery, creation, know-how, trade secret, technology, scientific or technological development, research data, works of authorship, and computer software regardless of whether subject to protection under patent, trademark, copyright, or other laws of the United States or other countries.

Intended Use

the function for which a room is designed and constructed. For example, if a room is designed with lab benches, sinks, fume hoods, and emergency showers it is likely a laboratory.

Internal Auditor ensures that UTMB information resources are being adequately secured, based on risk management, as directed by the CAO or the IRM acting on delegated authority for risk management decisions.
International Traffic in Arms Regulation (ITAR)- The Department of State implements the ITAR, which regulates the export of items on the Munitions Control List and technical information about them. Most of these items are military use items.
Internet a global system interconnecting computers and computer networks. The computers and networks are owned separately by a host of organizations, government agencies, companies, and colleges. The Internet is the present “information super highway.”
Interpreters and Translators
  1. Proficient Bilingual Staff and Providers: UTMB providers and staff who have passed a UTMB Spanish Language competency test, ensuring sufficient fluency in conversational Spanish and English.
  2. Medical Language Interpreters (MLI): UTMB staff who were hired specifically to provide interpretation services for Spanish-speaking LEP patients. MLI staff will be strongly encouraged to pass a UTMB-approved external assessment or who are graduates of health professions educational programs in which the secondary language was the language of instruction will also be allowed to function in this capacity.
  3. Language Specialist: Individuals who provide translations of written materials, as well as coordinate and conduct medical terminology training courses for UTMB providers and staff.
Intranet a private network for communications and sharing of information that, like the Internet, is based on TCP/IP, but is accessible only to authorized users within an organization. An organization’s intranet is usually protected from external access by a firewall.
Intraosseous catheter (IO catheter)

The basic principle of intraosseous infusion is the vascularity of the bone. An intraosseous (IO) catheter provides access to a noncollapsible marrow venous plexus, which serves as a route for the administration of medications, fluids, and blood.

Invasive procedure Surgical entry into tissues, cavities, or organs; repair of major traumatic injuries; cardiac catheterization and angiographic procedures; a vaginal or cesarean delivery or other invasive obstetric procedure during which bleeding may occur; or the manipulation, cutting, or removal of any oral or perioral tissues, including tooth structure, during which bleeding occurs or the potential for bleeding exists.
Inventory instrument count is a count of instruments that is performed on all cases. This count is performed as an individual activity by the scrub person prior to incision to verify the completeness of the instrument tray.
Irreversible Condition

A condition, injury, or illness that (a) may be treated but is never cured or eliminated; (b) leaves a person unable to care for or make decisions for the person's own self; and (c) is fatal without life-sustaining treatment provided in accordance with the prevailing standard of medical care.

Job Abandonment when an employee does not report to work and does not contact his/her supervisor for three consecutive work days. Job Abandonment also includes leaving the designated worksite without prior supervisory approval. Occurrences of job abandonment may result in disciplinary action which may include termination.
Joint Sponsorship

the collaboration between UTMB faculty, registered students, staff, alumni or a registered organization, with an association, organization, corporation or any individual or group that is not registered. 

Key Control Officer (KCO)

Representatives from each department who will be responsible for requesting keys and cores and maintaining this departmental information. A work order must be submitted to request keys and or cores. KCO’s must be approved by the Department Director or Administrator.

Key Personnel Key Personnel are defined as Individuals who contribute to the scientific development or execution of the project in a substantive, measurable way, whether or not salaries are requested. Typically, these Individuals have doctoral or other professional degrees, although Individuals at the masters or baccalaureate level should be included if their involvement meets the definition of Key Personnel. Consultants should also be included if they meet the same definition. Key Personnel must devote measurable Effort to the project whether or not salaries are requested. Key Personnel are generally listed on the Notice of Award and they may be designated as Primary or Supporting Individuals within the Effort reporting system.
Keying database Access database that keeps records of all approved keys and cores for all UTMB properties.
Kronos Workforce Central (Kronos)

The timekeeping system used by UTMB to record hours worked for all UTMB employees.

Laboratory Advisory Committee

A committee, appointed by hospital and clinic administration, with authority to regulate all laboratory testing within the UTMB Health System, and to review and respond to laboratory related issues affecting patient care. The committee:

  • As necessary will provide input for requests for new POCT or PPMP sites,
  • As necessary provides input for standard operating procedures,
  • As necessary will resolve issues of non-compliance as defined for maintenance, quality control, proficiency testing, training, competency assessment, and result reporting.
Latex Allergy

Persons will be considered as having a latex allergy and will need latex precautions in the delivery of care if he or she has any of the following:

  • A known latex allergic reaction during prior surgical or medical interventions.
  • A history of allergy symptoms during non-medical latex contact (e.g., blowing up balloons).
  • Spina bifida, including myelomeningocele and sacral or lumbosacral angenis; congenital urological anomalies, such as cloaca or bladder extrophy.
Latex Risk

Persons of the following groups will be considered as high risk for latex sensitivity and will be closely evaluated to determine the need for latex precautions in the delivery of care if (s)he:

  • Is or has been involved in the manufacturing of items containing natural rubber latex.
  • Has a history of multiple allergies, especially to foods such as bananas, chestnuts, kiwis, avocados, and other tropical fruits.
  • Has undergone early (i.e. childhood) or recurrent surgical or medical procedures.
  • Wears latex gloves on a regular basis (e.g., healthcare workers, food preparations, etc.).
  • Has a chronic illness.
  • Has a history of asthma.
  • Has a history of a spinal cord injury.
Latex-Safe Environment Those areas which minimize exposure to materials containing latex across the continuum of care.
Learning Disability (as defined by the Rehabilitation Services Administration) "A disorder in one or more of the central nervous system processes involved in perceiving, understanding, and/or using concepts through verbal (spoken) or written language or nonverbal means" (RSA PFD-85-7, 1985, p.2). Learning disabilities are commonly manifested as difficulties with reading, spelling, expressing ideas in writing, or solving mathematical problems.
Legal Guardian an individual or public agency appointed for a temporary, fixed, or indefinite term only by order of the court located in the county in which the patient resides.
Legal Guardian

an individual or public agency appointed for a temporary, fixed, or indefinite term only by order of the court located in the county in which the patient resides. Consent for a minor is given by either a:

  • parent
  • guardian
  • managing conservator
  • joint managing conservator
  • possessory conservator.

However, for invasive procedures, consent may be given by either parent or guardian. In the case of a divorce, only the parent appointed by the court as the managing conservator has the right to consent to medical care for the minor.

Legal instrument count is a count of instruments that is done on any surgical procedure in which the abdominal or thoracic body cavity has been entered. This count shall be performed by two people, one of whom shall be an RN. All instruments are counted prior to incision and when closing the cavity. There is no final legal instrument count unless necessitated
Level I Trauma Center

A regional tertiary care center capable of providing care for patients that have suffered severe physical injury caused by an external source in a range from injury prevention through rehabilitation.  This service includes 24 hour in-house surgeon coverage for patients of all age ranges.

Licensed Adoption Agency

An agency that functions as a child placing agency and has obtained a license to operate as such.

Licensed Independent Practitioner (LIP)

Any individual permitted by law and UTMB Bylaws to provide care, treatment, and services without direction or supervision. A licensed independent practitioner operates within the scope of the individual’s license, consistent with individually granted clinical privileges.  LIPs include physicians (M.D.s and D.O.s), nurse practitioners (NPs), physician assistants (PAs), and midwives.

Licensed Practitioner a person licensed to practice in one of the health professions set forth in Article 3.70-2 of the Texas Insurance Code
Life-sustaining Treatment

Treatment that, based on reasonable medical judgment, sustains the life of a patient and without which the patient will die.  The term includes both life-sustaining medications, CPR and artificial life support, such as mechanical breathing machines, kidney dialysis treatment, and artificial nutrition and hydration.  The term does not include the administration of pain management medication or the performance of a medical procedure considered to be necessary to provide comfort care, or any other medical care provided to alleviate a patient's pain.

Limited Data Set

A subset of protected health information (PHI) that excludes the direct identifiers listed below. All the direct identifiers listed below must be removed for the individual and relatives, employers, or household members of the individual.

  1. Names;
  2. Postal address information, other than town or city, state, and zip code;
  3. Telephone numbers;
  4. Fax numbers;
  5. Electronic mail addresses;
  6. Social security numbers;
  7. Medical record numbers;
  8. Health plan beneficiary numbers;
  9. Account numbers;
  10. Certificate/license numbers;
  11. Vehicle identifiers and serial numbers, including license plate numbers;
  12. Device identifiers and serial numbers;
  13. Web Universal Resource Locators (URLs);
  14. Internet Protocol (IP) address numbers;
  15. Biometric identifiers, including finger and voice prints; and
  16. Full face photographic images and any comparable images.
Limited Data Set A limited amount of Protected Health Information (PHI) that may be used and disclosed for research, public health or health care operations. This limited amount of PHI may be shared with another entity only after both parties have executed a data use agreement. See IHOP Policy 6.2.13, Use and Disclosure of PHI for Limited Data Set.
Limited English Proficiency Individuals with a limited ability to read, write, speak or understand English.
Long-term contract workers contract workers that provide an on-going UTMB service and their primary job location is UTMB.
Long-Term Training Instructions, teaching, or other education received by a state employee that is not normally received by other state employees and that is designed to enhance the ability of the employee to perform the employee's job. The term includes a course of study at a public or private institution of higher education, if the University spends money to assist the employee to meet the expense of the course of study or pays the salary of the employee to undertake the course of study as an assigned duty. For the purpose of this policy, LTT does not include training required by state or federal law or that is determined necessary by the University and offered to all employees performing similar jobs.
Loss of protective reflexes an inability to handle secretions without aspiration or to maintain a patent airway independently.
Major Life Activity

A major life activity is an activity of central importance to daily life.  Walking, sitting, standing, lifting, reaching, seeing, hearing, speaking, breathing, learning, and working are examples of major life activities along with major bodily functions inclusive of but not limited to hemic, lymphatic, musculoskeletal, special sense organs and skin, genitourinary and cardiovascular functions as identified by the ADAAA.

Major Modification

change to a building space that would affect or alter the use, physical layout or size of a particular space. For example, relocation or addition of walls, doors, openings in walls, built-in cabinets, building equipment, or building utilities (electrical, plumbing, data, telephone, security, etc)

Major permanent loss of function sensory, motor, physiologic, or intellectual impairment not present on admission requiring continued treatment for life-style change. When major permanent loss of function cannot be immediately determined applicability of the policy is not established until either the patient is discharged with continued major loss of function, or two weeks have elapsed with persistent major loss of function, whichever occurs first.
Management Plan

A written plan developed as provided in this policy that mitigates the conflict and is acknowledged and signed by both parties.

Managing Conservator

A competent adult, autorized or licensed child placing agency appointed by a court to provide the place where the minor will live and receive daily care.

Manual Lifting

Lifting, transferring, repositioning, and moving patients using a caregiver’s body strength without the use of lifting equipment/aids to reduce forces on the worker’s musculoskeletal structure.

Marketing

 

  1. To make a communication about a product or service that encourages recipients of the communication to purchase or use the product or service,  Marketing does not include communication  made:
    1. To provide refill reminders or otherwise communicate about a drug or biologic that is currently being prescribed to the individual, only if financial remuneration received by UTMB in exchange for making the communication is reasonably related to UTMB’s cost of making the communication.
    2. For the following treatment and healthcare operations purposes, except where UTMB receives financial remuneration in exchange for making the communication:
      1. To describe a health-related product or service (or payment for such product or service) that is provided by, or included in a plan of benefits of UTMB, including communications about: the entities participating in the UTMB health care provider network or health plan network; replacement of, or enhancements to, a health plan; and health-related products or services available only to a health plan enrollee that add value to, but are not part of, a plan of benefits. 
      2. For treatment of the individual;

For case management or care coordination for the individual, or to direct or recommend alternative treatments, therapies, health care providers, or settings of care including a communication by UTMB that encourages a change to a prescription drug included in UTMB’s drug formulary or preferred drug list.

  1. An arrangement between UTMB and any other entity whereby UTMB discloses PHI to the other entity, in exchange for direct or indirect remuneration, for the other entity or its affiliate to make a communication about its own product or service that encourages recipients of the communication to purchase or use that product or service.
  2. Notwithstanding 1 (B and C), a product specific written communication to a consumer that encourages a change in a prescription drug or a prescription medical device.
Master Patient Index (MPI)

This index identifies all patients who have ever been admitted to or treated by UTMB, or have been scheduled to receive treatment. It is the key to locating patient medical record information. It is not an index of legal identities but is an index of all identities used by patients.

The master index resides in Invision in an application called the PIDX (Patient Index); copies are maintained in MYUTMB and is named the Enterprise Patient Index (EPI), and in Epic.

Master's Graduation Rate The percent of students in an entering fall and spring cohort for a specific degree program who graduate within 5 years.
Maximo

the on line work order request system for repairs or facility maintenance, e.g, space painted, picture hung, new carpet, etc.

 

Maximum Medical Improvement (MMI) Maximum Medical Improvement occurs either on the earliest date after which, based on reasonable medical probability further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated; or at the expiration of 104 weeks from the date on which income benefits begin to accrue.
Mechanical Patient Lifting Equipment

Equipment used to lift, transfer, reposition, and move patients. Examples include portable base sling lifts, stand assist lifts, and mechanized lateral transfer aids

Medicaid Carve-in

340B entities may elect to use drugs purchased at 340B prices to bill for Medicaid patients. This activity is termed a “Medicaid carve-in.” If an entity chooses to use 340B drugs to bill Medicaid, it must indicate this on the Medicaid Exclusion File and list the appropriate Medicaid provider numbers or NPIs. Entities must inform HRSA whether they are carving in or out.

Medicaid Carve-out

340B entities may elect to use non-340B drugs to bill for Medicaid patients. This activity is termed a “Medicaid carve-out.” Entities may choose to do this so they can receive fair Medicaid reimbursement. Entities must inform HRSA whether they are carving in or out through the Medicaid Exclusion File.

Medical Device - any instrument, apparatus, or other article that is recognized in the official National Formulary, or the USP, or any supplement to them, or that is intended to be used to prevent, diagnose, mitigate, or treat a disease or to affect the structure or function of the body, with the exception of drugs. For example, a medical device may include, but is not limited to ventilators, monitors, dialyzers, and any other medical electronic equipment, implants, thermometers, patient restraints, syringes, catheters, in vitro diagnostic test kits and reagents, disposable components, parts, accessories, and related software.
Medical Device A medical device is a device used in the diagnosis, treatment, cure, mitigation, or prevention of a disease or physical condition. These may include electrical or mechanical equipment, biologics, tissue, blood products, drugs, food, or dietary supplements.
Medical Device Failure or Malfunction

failure of the device to meet its performance specifications or otherwise perform as intended. Performance specifications include all claims made in the labeling for the device. A malfunction should be considered reportable if:

  • the chance of a death or serious injury resulting from a recurrence of the malfunction is not remote;
  • the consequences of the malfunction affect the device in a catastrophic manner that may lead to a death or serious injury;
  • the malfunction causes the device to fail to perform its essential function and compromises the device's therapeutic, monitoring or diagnostic effectiveness which could cause or contribute to a death or serious injury, or other significant adverse device experiences. The essential function of a device refers not only to the device's labeled use, but for any use widely prescribed within the practice of medicine;
  • the malfunction involves a long-term device implant that would prevent the implant from performing its function;
  • the device is considered life-supporting or life-sustaining, and thus essential to maintaining human life; or
  • the manufacturer takes, or would be required to take an action under section 518 or 519(g) of the FD&C Act as a result of the malfunction of the device or other similar devices.
Medical Forensic Sexual Assault Exam with Evidence Collection (MFSAEEC) An exam performed by medical personnel for documenting the history of an assault; assessing and documenting findings of trauma and injuries during a head-to-toe examination; assessing and documenting genital injuries; and providing treatment and collecting evidence following a sexual assault. The exam is requested and/or ordered by Law Enforcement Departments, District Attorneys or County Attorneys of the county in which the assault occurred. The exam may also be requested by patients 18 years or older that do not wish to involve law enforcement.
Medical indigence Medically indigent patients include persons for whom medical bills would threaten the household financial viability. Qualifying as a medically indigent patient does not require qualification as financially indigent. Medically indigent persons qualify for reductions in their obligations to pay UTMB for medical services rendered. The financial viability of patients in this group must be threatened due to:  (1) catastrophic illness, (2) multiple unrelated illnesses, or (3) other factors.  The eligibility for financial assistance under the Medical Indigence program at UTMB is based on several factors including but not limited to income, dependents, Texas Residency, the patient's outstanding UTMB balance for both Hospital and Physician charges as a percentage of the applicant’s income as well as disposable income.
Medical Necessary Service A medically necessary service or treatment is one that is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, consistent with the applicable standard of care, and is not considered a cosmetic surgery or treatment.
Medical Power of Attorney (MPOA)

A document delegating authority to an agent to make health care decisions on the principal’s behalf if the principal’s attending physician certifies that the principal is incompetent (i.e., lacks decisional capacity). 

Medical Record Custodian The person or department responsible for the maintenance, retention, access, data integrity, and data quality of Protected Healthcare Information (PHI); including protecting patient privacy and providing information security, analyzing clinical data for research and public policy, preparing PHI for accreditation surveys, and complying with standards and regulations regarding PHI.
Medical record form

any UTMB approved paper form filed permanently in the UTMB medical record and identified by an official form number assigned by the Health Information Management Department (HIM). These forms have been approved by HIM, subject matter experts, the Health Information Committee, Legal Affairs, and/or Risk Management.

Medical Review Officer (MRO) a Medical Review Officer is a licensed physician who is responsible for receiving and reviewing laboratory results generated by UTMB’s drug testing program and evaluating the medical explanations for certain drug test results
Medical Review Officer (MRO) A licensed physician responsible for receiving laboratory results, who has knowledge of substance abuse disorders and has appropriate medical training to interpret and evaluate an individual’s positive test result together with that individual’s medical history and any other relevant biomedical information.
Medical screening exam The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. It is an ongoing process and must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. The exam will include information about the chief complaint, the patient's vital signs, mental status assessment, general appearance, and a focused physical exam related to the patient's complaint. Note: Triage is not the equivalent of a medical screening examination. The medical screening exam must be the same that UTMB would perform on any individual coming to the ER with those signs and symptoms regardless of the individual's ability to pay for medical care.
Medical Treatment a health care treatment, service, or procedure designed to maintain or treat a patient's physical or mental condition, as well as preventative care.
Medication Error Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, or systems (e.g., prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use).
Medication Reconciliation a process for reviewing the patient’s current medications for duplications, omissions, and interactions while also comparing the patient's current medications with those medications ordered for the patient while under the care of the organization in order to identify and resolve any discrepancies. 
Medication use process The cycle of medication management which includes ordering, dispensing, administering, and monitoring medication use, as well as all the systems that support these processes.
Medications any prescription medication, sample medication, herbal remedy, vitamin, nutraceutical, vaccine, or over-the-counter drug; diagnostic and/or contrast agent used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications, respiratory therapy treatments, parenteral nutrition, blood derivatives, and intravenous solutions (plain, with electrolytes and/or drugs); and any product designated by the Food and Drug Administration (FDA) as a drug. This definition does not include enteral nutrition solutions (which are considered food products), oxygen, and other medical gases.
Military Caregiver Leave
  • A current member of the Armed Forces (including a member of the National Guard or Reserves) who is undergoing medical treatment, recuperation, or therapy, is in outpatient status, or is on the temporary disability retired list, for a serious injury or illness; or 
  • A veteran of the Armed Forces (including the National Guard or Reserves) discharged within the five-year period before the family member first takes military caregiver leave to care for the veteran and who is undergoing medical treatment, recuperation, or therapy for a qualifying serious injury or illness.  A veteran who was dishonorably discharged does not meet the FMLA definition of a covered service member.
Minimal Risk is the probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.
Minimal sedation (anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Cognitive functions and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected.
Minimum Necessary

UTMB personnel must limit PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. 

Minimum Necessary

When using or disclosing PHI or when requesting PHI from another health care provider or health organization, UTMB personnel must limit PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure or request.  Minimum necessary does not apply in the following circumstances:

  1. Disclosures by a health care provider for treatment (students and trainees are included as health care providers for this purpose)
  2. Uses and Disclosures based upon a valid authorization to use and disclose PHI
  3. Disclosures made to the Secretary of Health and Human Services
  4. Uses and Disclosures required by law;
  5. Uses and Disclosures required by other sections of the HIPAA privacy regulations.
Minor an individual under the age of 18 who has not had the disabilities of minor removed by a court for general purposes (i.e., has not been legally emancipated by a court) or who is not: legally married; serving in the armed forces; or at least 16 years old and living away from home and managing his/her own financial affairs.
Minor

is defined as an individual under the age of 18 and who has not been legally emancipated by a court and is

  • not legally or previously married;
  • not serving in the armed forces;
  • not presently an offender in the Texas Department of Criminal Justice or other correctional facility; or,
  • not at least 16 years old and living away from home and managing their own financial affairs
Minor A 'minor', is an individual under the age of 18 and who is 1) not legally emancipated by a court; 2) not legally or previously married; 3) not serving in the armed forces; or, 4) not at least 16 years old and living away from home and managing their own financial affairs
Minor

an individual under the age of 18 who has not been legally emancipated by a court and is not:

  • Legally or previously married;
  • Serving in the armed forces;
  • Presently an offender in the Texas Department of Criminal Justice or other correctional facility; or
  • At least 16 years old and living away from home and managing his or her own financial affairs.

(Note: If a minor has been emancipated, UTMB can no longer recognize the minor’s parent, guardian or person acting in loco parentis, unless there is a legal justification other than minority granting the individual the ability to be treated as the personal representative.)

Minor Modification

change to a building space that does not affect or alter the use, physical layout or size of a particular space. For example, repainting walls or replacement of flooring or any cosmetic improvements.

Minor Relocation

those relocations that have little or no impact outside the requesting entity, place no demand on the capital budget, involve only minor modifications, and does not change the function of any space. These are typically moves within departmentally assigned space.

Minor Space Reassignment

those reassignments that have little or no impact outside the requesting entity, place no demand on the capital budget, involve only minor modifications, and does not change the function of any space.

Miscellaneous Items are small items that have the potential for being retained in the surgical wound. These include vessel loops, umbilical tapes, cautery scratch pads, bulldogs and micro clips.
Misconduct/fraud in research means fabrication, falsification, plagiarism, or other practices that materially deviate from those that are commonly accepted within the academic community for proposing, conducting, or reporting research. It does not include honest errors or honest differences in interpretations or judgments of data.
Mission Critical Activities

(1) Significant operational and/or business support activities (either provided internally or externally) without which the business or government agency would be unable to achieve its objective(s). (2)  Any supported health care delivery activity, which, if interrupted, would result in a life safety event.

Mission Statement The reason the organization exists.
Mixed-use Setting

A hospital area that serves a mixed patient type of both inpatients and outpatients. These include facilities such as surgery centers, cardiac catheter labs, infusion centers, and emergency departments.

Mobile Communications Device Cellular telephones or personal digital assistants (PDA) with email capability, or telephone/PDA combinations, and any necessary accessories (including batteries, hands-free devices, cases, carrying devices, chargers, and data cabling).
Moderate sedation (conscious sedation)

A drug-induced depression of consciousness during which a patient responds purposefully to verbal commands, either alone or accompanied by physical stimulation. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is maintained. Sedation is a continuum, and it is not always possible to predict how an individual patient will respond.  However, in general, one should consider the effect on the patient to be that of moderate sedation/analgesia under the following circumstances:

  1. The prescribing LIP’s intent is to produce a depression of consciousness that exceeds simple reduction of anxiety or simple relief of pain.  For example, the sedation/analgesia may be intended to, among other things, produce amnesia of a short duration          Or,
  2. Administration by any route of sedatives and/or narcotics in doses that are reasonably expected to produce a moderate sedating and analgesic effect for this individual patient in order to allow the patient to tolerate unpleasant procedural therapies of a short duration.
     
Monthly Employee

An exempt employee who is paid once each calendar month based on UTMB's published Payroll Calendar.

Morse Fall Scale (MFS) is a fall risk assessment tool that predicts the likelihood of an adult patients' falling so that preventive strategies and resources may be targeted to prevent falls in the patients most likely to fall.
Motorized or non-motorized recreational transportation

Hoverboards, Segways, skateboards, roller skates, scooters, bicycles, self-balancing scooters, and any other motorized or non-motorized mode of personal and recreational transportation for pedestrians.  Excludes personal automobiles, motorcycles, and EPAMDs.

National Drug Code (NDC)

Drug products are identified and reported using a unique, three-segment number, called the National Drug Code (NDC), which serves as a universal product identifier for human drugs. The FDA publishes the listed NDC numbers and the information submitted as part of the listing information in the NDC Directory, which is currently updated semimonthly. The NDC is an 11-digit number; the first segment (5 digits) of the NDC indicates the manufacturer, the second segment (4 digits) indicates the drug product, and the third segment (2 digits) indicates the package size.

National Provider Identifier (NPI)

The National Provider Identifier (NPI) is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).

Nature and Extent

shall include a description of the activity, the time commitment, and the anticipated length of time the commitment is expected to continue.

Near Miss (also called a close call) is an event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. An example of a near miss would be: surgical or other procedure almost performed on the wrong patient due to lapses in verification of patient identification but caught at the last minute by chance. Near misses are opportunities for learning and afford the chance to develop preventive strategies and actions. Near misses will receive the same level of scrutiny as adverse events that result in actual injury.
Neglect of a child failure to provide a child with food, clothing, shelter and/or medical care; and/or leaving a child in a situation where the child is at risk of harm.
Neglect of a person 65 years or older or an adult with disabilities results in starvation, dehydration, over- or under-medication, unsanitary living conditions, and lack of heat, running water, electricity, medical care, and personal hygiene.
New Doctoral Degree Program A doctoral degree program approved by the Coordinating Board for a period of less than five years.
Next of kin of a covered service member

nearest blood relative other than the covered service member’s spouse, parent, son, or daughter, in the following order of priority: Blood relatives who have been granted legal custody of the covered service member by court decree or statutory provisions, brothers and sisters, grandparents, aunts and uncles, and first cousins, unless the covered service member has specifically designated in writing another blood relative as his or her nearest blood relative for purposes of military caregiver leave under the FMLA. When no such designation is made, and there are multiple family members with the same level of relationship to the covered service member, all such family members shall be considered the covered service member’s next of kin and may take FMLA leave to provide care to the covered service member, either consecutively or simultaneously. When such designation has been made, the designated individual shall be deemed to be the covered service member’s only next of kin.

Non-behavioral Restraints use of restraints to protect the physical safety of the nonviolent or non–self-destructive patient.
NON-ESSENTIAL (“N”) employees whose presence is not essential during a declared emergency status, but who cannot leave until released by supervisor and must return to work as conditions permit. Non-benefit eligible employees should be classified as non-essential and will not be eligible for Emergency Leave.
Non-Exempt Employee

An employee who is paid hourly and entitled to overtime for any hours worked in excess of 40 hours during a work week.

NON-HEALTHCARE OCCUPANCY Buildings used for activities other than patient care. This includes, but is not limited to research, business, administration, warehouse and industrial.
Non-parent Managing Conservator has essentially the same rights and duties as parent managing conservator(s), including the right to consent to medical, psychiatric, psychological, dental, and surgical treatment.
Non-Physician Practitioner (NPP)

Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants.

Non-Probationary employee Faculty are not subject to the six month probationary period for job performance but are subject to rules related to use of vacation time by state employees during the first six months of employment.
Non-purchase Order Invoice Payment Process

supplier invoices that per procurement policy or guidelines do not require an advance Purchase Order.

Non-Substantive Revision

Editorial or technical revisions, for example revisions reflecting institutional changes, such as language, definitions, reference citations and grammar.

Noncampus Building or Property Any building or property owned or controlled by a student organization officially recognized by UTMB; or any building or property owned or controlled by UTMB that is used in direct support of, or in relation to, UTMB’s educational purposes, is frequently used by students, and is not within the same reasonably contiguous geographic area of UTMB.
Notice of Address Discrepancy

a notice sent by a consumer reporting agency that notifies UTMB of a substantial difference between the address that UTMB provided to request the consumer report and the address(es) in the consumer reporting agency’s file for the individual.

Nursing personnel includes the RNs and the Surgical Technologist
Obligation of funds the entering into an agreement — oral or written — for the performance of services or the delivery of goods.
Occupational Disease A disease arising out of the performance of, and in the course of, employment that causes damage or harm to the physical structure of the body. The term also includes other diseases or infections that naturally result from the work-related disease. The term does not include an ordinary disease of life to which the general public is exposed, unless that disease of life is the result of an incident related to a compensable injury or occupational disease. The term includes repetitive trauma injuries.
Occupational Exposure Limit / Permissible Exposure Limit (OEL/PEL)

the time-weighted average threshold limit a person working an 8 hour shift can be exposed to a chemical without suffering ill effects.

Occupational exposures to blood and body fluids
  • Percutaneous injury (e.g. needle stick, laceration with a sharp object)
  • Contact of mucous membranes or ocular membranes (mucosal exposure)
  • Contact of non-intact skin (e.g. skin that is chapped, abraded) with blood or other potentially infectious fluid (semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids; bloody body fluids and unfixed tissue).
Off-cycle checks

Check issued by Payroll Services for salary and/or wages were due to be paid on a prior scheduled payday, but were not processed due to late assignments, incomplete records, and/or some other error.  Off-cycle checks are an exception to payroll processing should never be substituted for the timely processing of the employee's pay.

Offender / Correctional Patient

For the purpose of this policy, an 'offender/correctional patient' is a patient under the custody of a law enforcement agency (e.g., city or county jail) or a correctional institution (e.g, Texas Youth Commission (TYC) or Texas Department of Criminal
Justice (TDCJ).

Office of Foreign Assets Control ("OFAC") The Office of Foreign Assets Control ("OFAC") of the U.S. Department of the Treasury administers and enforces economic and trade sanctions based on U.S. foreign policy and national security goals against targeted foreign countries, terrorists, international narcotics traffickers, and those engaged in activities related to the proliferation of weapons of mass destruction.
Office of Pharmacy Affairs (OPA)

The Office of Pharmacy Affairs (OPA) is the HRSA office responsible for administering the 340B Program.

 

Office of Sponsored Programs Finance (OSPF) OSPF is responsible for ensuring that policies and procedures are in place for Effort Reporting.
Official Functions Events sponsored by a University entity which would include both university and non-university attendees. The purpose would typically be a recognition event.
Official University Business Driving a vehicle during the course and scope of employment for the University regardless of the frequency of driving or operating duties.
Ombudsperson is a dispute resolution practitioner whose major function is to provide confidential and informal assistance to the faculty. The Ombudsperson facilitates early and open communication, encourages negotiation and assists in the resolution of conflict through available institutional channels.
On-call period – the hours that on-call employees are required to be accessible to return to work or resolve issues from a remote location. Employee must be in an entity/department and position designated as on-call eligible. Employee must be accessible by telephone, page or other electronic device during the on-call period.
Out-of-Hospital DNR (OOHDNR) Order

An order, prepared and signed by the attending physician of a person, that  documents the instructions of a person or the person's legally authorized representative and directs health care professionals acting in an out-of-hospital setting not to initiate or continue the following life-sustaining treatments: cardiopulmonary resuscitation (CPR); endotracheal intubation or other advanced airway management; artificial ventilation; defibrillation; transcutaneous cardiac pacing; and other life-sustaining treatments as specified by the Texas Board of Health.  The term does not include authorization to withhold medical interventions or therapies considered necessary to provide comfort care or to alleviate pain or to provide water or nutrition.

Out-of-hospital setting A location in which health care professionals are called for assistance, including long-term care facilities, in-patient hospice facilities, private homes, hospital outpatient or emergency departments, physician's offices, and vehicles during transport.
Outcome The result of the performance (or nonperformance) of a function(s) or process(es).
Outpatient Clinic

To purchase/use 340B drugs, a hospital outpatient clinic must:  

  •  Be an integral part of a 340B eligible hospital.
  • Appear as a reimbursable clinic above line 96 on Worksheet A of the hospital’s most recently filed Medicare cost report.
  • Have patients that meet the criteria in the 340B patient definition guideline.
  • Submit to HRSA the most recently filed cost report to verify clinic eligibility.
  • Be listed on 340B OPAIS as eligible to participate.
OUTPATIENT HEALTHCARE

Occupancies which provide services with no sleeping facilities and are occupied by persons who are mostly capable of self-preservation. Out-patient healthcare occupancies are located in McCullough Building, Clinical Sciences Building, UTMB Health Clinics Building, Primary Care Pavilion and all other clinics.

Outpatient Status

Patient status, including outpatient status, is tracked in EPIC. Examples of outpatient statuses include, but are not limited to: ancillary, burn/tub clinic series, cardiac rehab services, holdover, hospital outpatient surgery, inter campus transfers, L&D possible, observation, and transportation.

Outside Activity

any activity performed by an employee, other than fulfilling employment obligations at UTMB or a U.T. System institution, including distance teaching. An activity is not considered an outside activity if UTMB or a U.T. System institution is the only entity reimbursing or compensating the employee for engaging in the activity.

Outside Entity

any organization (including for-profit or not-for-profit and whether incorporated or otherwise) that is not owned or controlled by UTMB, or any individual that is not employed or otherwise affiliated with UTMB.

Own Use

Purchases that reasonably may be regarded as being used by the hospital in the sense that such use is a part of, and promotes, the hospital’s intended institutional operation in the care of persons who are its patients.

Owner the manager or agent responsible for the function which is supported by the resource, the individual upon whom responsibility rests for carrying out the program that uses the resources. The owner is responsible for establishing the controls that provide the security. The owner of a collection of information is the person responsible for the business results of that system or the business use of the information. Where appropriate, ownership may be shared by managers of different departments.
P.A.S.S. Concept (to use a fire extinguisher)

• Pull the pin.  This unlocks the operating level and allows you to discharge the extinguisher.
• Aim low.  Point the extinguisher nozzle or hose at the base of the fire.
• Squeeze the level below the handle.  This discharges the extinguisher agent.
• Sweep from side to side, moving carefully toward the fire.  Keep the extinguisher aimed at the base of the fire and sweep back and forth until the flames appear to be out.  Watch the fire area to see if the fire reignites.
 

 

 

 

 

Parent

includes the child's biological mother and father (including a man adjudicated to be the biological father, or an adoptive mother or father, but not a parent with whom the parent-child relationship has been legally terminated.

Patient care alarm is any alarm that is used in patient care to alert healthcare providers of patient safety issues including but not limited to: cardiac monitors, ventilators, infusion pumps, medical gas alarms, patient call systems, and bed or elopement alarms. Exclusions from this policy would be such as fire alarms, laboratory alarms, refrigerator alarms and elevator alarms.
Patient education is an individualized, systematic, structured process to assess and impart knowledge or develop a skill in order to effect a change in behavior. The goal is to increase comprehension and participation in the self-management of health care needs. The patient/family/significant others play an active part in the process. Patient education is an important component of care in both inpatient and ambulatory settings.
Patient Handling Aids

Equipment used to assist in the lift or transfer process. Examples include gait belts, stand assist aids, sliding boards, and surface friction-reducing devices.

Patient Safety Event

an event, incident, or condition that could have resulted or did result in harm to a patient and can be but is not necessarily the result of a defective system or process design, a system breakdown, equipment failure, or human error. They can also include adverse events, no-harm events, near misses, and hazardous conditions.

Patrol Jurisdiction The patrol jurisdiction of The University of Texas System Police Officers is generally the property owned, leased, rented, or otherwise under the control of the U.T. System or its institutions.
Payment

Any activities undertaken either by a health plan or by a health care provider to obtain premium or fulfill its responsibility for coverage and the provision of benefits or to obtain or provide reimbursement for the provision of health care. These activities include, but are not limited to:

  1. Determining eligibility, and adjudication or subrogation of health benefit claims
  2. Risk adjusting amounts due based on enrollee health status and demographic characteristics
  3. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and
  4. Related health care processing
  5. Review of healthcare services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges
  6. Utilization review activities, including pre-certification and preauthorization services, concurrent and retrospective review of services
  7. Disclosure to consumer reporting agencies of certain Protected Healthcare Information (PHI) relating to collection of premiums or reimbursement.
Payment

Any activities undertaken by a health plan or health care provider to obtain a premium or fulfill its responsibility for coverage and the provision of benefits, or to obtain or provide reimbursement for the provision of health care. These activities include, but are not limited to:

  1. Determining eligibility and adjudication or subrogation of health benefit claims;
  2. Risk adjusting amounts due based on enrollee health status and demographic characteristics;
  3. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and related health care processing;
  4. Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges;
  5. Utilization review activities, including pre-certification and preauthorization services and concurrent and/or retrospective review of services; and
  6. Disclosure to consumer reporting agencies of certain PHI relating to collection of premiums or reimbursement.
Payroll Department The institutional office charged with the responsibility of maintaining the payroll system for the institution. This office is charged with the maintenance of the payroll system and the oversight of all payroll related transactions
Personal Representative Any adult who has decision-making capacity and who is willing to act on behalf of a patient. A personal representative would include an individual who has authority, by law or by agreement from the individual receiving treatment, to act in the place of the individual. This includes parents, legal guardians or properly appointed agents, such as those identified in Medical Power of Attorney documents, or individuals designated by state law.
Personally Identifiable Information

includes, but is not limited to:

  1. the student's name;
  2. the name of the student's parent or other family members;
  3. the address of the student or student's family;
  4. a personal identifier, such as the student's Social Security number, student number, or biometric record (e.g., fingerprints, retina and iris patterns, voiceprints, facial characteristics, handwriting, etc.);
  5. indirect identifiers such as the student's date of birth, place of birth and mother's maiden name;
  6. other information that, alone or in combination, is linked or linkable to a specific student that woud allow a reasonable person in the community, who does not have a personal knowledge of the relevant circumstances, to identify the student with reasonable certainty; and
  7. information requested by a person who UTMB reasonably believes knows the identify of the student to whom the education record relates.
Petty Cash

Funds maintained by individual departments in cash form for the purpose of obtaining miscellaneous items or paying for minor unanticipated operating expenses.  Bank accounts are established for official UTMB product or service transactions and are not petty cash funds.

Phased Retirement

Phased Retirement is an option that may be offered to a tenured faculty member to retire and relinquish their tenure and any endowed position in exchange for a set term of reduced appointments in teaching, clinical service, and/or research. The tenured faculty member would officially retire, then maintain a part-time term appointment without tenure until the expiration of the Phased Retirement Agreement.  The Phased Retirement Agreement may not exceed two years.

Phased Retirement Agreement

A legally binding contract that sets the terms for phasing a tenured faculty appointment from 100% employment to full retirement.  The terms must specify the beginning and ending date of the agreement, the fiscal years involved, the percentage appointment to be worked during each fiscal year, and a description of the expected workload, academic duties, and compensation.

Photography For the purposes of this policy “photograph(s)” and “photography” will be used to indicate a recording of a patient’s likeness by a number of visual means, including but not limited to still photography, videotaping, digital imaging, scans and other media. Radiographic imaging is not included in this definition.
PHS Awarding Component

the organizational unit of the Public Health Service (PHS) that funds research.

Physician as used throughout this policy includes medical doctors, doctors of osteopathy, and dentists
Planned and Unplanned Services Unplanned Services: Eligible patients may receive discounts for unplanned services such as emergency services or an unplanned admission. However, discounts will not apply to co-payments nor to emergency room contract physician charges. Planned Services: Eligible patients may be accepted into a service area as a charity patient based on a number of factors. These factors may include, but are not limited to, issues such as the availability of financial, human, and other resources within UTMB, county of residence, primary diagnosis and co-morbidities, stage of disease, history of the problem, prognosis without treatment, success rates of proposed treatments and procedures with similar figures for morbidity and mortality, the educational benefit of providing care to UTMB trainees, and the priority of other charity care cases.
Point of Care Testing (POCT) POCT is laboratory testing performed at or near the patient site, usually by non-laboratory employees (e.g., physicians, nurses, respiratory therapists, and perfusionists). The central criterion of POCT is that it does not require permanent dedicated space. Examples include kits and instruments that are hand-carried or otherwise transported to the vicinity of the patient for immediate testing at that site. POCT does not include limited-service satellite laboratories with fixed dedicated testing space. Synonyms: bedside tests, alternative site test, near patient testing.
Portable Heating Device any type of portable heating equipment that is free-standing and or a self contained unit that generates and delivers heat to a local zone within the building or area
Position is defined as both full-time and part-time positions (including PBL), whether the position is filled or to be filled by a regular or temporary worker, but not including a position filled by a temporary worker provided by a temporary employment agency or contractor; the employment agency or contractor is expected to conduct and will be held responsible for conducting the criminal background check.
Positive Drug Test Test results that are above the federal government’s cut-off levels: marijuana (THC), 50 ng/ml; cocaine, 300 ng/ml; amphetamines, 1,000 ng/ml; opiates, 2000 ng/ml; and PCP, 25 ng/ml.
Possessory Conservator

one or more court-appointed person(s) with approved possession of the child during specified times and conditions.

Potential Adverse Drug Event An error in the medication use process that if it had reached the patient, could have caused injury.
Pre-existing conditions any condition at or above the ceiling level that is found to not be in compliance with UTMB standards and codes. Pre-existing conditions should be reported to FOAM maintenance via a work order request.
Premises a building or a portion of a building. It does not include a public or private driveway, street, sidewalk or walkway, parking lot, parking garage, or other parking area.
Prescribe

Provide a prescription for a medication to an individual to be filled at a UTMB-owned pharmacy, Class D clinic pharmacy, outpatient pharmacy, or contract pharmacy.

President the President of UTMB
Primary Care Physician The regular source of health care to whom a patient goes for regular check ups, when sick or for on-going health care. A primary care physician may also be the family practitioner. The primary care physician may be a facility such as a clinic or a health department or a senior center.
Primary Name the name the patient is currently using or the name required by the patient’s health insurance carrier.
Primary Residence The address at which a person resides most of the time, considers as his/her home, and does not use on a temporary or sporadic basis (such as a vacation or second home). The Proof List must be used to provide proof of the Primary Residence. If a person divides his/her time equally between two residences, one in-state, one out-of- state, and one Residence Proof and two Residence Indicators are provided that show in-state residence, that residence shall be considered primary for the purposes of this policy.
Principal

An adult who has executed a medical power of attorney (usually, the patient).

Principal Employer UTMB is considered the principal employer for all full time employees. This excludes independent contractors who are paid by a private employer or other State organizations.
Principal Investigator

the lead person, whom has the requisite expertise, to oversee a particular project. He or she assumes the full responsibility for the programmatic, administrative, ethical, legal, technical, operational and fiscal aspects for the management of the project including adherence to all requirements of the funding entity.

Printed Art

Art that is non-original and created for mass production.

Prisoner/Offender a person incarcerated in or otherwise confined to a correctional institution or other persons held in lawful custody.
Privacy Stickers refer to special white labels with a black backing available through Materials Management (MM). The privacy sticker inhibits view of the patient’s printed label from both sides of a plastic bag, and leaves a black film if removed further obliterating PHI.
Private Mode Announcements

These are fire alarm announcements using coded messages to communicate the activation of the fire alarm system and other information such as location.  This type of coded announcement is designed to alert just the appropriate staff in order to effect the proper emergency response without causing undue disruption to patients.  Private mode announcements are only used in inpatient areas.  Typically the coded announcement follows the format:  “Dr. Red to John Sealy Hospital, 3rd floor, with the building and location changing as applicable.

Privileges

The process whereby the specific scope and content of patient care services (that is, clinical privileges) are authorized for a health care practitioner by a health care organization based on evaluation of the individual’s credentials and performance. See also licensed independent practitioner<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>

Probationary Employee All newly hired regular employees of UTMB (Classified, Administrative, and Professional).
Probationary Period A period of six months (180 days) for a new UTMB employee. The period begins with the first day of appointment to a regular position
Professional Diagnosticians An individual who possesses the knowledge, skills and professional credentials to assess and diagnose a specific disability and recommend reasonable accommodations based on a specific disability.
Program Manager assigned IR ownership, responsible for the information used in carrying out program(s) under their direction and provides appropriate direction to implement defined security controls and procedures. (Materials Management, Human Resources, Research Administrative Services, Correctional Managed Healthcare, Library, etc).
Project Year The period from the start date to the end date of a specific sponsored agreement. These may or may not follow UTMB’s Fiscal Year.
Proof of immunity documentation of previous immunizations or serologic evidence of immunity.
Protected Health Information (PHI)

Individually identifiable health information transmitted or maintained in any form or medium, including oral, written, and electronic. Individually identifiable health information relates to 1) the past, present, or future physical or mental health, or condition of an individual; 2) provision of health care to an individual; or 3) past, present, or future payment for the provision of health care to an individual. Information is considered PHI where there is a reasonable basis to believe the information can be used to identify an individual. Demographic information on patients is also considered PHI.

Protocols

is defined narrowly by the TSBME and applies to RNs with advanced practice authorization (APN) by the BNE or to Physician Assistants as defined by TSBME:

Protocols - Delegated written authorization to initiate medical aspects of patient care including authorizing a physician assistant or advanced practice nurse to carry out or sign prescription drug orders pursuant to the Medical Practice Act, Texas Occupations Code Annotated, §§157.051-157.060 and §193.6 of this title (relating to the Delegation of the Carrying Out or Signing of Prescription Drug Orders to Physician Assistants and Advanced Practice Nurses). The protocols must be agreed upon and signed by the physician, the physician assistant and/or advanced practice nurse, reviewed and signed at least annually, maintained on site, and must contain a list of the types or categories of dangerous drugs available for prescription, limitations on the number of dosage units and refills permitted, and instructions to be given the patient for follow-up monitoring or contain a list of the types or categories of dangerous drugs that may not be prescribed. Protocols shall be defined to promote the exercise of professional judgment by the advanced practice nurse and physician assistant commensurate with their education and experience. The protocols used by a reasonable and prudent physician exercising sound medical judgment need not describe the exact steps that an advanced practice nurse or a physician assistant must take with respect to each specific condition, disease, or symptom.

Provider Performed Microscopy Procedures (PPMP). microscopic examination of a specimen obtained during a patient’s visit, that is personally performed by the provider or by a member of the group practice using brightfield or phase contrast microscope.
Proxy

A person designated and authorized by a directive  to make a treatment decision for another person in the event the other person becomes incompetent or otherwise mentally or physically incapable of communication.

Psychotherapy Notes Notes (i.e., process notes) that capture the therapist’s impressions about the patient containing details of the conversation considered to be inappropriate for the medical record, and are used by the provider for future sessions. Psychotherapy notes can also be recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes are kept separate from the rest of the individual’s medical record. These notes typically exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms and progress to date
Public Art

Art that is displayed in public spaces.

Public Assembly Halls

An occupancy used for a gathering of 50 or more persons for deliberations, worship, entertainment, eating, drinking, amusement, awaiting transportation, or similar uses.”

Public Domain means information that is published and generally accessible or available to the public.
Public Health Authority

An agency or authority of the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, or a person or entity acting under a grant of authority from a public agency that is responsible for public health matters as part of its official mandate.

Public property All public property, including thoroughfares, streets, sidewalks, and parking facilities, that is within the UTMB campus, or immediately adjacent to and accessible from it.
Public Spaces

Places where general public gathers, meets, dines, relaxes, circulates and wait.  Areas include, but are not limited to, entries, lobbies, corridors, waiting areas, dining areas and all exterior spaces.

Qualified Individual Individual with a disability who, with or without a reasonable accommodation, can perform the essential job functions of the employment position the individual holds or desires. A qualified individual cannot be someone currently engaging in the illegal use of drugs, but can be someone who no longer illegally uses drugs and who has been successfully rehabilitated or is currently in the process of supervised rehabilitation
Qualified Legal Alien

A person who:

  • Has been admitted to the U.S. for Lawful Permanent Residence under the Immigration and Nationality Act or
  • Has been admitted to the U.S. as an asylee/refugee; an alien whose deportation is being withheld; a Cuban/Haitian entrant; an Amerasian Lawful Permanent Resident; a victim of severe trafficking; a U.S. military active duty or veteran, spouse/dependents; and the alien battered spouse or child(ren) of a U.S. military active duty or veteran regardless of the length of residence in the United States.

An alien whose presence in the United States is based solely upon a non-immigrant visa (e.g., student visas, work permits, visitors’ permits or other temporary circumstances) is not a Qualified Legal Alien.

Note: Qualified alien status is not required for emergent or unplanned services. e.g.: Emergency Department outpatients or Emergency Department generated admissions.

Qualified Medical Personnel (QMP) An MD, RN, Advanced Practice Nurse, PA, or LVN at an off-site clinic who has been educated on the process for medical screening and trained in the appropriate handling of emergency situations within the scope of their education and experience.
Qualified Nurse a registered nurse who has completed the required restraint training and competency assessment.
Qualified Patient A patient with a terminal or irreversible condition that has been diagnosed and certified in writing by the attending physician.
Qualified Protective Order

With respect to PHI requested for judicial and administrative proceedings, an order of a court or of an administrative tribunal or a stipulation by the parties to the litigation or administrative proceeding that:

  1. Prohibits the parties from using or disclosing the PHI for any purpose other than the litigation or proceeding for which such information was requested; and
  2. Requires the return to UTMB or destruction of the PHI (including all copies made) at the end of the litigation or proceeding.
Qualified Relatives

Qualified Relatives:  Those persons from the following list, in descending order of priority, who are authorized along with the attending physician to execute or issue an OOHDNR order on behalf of a person who (i) has not executed or issued an OOHDNR order, (ii) is incompetent or otherwise mentally or physically incapable of communication, and (iii) does not have a legal guardian, proxy, or agent under a medical power of attorney:

  1. the patient's spouse;
  2. the patient's reasonably available adult children;
  3. the patient's parents; or
  4. the patient's nearest living relative
Qualifying Exigency Leave

Leave of up to 12 workweeks of unpaid, job-protected leave during any 12 month period for qualifying exigency  for foreign deployment of the employee’s spouse, son, daughter, or parent who is on covered active duty or has been notified of an impending call or ordered to covered active duty.

Quality Assurance Unit (QAU) Any person or organizational element, except the Study Director, designated by testing facility management to perform the duties relating to quality assurance of nonclinical laboratory studies. The QAU shall be responsible for monitoring each study to assure management that the facilities, equipment, personnel, methods, practices, records, and controls are in conformance with regulations in this part. For any given study, the QAU shall be entirely separate from and independent of the personnel engaged in the direction and conduct of that study. (21 CFR Part 58 Subpart A58.3(l) and Subpart B58.35) Testing Facility Management associated with the Institution include Executive Vice President, Provost, and Director, RSA.
Quid Pro Quo

is the value of the table; ticket or merchandise less the value of goods or services received by the purchaser/donor and must be established prior to any solicitation.

R.A.C.E. Concept (for fire alarm response)

• Rescue anyone in immediate danger.
• Alarm the building occupants and UTMB Police by calling the fire phone at Extension 21211 and activating the closest fire alarm pull station located by each stairwell entrance door or exit door.  Be prepared to give your name, title, extension number, location and the extent of the fire.
• Contain or Confine the fire or smoke by closing doors and windows.  Do not lock doors.
• Extinguish or Evacuate the building as defined in this plan.

Return to normal operations after an “all clear” has been given by approved personnel

Raffle

The award of one or more prizes by chance at a single occasion among a single pool or group of persons who have paid or promised a thing of value for a ticket that represents a chance to win a prize.

Range of Compensation

includes a range of outside compensation as follows:

(1) $0-$4,999;

(2) $5,000 - $9,999;

(3) $10,000 - $19,999;

(4) amounts between $20,000-$100,000 by increments of $20,000;

(5) amounts above $100,000 by increments of $50,000;

NOTE: If compensated in stock options, disclose the number of shares of common stock par value of .01 and the percentage of the fully diluted value of the company at time of compensation.

Rape

as a reviewable sentinel event, is defined as un-consented sexual contact involving a patient and another patient, staff member, or unknown perpetrator while being treated or on the premises of the health care organization, including oral, vaginal, or anal penetration or fondling of the patient’s sex organ(s) by another individual’s hand, sex organ, or object. One or more of the following must be present to determine reviewability.

  • Any staff witnessed sexual contact as described above
  • Sufficient clinical evidence obtained by the organization to support allegations of un-consented sexual contact
  • Admission by the perpetrator that sexual contact, as described above, occurred on the premises
Reasonable Accommodation

Change or modification that enables a qualified individual with a disability to enjoy equal opportunity and/or access. Reasonable accommodation is required for persons with known physical or mental limitations arising from disabilities. UTMB is not required to provide “best” or “most desired” accommodation; the University can meet this obligation as long as its proposed accommodations are sufficient to satisfy the employment, learning or accessibility needs of the employee or student. Whether a proposed accommodation is reasonable will be determined by the ADA Coordinator. Accommodations that constitute an undue hardship are not reasonable.  Leave may be considered as a reasonable accommodation in consideration of the Americans with Disability Act.

Reasonable Accommodations

Basic activities (cognitive, psychomotor, and affective) that a student must be able to complete within each professional program of the various schools.  A description of more specific essential functions for each of the programs within the schools may be obtained through the Admissions Director of each program.

 

Recall/Alert/Safety/Hazard Notice A recall, alert, or safety hazard notice is sent by a manufacturer or the FDA and communicates a known or potential defect or unsafe condition of a medical device.
Recertification

HRSA is required by statute to conduct annual recertification of participating 340B covered entities’ information listed in 340B OPAIS. As part of this process, an Authorizing Official from each 340B entity certifies basic information about the entity and its 340B compliance. Covered entities with inaccurate information in 340B OPAIS run a high risk of being removed from the program.

Record Any item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for UTMB
Record of Impairment An individual with history of a physical or mental impairment that substantially limits one or more major life activities. This includes persons who have had a disabling impairment but have recovered in whole or in part and are not now substantially limited. Also included are persons who are not, and may have never actually been, impaired but nonetheless have been misclassified as having a disability.
Redlined Draft

Policy drafted using Microsoft Word “track changes” function to show proposed revisions to existing policy.

Referring Physician The source behind a particular episode of health care. The referring physician may be the primary care physician, may be a faculty member, and may be the consulting physician to whom the primary care physician referred the patient.
Refusal to submit (to a controlled substances test) (49 CFR part 40.191(a)(b) and (c)

means employee:

  1. Fails to appear for any test (except a pre-employment test) within a reasonable time;
  2. Fails to remain at the testing site until the testing process is complete; for pre-employment it is not deemed a refusal;
  3. Fails to provide a urine specimen for any drug test; for pre-employment it is not deemed a refusal;
  4. If directly observed or monitored, fails to permit the observation;
  5. Fails to provide a sufficient amount of urine without adequate medical explanation;
  6. Fails or declines to take a second test the supervisor or collector has directed the employee to take;
  7. Fails to undergo a medical examination or evaluation;
  8. Fails to cooperate with any part of the testing process; or
  9. For an observed collection, fails to follow the observer’s instructions;
  10. Possesses or wears a prosthetic or other device that could interfere with the collection process;
  11. Admits to the collector or MRO that he/she has adulterated or substituted the specimen.
Regarded as Disabled

The individual has been subjected to an action prohibited by the ADA as amended because of an actual or perceived impairment that is not both “transitory and minor.”

Registered Student Organization

An organization whose members consist of current UTMB students, faculty and/or staff that has completed the necessary registration criteria as outlined in the Student Organizations Handbook, published by the Office of Student Life.  The organization may be profession and discipline specific, cultural, religious or social.

Registration is defined as the recognition of successful completion of mandated requirements for the practice of a particular profession. Compensation for completing registration is included in the base salary of the particular job category.
Regular Business Hours

8 am - 5 pm Monday - Friday excluding UTMB recognized holidays.

Regular Employees Classified, Administrative and Professional employees who are appointed at least half time (20 hours per week) for a period of four and one-half months or more.
Regulatory Science The science of developing new tools, standards, and approaches to assess the safety, efficacy, quality, and performance of all FDA-regulated products. (www.fda.gov)
Reimbursement for Travel Expense

UTMB business-related expenses, whether travel related or not, that have been paid for by employees, the receipts for which are presented for reimbursement

Repetitive Trauma Injury Damage or harm to the physical structure of the body occurring as a result of repetitious, physically traumatic activities that occur over time and arise out of and in the course and scope of employment.
Replenishment (340B Outpatient Drug)

340B outpatient drug replenishment occurs when a non-340B drug is initially dispensed to a 340B eligible patient, and an entity later replaces the non-340B dispensed drug with 340B purchased inventory. The replaced inventory, although it was purchased at 340B prices, is no longer considered 340B inventory, as the title passes to the pharmacy after purchase.

Reporting Period The period covered by the Financial Status Report submitted to an external sponsor. Typically, the Reporting Period is a twelve-month period but could cover a period of less than twelve months or multiple years as defined by the sponsor. Federal financial reports are generally due within 90 days from the expiration date of the Sponsored Project. Other financial reports may be due as soon as 30 days from the expiration date.
Representative Sample a sample that satisfies each type of information or document requested. A representative sample is only used when the responsive documents are voluminous to produce and the requested documents are substantially similar in context or type.
Research as defined in the Federal Regulations as a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Activities that meet this definition constitute research for purposes of this policy, whether or not they are conducted or supported under a program, which is considered research for other purposes.
Research

a systematic investigation designed to develop or contribute to generalizable knowledge, including biomedical, behavioral and social-sciences research or other scholarly activity.

Research Any systematic investigation, study or experiment designed to develop or contribute to generalizable knowledge. The term includes both basic and applied Research and product development.
Research A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalized knowledge. Activities which meet this definition constitute research for purposes of this policy whether or not they are conducted or supported under a program that is considered research for other purposes. For example, some demonstration and service programs may include research activities.
Research Animals Any animal located, housed, and/or maintained within any facility located on UTMB property subject to research or other procedure associated with an animal research protocol.
Research Conflict of Interest (RCOI)

a significant outside interest of a UTMB employee or one of the employee’s immediate family members that could directly or significantly affect the employee’s performance of his or her institutional responsibilities. The proper discharge of an employee’s institutional responsibilities could be directly or significantly affected if the employment, service, activity, or interest: (1) might tend to influence the employee’s conduct, decisions, or judgment in the design, conduct, or reporting of research results or in exercising an institutional responsibility related to research; (2) could reasonably be expected to impair the employee’s judgment in performing his or her non-research related institutional responsibilities; or (3) might require or induce the employee to disclose confidential or proprietary information acquired through the performance of institutional responsibilities.

Research Operations Research Operations is the UTMB institutional office charged with the administrative oversight of sponsored research. Research Operations is responsible for ensuring that policies and procedures are in place to assure the proper stewardship of externally funded projects, including Cost Transfer policies
Research Protocol A formal description and design for a specific research project. A protocol involving human subject research must be reviewed and approved by an Institutional Review Board (IRB) if the research is not exempt, and by an IRB or other designated institutional process for exempt research.
Research Services Research Services is UTMB’s institutional office charged with the administrative oversight of sponsored research.
Research Services Research Services is the UTMB institutional office charged with the administrative oversight of sponsored research. Research Services is responsible for ensuring that policies and procedures are in place to assure the proper stewardship of externally funded projects, including Cost Sharing policies
Researcher(s)

includes any faculty member and all others, including trainees at all levels, who are engaged in any area of basic, translational, clinical, epidemiologic, health services, or community-based research.

Respirator

a device (as a gas mask) worn over the mouth and nose to protect the respiratory system by filtering out dangerous substances (as dust or fumes) from inhaled air.

  • Air-Purifying Respirator: A respirator which cleans contaminants from the air via cartridges and/or filters before the air is inspired by the wearer. These are the most commonly used respirators and are available in half-mask, full-face or powered units.
  • Powered Air-Purifying Respirator (PAPR): An air purifying respirator that uses a blower to force the ambient air through air-purifying elements to the inlet covering.
Responsible Entity

Office, department, body, or individual designated by the Responsible Vice President to develop and implement a policy, communicate with and train the university community on its requirements, and execute its timely updating and revisions. Examples of possible responsible entities include, the Council of Deans, Human Resources, and Nursing Services.

Responsible Vice President

Refers to the Executive Vice President of UTMB’s Academic, Health System, and Business & Finance divisions. In those areas that report directly to the President, the term refers to the Senior Vice President, Vice President, or Associate Vice President, whichever is highest ranking for the unit. Depending upon the scope of its subject matter, a policy may have more than one Responsible Vice President.

Restraints

A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort).

The following are excluded from this definition:

  1. Devices used for security, detention or public safety reasons on patients in forensic custody and those devices are not involved in the provision of health care. ( Refer to Policy 9.9.1.)
  2. A voluntary mechanical support used to achieve proper body position, balance, or alignment so as to allow greater freedom of mobility than would be possible without mechanical support.
  3. A positioning or securing device used to maintain the position, limit mobility or temporarily immobilize during medical, dental, diagnostic, or surgical procedures.
  4. The brief physical holding of a patient without undue force, used as part of a behavioral plan for the purpose of providing emotional comfort and/or calming to the patient or physical safety to the client, other clients, staff member(s) or others.
  5. Use of cribs in age or developmentally appropriate individuals, infant snuggling or bundling for developmental purposes and use of side rails in response to medical interventions or physical condition to provide patient safety while not intending to restrict patient from getting out of bed.
Restriction Agreed upon limitation of UTMB’s ability to use and disclose PHI. For instance, UTMB and the patient may agree that the patient’s information is not to be used for certain Treatment, Payment or health care Operation (TOP) functions, (e.g., The patient may request UTMB not include their information in the Patient Directory.)
Retire

Withdrawal from employment with The University of Texas System or a component institution with a retirement benefit.

Retiree

A retiree is any tenured faculty member who voluntarily terminates employment with the University and who meets the service requirements for retirement under the Teacher Retirement System or the Optional Retirement Program.

Reverse Reconciliation a modification of the medication reconciliation process in which information is only obtained for specific medications/classes of medication deemed relevant to the current service being provided. 
Risk Assessment (Analysis)

A systematic and analytical approach that identifies and assesses risk to business processes and provides recommendations to avoid or reduce the risk.

Root Cause Analysis (RCA)

a process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or near misses. RCA will be the form of focused review that is used for all adverse events or near misses requiring analysis since it further refines the implementation and increases the quality and consistency of our focused appears.

Safe Medical Device Act of 1990 this act was passed by the United States Congress to better protect the public health by increasing reports of device related adverse events by both manufacturers and user facilities.
SAFE room A room designated for and supplied with special equipment to perform the MFSAEEC.
SAFE TEAM The UTMB response team to a sexual assault patient. This team includes the SANE, a social worker, and the charge nurse.
Safety-sensitive function means all time from the time an employee begins to work or is required to be in readiness to work until the time he/she is relieved from work and all responsibility for performing work.
Same Day Admit is surgery that is scheduled for patients who come in on the morning of surgery and have a planned hospitalization.
Same Day Surgery is surgery that is scheduled for patients who come in on the morning of surgery and are discharged postoperatively.
SAMHSA (Substance Abuse and Mental Health Services Administration) – the federal agency responsible for formulating federal drug testing procedures.
School ADA Liaison (SAL) The SAL is the administrative official responsible for student affairs or his/her designee in each school will also be the School ADA Liaison.
Scribe

An individual who is present during the provider’s performance of a clinical service and documents on behalf of the provider everything dictated or performed during the course of the encounter.

Search Warrant

A court order directing the search of and seizure of, specific evidence or instruments of a crime set forth in the warrant.  A judge must sign the warrant after law enforcement officers have established probable cause to believe evidence of a crime exists at a specific location.

Secondary Employer for employees whose principal employer is UTMB, the secondary employer is the other state agency to which they are applying for dual employment
Security sensitive areas

Security sensitive areas are all of the physical locations at the utmbHealth (UTMB) designated by the President or his designee.  Also included are any UTMB controlled facilities throughout the State of Texas.  These locations include, but are not limited to, areas providing direct patient care, laboratories, child care, pharmacy services and offices of senior level administrative positions.  Due to the high-risk nature of some work on campus, security sensitive areas have been divided into two security levels and all employees working in these areas are required to have the level of criminal history background check designated for the area in which they work.  These levels are as follows:

Level I - Criminal history record information on applicants who are under final consideration, following normal screening and selection processes. This criminal history includes, but is not limited to, sex offender registry, terrorist watchlists and State and Federal Office of Inspector General (OIG) sanctions checks.

Level II – Department of Justice (DOJ) background check on applicants who are under final consideration, following normal screening and selection processes, for a position that will have access to select agents or unescorted access to certain radioactive material. This criminal history includes, but is not limited to, sex offender registry, terrorist watchlists and State and Federal OIG) sanctions checks.

Security sensitive positions for UTMB will be designated by the President or his designee and will comply with University of Texas System Business Procedures Memorandum 29-11-02. Maintenance of the institutional list of security-sensitive positions will be the responsibility of Human Resources.
Segment As used in this document pertains to a category of students, vendors, patients, employees, etc.
Select Agent has the meaning assigned in 18 U.S.C. 175b, as that section may be amended from time to time. UTMB will conduct security clearance for individuals having access to select agents only until the Department of Justice implements its process for checking backgrounds on these individuals
Self Pay Self-pay patients (persons who are personally responsible for their bills because they do not have third party coverage, but do not qualify for discounts up to 40% for inpatient services and 50% for outpatient services received.
Sensitive Digital Data includes social security numbers, protected health information (PHI), sensitive research data, digital data associated with an individual and /or digital data protected by law.
Sensitive Information the classification of data requiring special precautions to protect it from unauthorized modification or deletion. It may be either public or confidential but requires a higher than normal assurance of accuracy and completeness. The controlling factor for sensitive data is assuring and maintaining integrity.
Sensitive Personal Information Individual's first name or first initial and last name in combination with any one or more of the following items: a) social security number; driver's license number or government-issued identification number; or account number, credit or debit card number; or b) information that identifies an individual and relates to: the physical or mental health or condition of the individual; the provision of health care to the individual; or payment for the provision of health care to the individual.
Sentinel Event an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Serious Health Condition

An illness, injury, impairment, or physical or mental condition that involves:  inpatient care in a hospital, hospice, or residential medical care facility; or continuing treatment by a health care provider.

Serious Injury or Illness for a Covered Veteran

An injury or illness that was incurred or aggravated by the member in the line of duty on active duty in the Armed Forces and manifested itself before or after the member became a veteran, and is:

  1. A continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a member of the Armed Forces and rendered the service  member unable to perform the duties of the service member’s office, grade, rank, or rating; or
  2. A physical or mental condition for which the covered veteran has received a VA Service Related Disability Rating (“VASRD”)  of 50 percent or greater and such VASRD rating is based, in whole or in part, on the condition precipitating the need for caregiver leave; or
  3. A physical or mental condition that substantially impairs the veteran’s ability to secure or follow a substantially gainful occupation by reason of a disability or disabilities related to military service or would do so absent treatment; or
  4. An injury, including a psychological injury, on the basis of which the covered veteran has been enrolled in the Department of Veterans Affairs Program of Comprehensive Assistance for Family Caregivers.
Service centers

UTMB activities that provide goods or services to the UTMB community.  Service centers charge the user a rate based on actual cost incurred in providing the good or service.  It is the expectation that service center rates will be sufficient to cover the cost of operations.  For purposes of this policy the following definitions are provided to identify different types of service center activities and the expectations for the operation of those activities.

 

Note:  Activities with sales primarily to individuals are not considered service centers but instead are considered Auxiliary Enterprises.

 

Sexual assault

Sexual assault occurs when one person threatens, or uses violence or coercion to cause another person to participate in any type of forced sexual activity.  Sexual assault is a crime. A student charged with sexual assault can be prosecuted under state criminal statutes and/or disciplined under UTMB’s Code of Student Conduct. 

Sexual Assault Evidence Collection Kit (SA Kit) A pre-packaged kit that contains materials, supplies and records used to collect and document forensic evidence post sexual assault.
Sexual assault nurse examiner (SANE) A specially trained Registered Nurse who has received classroom and clinical training to perform sexual assault exams and collect forensic evidence.
Sexual Harassment

Sexual harassment includes, but is not limited to:

  1. Any criminal offense under the Texas Penal Code of a sexual nature, including rape, sexual assault, sexual battery, sexual coercion, or other acts of sexual violence; and
  2. Unwelcome sexual advances, requests for sexual favors, or verbal or physical conduct of a sexual nature when:
  1. submission to such conduct is made either explicitly or implicitly a term or condition of employment or student status or participation in University activities; or
  2. such conduct is sufficiently severe or pervasive that it substantially interferes with an individual's education, employment, or participation in University activities, or creates an objectively hostile environment; or
  3. such conduct is intentionally directed towards a specific individual and has the effect of unreasonably interfering with that individual's education, employment, or participation in University activities, or creating an intimidating, hostile, or offensive environment.

Examples of inappropriate behavior that may constitute sexual misconduct and/or sexual harassment include, but are not limited to: 

  1. Intentional touching;
  2. Explicit or implicit propositions to engage in sexual activity;
  3. Gratuitous comments of a sexual nature such as explicit statements, questions, jokes or anecdotes;
  4. Remarks of a sexual nature about a person's clothing or body;
  5. Remarks about sexual activities or speculation about sexual experiences;
  6. Exposure to gratuitous sexually suggestive visual displays such as photographs, graffiti, posters, calendars or other materials;
  7. Deliberate physical interference with or restriction of an individual's movements;
  8. Persistent, unwanted sexual/romantic attention;
  9. Subtle or overt pressure for sexual favors; and/or
  10. Deliberate, repeated humiliation or intimidation based upon the sex of the individual.
Sexual Misconduct

Sexual misconduct includes, but is not limited to, unwelcome sexual advances, requests for sexual favors, or verbal or physical conduct of a sexual nature directed towards another individual that does not rise to the level of sexual harassment but is unprofessional and inappropriate for the workplace or classroom.

Shadowing Means, following physicians or other clinical personnel.
Sharps are items with edges or points capable of cutting, or puncturing through other items. This includes suture needles, scalpel blades, hypodermic needles, and electrosurgical needles, and blades.
Shelled Space

space that is vacant and maintained to minimum life safety and environmental conditions.

Short-term service providers individuals who provide services to UTMB on a short-term basis and their primary job location is not at UTMB.
Signage and Wayfinding

is an information delivery system that assists in directing us to our destination.

Significant Events

matters including, but not limited to, reports of death or serious injury occurring on campus or involving a member of the university community; allegations of fraud or fiscal loss of $100,000 or more; allegations involving impropriety or failure to follow law or policy by the Chancellor, a System Executive Vice Chancellor or Vice Chancellor, the General Counsel to the Board, or the System Chief Audit Executive; or an institutional president or vice president; allegations of sexual misconduct; allegations related to the care or safety of minors; material concerns expressed by federal and state oversight agencies; security breaches involving confidential records; potential media reports that may impact the reputation of the university; or matters that reflect a systemic threat to patient safety.

Significant Financial Interest

A covered individual’s disclosure statement must include the following information about the covered individual and covered family members, but only in regard to interests that reasonably appear to be related to the individual’s institutional responsibilities:

  1. From a Publicly-Traded Entity: the total amount and source of payments received in the preceding twelve (12) months from a publicly-traded entity and the value of any equity interest held in the entity on the date of disclosure, including: (a) salary or other payments for services such as consulting fees, honoraria, or paid authorship; and (b) equity interests held, including stock, stock options, or other ownership interest or entitlement to such an interest, valued by reference to public prices or other reasonable measures of fair market value.
  2. From a Non-Publicly Traded Entity: the total amount and source of payments received in the preceding twelve (12) months from a non-publicly traded entity and a description of any equity interest held in the entity on the date of disclosure, including: (a) salary or other payments for services such as consulting fees, honoraria, or paid authorship; and (b) equity interests held in any amount, including stock, stock options, or other ownership interest or entitlement to such an interest.
  3.  Travel:  any reimbursed or sponsored travel provided in the preceding twelve (12) months. The disclosure of travel must include the purpose of the trip, the identity of the sponsor/organizer, the destination, the duration, the value, and whether a Covered Family Member accompanied the Covered Individual on the trip. The Conflict of Interest Official may request further information about a Covered Individual’s travel, including the monetary value of the travel, in order to determine whether the travel constitutes a RCOI.

(NOTE – There is a $5,000 threshold in 1-3 above that is only relevant for determination of whether the interest is a Significant Financial Interest.  For purposes of disclosure, there is a $0 threshold.  Therefore, covered individuals shall disclose any payments that reasonably appear to be related to the individual’s institutional responsibilities, regardless of dollar amount.)

 

  1. Intellectual Property and Royalties:  a description of intellectual property rights held and any agreements to share in royalties related to those rights; and the amount and source of royalty income that the Covered Individual or Covered Family Member received or had the right to receive in the preceding twelve (12) months.
  2. Gifts: the value and source of a single gift that the Covered Individual received in the preceding twelve (12) months that exceeds $250 in value, or multiple gifts from a single entity that in the aggregate exceed $250 in value, other than gifts from a Covered Family Member, or close personal friend with whom the Covered Individual has an independent relationship unrelated to his/her status or work at UTMB.
  3. Fiduciary Positions: service as an officer, director, or fiduciary for a for-profit or nonprofit entity in the preceding twelve (12) months for which the Covered Individual received any sort of compensation, salary, or payment for expenses, and the name and principal address of the entity.

NOTE – Some of the interests described above require Covered Individuals to seek and acquire prior approval before engaging in the activity.  Others allow covered individuals to update their disclosure statements within 30 days of acquiring the interest.  Please consult IHOP 6.5.3 - Individual Conflicts of Interest, Conflicts of Commitment, a

Significant Institutional Conflict of Interest

an institutional conflict of interest is deemed to be “significant” when the financial interest or outside activities of UTMB, or of its Institutional Officials, may compromise, or appear to bias, purchasing activities, investments, research, teaching, outreach and other institutional duties or activities.

Significant matters

Those matters, which in the exercise of individual best judgment, reflect a significant achievement, present a substantial concern or interest, and/or have the potential to impact the reputation of the institution in a substantial matter.

Skill Assessment A written and/or system assessment designed to validate that the student has a basic understating of the curriculum for which they have received training.
Small Order Purchase System:

Routine small dollar purchase orders that require the department to contact the vendor for a price quote and are created utilizing the PeopleSoft system.

Social Media any online networking service on which people publish, converse and share content from works of user-created video, audio, text or multimedia with the general public or with discreet groups of friends, colleagues or followers. Examples include but are not limited to: online posts/comments; media messaging service (MMS); Twitter®, Facebook ®, Linked-In®, YouTube ® and all other social networks; and personal and organizational websites, blogs, wikis, and similar outlets.
Source Data

Data from which interpretations, summaries, or notes are derived, regardless of media. This data includes health information stored in any original media. Examples of Source Data include, but are not limited to, paper diagnostic tests or tools, x-rays, videotapes, ultrasounds, fetal monitor strips, photographs (either conventional photos or digital images), and ancillary or supporting systems (e.g. . pharmacy information systems and radiation oncology information systems). These forms of Source Data have unique retention schedules. The UMR must contain a written interpretation of all Source Data. Source Data is distinct from the written interpretations of significant clinical information that is included in the UMR and is not part of the official UTMB Legal Medical Record.

Space Assignment the process whereby custody of a space is formally transferred to a UTMB entity.
Space Reassignment the process whereby custody of a space is formally transferred from one UTMB entity to another.
Space Reassignment Minor those reassignments that have little or no impact outside the requesting entity, place no demand on the capital budget, involves only minor modifications, and does not change the function of any space.
Space Reassignment Standard those reassignments that do not meet criteria for a minor space reassignment.
Space Usage Agreement a general term used in this policy to describe sections of a contract, tenancy agreement, Memorandum of Understanding, or similar document that stipulates the conditions whereby an entity is assigned use of space. Agreements should cover all privileges and costs associated with the space assignment, including identification of dedication and common spaces involved, and any other terms of agreement.
Specialized Areas An area that operates under unique conditions due to the contents of or processes performed there. These areas shall be so designated by EHS-OS&FP.
Split-billing Software

Split-billing software is used in settings in which a 340B entity uses multiple wholesaler contracts for drug purchasing. This software helps the entity track and separate (“split”) the 340B-eligible dispensations from.

Sponsored Project An externally funded activity that is governed by specific terms and conditions. Sponsored Projects must be separately budgeted and accounted for subject to terms of the sponsoring organization. Separately budgeted means that a project budget has been prepared to identify the costs necessary to meet the objectives of the project. Sponsored Projects may include grants, contracts, and cooperative agreements for research, instruction and training, and other public service activities. Sponsored programs involve a specific commitment of time of the principle investigator and other key personnel and can be either: 1) externally funded activities for which a formal written agreement, such as a cooperative agreement, contract, or grant is entered into by UTMB and by a sponsor; or 2) internally funded activities which are separately budgeted and accounted for by UTMB as a result of a formal application and approval process within UTMB. For externally funded programs, the commitment of time can either be paid or unpaid by the sponsor (see mandatory and voluntary committed Cost Sharing definitions). A sponsored program may be thought of as a transaction in which there is a specified statement of work with a related, reciprocal transfer of something of value.
Sponsoring Department UTMB department that is working with an external non-UTMB entity who is requesting access to Protected Health Information. Examples of sponsoring departments are research coordinators working with Pharmaceutical companies on an IRB approved study, Institutional Compliance working with the Office of Inspector General, and Quality Management working with Joint Commission.
Spring Enrollment Commonly used benchmark measure of enrollment headcount, taken on the census date of the spring semester
Stabilize The provision of such medical treatment of the condition as may be necessary to assure, within reasonalbe medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual froma facility, or, with respect toa pregnant woman in labor, that the woman has delivered (including the palacenta)
Stakeholder

Individual, function, or organization identified by the policy owner, whose role or professional expertise relates to the subject of the policy, and who, therefore, is consulted for comment on the draft.

Stakeholder Review Process A process for obtaining advisory input from faculty, staff and student governance bodies that may be affected by changes in IHOP policies and procedures.
Standard Relocation

the process by which a person, unit, or activity is moved from one location to another.  It includes associated activities such as space reassignment, modification of space to suit the new use, changeover of computer and telephone connections, and physical movement of room contents.

Standing delegation order Written instructions, orders, rules, regulations, or procedures prepared by a physician and designed for a patient population with specific diseases, disorders, health problems, or sets of symptoms. Such written instructions, orders, rules, regulations or procedures shall delineate under what set of conditions and circumstances action should be instituted. These instructions, orders, rules, regulations, or procedures are to provide authority for and a plan for use with patients presenting themselves prior to being examined or evaluated by a physician to ensure that such acts are carried out correctly and are distinct from specific orders written for a particular patient, and shall be limited in scope of authority to be delegated. Standing delegation orders do not refer to treatment programs ordered by a physician following examination or evaluation by a physician, nor to established procedures for providing of care by personnel under direct, personal supervision of a physician who is directly supervising or overseeing the delivery of medical or health care. Such standing delegation orders should be developed and approved by the physician who is responsible for the delivery of medical care covered by the orders. Twelve (12) stipulations are delineated in the BNE Position Statement 15.5, Nurses with Responsibility for Initiating Physician Standing Orders and the standing delegated orders.
Standing Delegation Order

Written instructions, orders, rules, regulations, or procedures prepared by a physician and designed for a patient population with specific diseases, disorders, health problems, or sets of symptoms.  Such written instructions, orders, rules, regulations or procedures shall delineate under what set of conditions and circumstances action should be instituted.  These instructions, orders, rules, regulations, or procedures are to provide authority for and plan for use with patients presenting themselves prior to being examined or evaluated by a physician to ensure that such acts are carried out correctly and are distinct from specific orders written for a particular patient, and shall  be limited in scope of authority delegated.  Standing delegation orders do not refer to treatment programs ordered by a physician following examination or evaluation by a physician, nor to established procedures for the provision of care by personnel under direct, personal supervision of a physician who is directly supervising or overseeing the delivery of medical or health care.  Standing delegation orders should be developed and approved by the physician who is responsible for the delivery of medical care covered by others. 

Standing medical orders Orders, rules, regulations or procedures prepared by a physician or approved by a physician or the medical staff of an institution for patients which have been examined or evaluated by a physician and which are used as a guide in preparation for and carrying out medical or surgical procedures or both. These orders, rules, regulations or procedures are authority and direction for the performance for certain prescribed acts for patients by authorized persons as distinguished from specific orders written for a particular patient.
Student means an individual who is or has been in attendance at UTMB. It does not include persons who have been admitted but did not attend UTMB.
Student a person currently enrolled at UTMB, or who is accepted for admission or readmission to UTMB, or who has been enrolled at the University in a prior semester or summer session and is eligible to continue enrollment in the semester or summer session that immediately follows (or who is attending an educational program sponsored by UTMB while that person is on campus), or a person who engaged in prohibited conduct at a time when he or she met the criteria of student
Student

As used in IHOP - 07.01.03 - Student Conduct and Discipline, includes: (1) a person currently enrolled at UTMB; (2) a person accepted for admission or readmission to UTMB; (3) a person who has been enrolled at UTMB in a prior semester or summer session and is eligible to continue enrollment in the semester or summer session that immediately follows; and (4) a person who engaged in prohibited conduct at a time when he or she met the criteria of 1, 2, or 3 above (e.g., because the facts were not known while the student was enrolled, or an investigation or hearing process was initiated but not completed while the student was enrolled).  Once a proceeding or investigation has been initiated, a student’s rights and obligations are not affected in any way if he or she ceases to be enrolled as a student. If a student withdraws while an investigation is in progress, the withdrawal may be reflected on the transcript.

Student Affairs Officer

The faculty member designated by the Deans to investigate and administer academic conduct and discipline cases under this policy for their respective school.  The following titles have been assigned to this position amoung the four schools:

  • School of Health Professions (SHP) - Associate Dean for Academic and Student Affairs
  • School of Medicine (SOM) – Associate Dean for Admissions and Student Affairs
  • School of Nursing (SON) – Associate Dean for Student Affairs and Admissions
  • Graduate School of Biomedical Sciences (GSBS) – Senior Associate Dean for Student Affairs
Student Conduct and Discipline Officer

The administrative officer designated by the Chief Student Affairs Officer to investigate and administer non-academic conduct and discipline cases under this policy.

Student Full Time Equivalent (Student FTE) A measure that seeks to standardize enrollment by controlling for enrollment status (full or part time) and enrollment level (undergraduate, graduate or professional).  Student FTE is measured by dividing the total semester credit hours produced by students in a graduate or undergraduate program during a given time period (semester, academic year) and dividing by the number of semester credit hours considered full time. UTMB uses 12 hours per semester for undergraduates and 9 hours for graduate students. Since medical students do not use semester credit hours, one student equals one FTE.
Student Time-to- Degree The average of the number of semesters taken by program graduates from the time of enrollment in the program until graduation.
Study Director (associated with GLP study): The individual responsible for the overall conduct of a nonclinical laboratory study. The study director has overall responsibility for the technical conduct of the study, as well as for the interpretation, analysis, documentation and reporting of results, and represents the single point of study control. (21 CFR Part 58 Subpart A58.3(m) and Subpart B58.33) The ORNcS Study Director provides support for both regulated and non-regulated scientific studies regarding regulatory oversight, summaries and protocols. The ORNcS Study Director will work with the PI, Director RSA and technical staff associated with given study.
Study Protocol For GLP studies, each study shall have an approved written protocol that clearly indicates the objectives and all methods for the conduct of the study. (21 CFR Part 58 Subpart G 58.120) A Regulated Study Protocol is written by the Study Director under the guidelines provided by the PI and Director, RSA and approved by same.
Study Related Injuries are injuries or complications arising from the performance of the study in accordance with the protocol or use of the investigational drug or device. Study related injuries do not include the normal progression of the subject’s disease, injuries or complications that would have incurred had they not participated in the clinical trial, or injuries resulting from, or caused by, negligence or willful misconduct of university study personnel.
Study Subject Insurance is a non-governmental employer or commercial sponsored health plan, policy or program to pay for health care costs.
Subpoena A written legal writ requiring an appearance in court to give testimony or to supply documents pertaining to a specific legal investigation.
Subpoena

An order issued by a court of law, the Office of Inspector General, or the Department of Justice which requests documentary information and/or testimonial information for use in a criminal, civil or administrative investigation. 

Subsidiary Medical Record (SMR) A medical record maintained by a department other than HIM, which contains original/official information in paper or electronic form concerning outpatient health care administered by UTMB health care providers to UTMB patients.  SMRs are subsets of the UMR.
Substance Abuse Professional (SAP) A SAP is a licensed health care professional (as outlined in 49 CFR) who evaluates employees who have violated a DOT drug and alcohol program regulation and makes recommendations concerning education, treatment, follow-up testing, and aftercare
Substantial Interest in a Business Entity

for purposes of this policy, means:

(1) a controlling interest;

(2) ownership of more than 10 percent of the voting interest;

(3) ownership of more than $5,000 of the fair market value;

(4) a direct or indirect participating interest by shares, stock, or otherwise, regardless of whether voting rights are included, in more than 10 percent of the profits, proceeds, or capital gains; or

(5) service as an officer.

NOTE: Does not include income from investment vehicles, such as mutual funds or retirement accounts, as long as the employee does not directly control the investment decisions made in those vehicles.

Substantially Complete

relative to construction projects, means that point when a building or a portion of a building is sufficiently finished so that the owner can use the space for its intended use. UTMB requires that all life safety systems be operational and that all spaces can be secured prior to accepting substantial completion. This is the point in the project where UTMB takes control and responsibility for the space back from the contractor.

Substantially Limits

The ADAA provides that a disability should be construed “broadly” in favor of expansive coverage.  An impairment is a disability if it substantially limits the ability of an individual to perform a major life activity as compared to most people in the general population.

Substantive Change

a significant modification or expansion of the nature and scope of an accredited institution.  Under federal regulations, substantive change includes:

  1. Any change in the established mission or objectives of the institution
  2. Any change in legal status, form of control, or ownership of the institution
  3. The addition of courses or programs that represent a significant departure, either in content or method of delivery, from those that were offered when the institution was last evaluated
  4. The addition of courses or programs of study at a degree or credential level different from that which is included in the institution’s current accreditation or reaffirmation.
  5. A change from clock hours to credit hours
  6. A substantial increase in the number of clock or credit hours awarded for successful completion of a program
  7. The establishment of an additional location geographically apart from the main campus at which the institution offers at least 50 percent of an educational program.
  8. The establishment of a branch campus 
  9. Closing a program, off-campus site, branch campus or institution
  10. Entering into a collaborative academic arrangement such as a dual degree program or a joint degree program with another institution
  11. Acquiring another institution or a program or location of another institution
  12. Adding a permanent location at a site where the institution is conducting a teach-out program for a closed institution
  13. Entering into a contract by which an entity not eligible for Title IV funding offers 25% or more of one or more of the accredited institution’s programs
Substantive Revision

A considerable or significant revision to the essential scope or purpose of a policy or procedure that changes the current practice, procedure, or actions required by a policy. (For specific examples of substantive revisions, please see the IHOP Policy Development Guide on the Policies and Procedures website).

Suicide Attempt is an effort to commit suicide involving definite risk. The outcome frequently depends on circumstances alone and is not under the person’s control.
Suicide Precautions are continuous interventions aimed at providing a safe environment for patients identified as exhibiting suicidal behavior and/or ideations.
Suicide Risk Assessment identifies specific individual characteristics and environmental features that may increase or decrease the possibility of suicide.
Suicide Risk Screening

is a method to separate patients who are at risk for suicide from those who have low or no risk of suicide.

Suicide Threat is a statement of intent to commit suicide that is accompanied by behavior changes indicative of suicidal tendencies.
Supervisee

Any person whose terms and conditions of employment or student status are directly or indirectly controlled or affected by a supervisor.

Supervisor

For staff, the person to whom they report; and for faculty, their Chair or Dean.

A University faculty member or employee who has direct or indirect supervisory, teaching, evaluation or advisory authority over an employee or student.

 

Surgical and Nonsurgical Invasive Procedures Procedures that expose patients to more than minimal risk, including procedures done in settings other than the operating room and procedure areas (e.g., at clinics and the bedside). Certain routine “minor” procedures such as venipuncture, peripheral IV line placement, insertion of an NG tube or Foley catheter are not within the scope of this policy.
Surgical count is an audible and concurrently visual count conducted between two people: the RN (circulator) and the scrub person.
Surgical Sponges (4 x 4’s or 4x 8’s) are soft goods used to absorb fluids, protect tissues, or apply pressure or traction. This includes radiopaque gauze sponges, radiopaque laparotomy sponges, tonsil sponges, radiopaque cottonoids, and peanuts or dissectors.
Surrogate decision maker

A person with decision-making capacity who is identified as the person who has authority to consent to medical treatment on behalf of an incapacitated patient in need of medical treatment.  Examples of a surrogate decision maker include a family member, spouse, domestic partner, same sex partner, or friend.

symptoms of alcohol and drug abuse Major symptoms of alcohol and drug abuse may include declining work performance as manifested by unavailability, missed appointments, lapses in judgment, incomplete medical records, poorly communicated nocturnal phone orders, mood swings, unexplained absences, embarrassing behavior, signs of intoxication or self-medication, and/or withdrawal from hospital or other professional activities. Family problems and change in character or personality are further accompaniments of a substance abuse disorder.
System Review Panel A panel responsible for reviewing the actions of each UT System’s component’s expert review panel to assure uniform and consistent compliance with these guidelines and applicable statutes and regulations. The panel shall be composed of an expert in blood-borne infections (including HIV and HBV) from each health component institution appointed by the President and representatives from The U.T. System Office of Health Affairs, Office of Academic Affairs, and Office of General Counsel.
Tailgating (Piggybacking) Means that, without officially having an appointment, an individual is accompanying a industry vendor who has a verifiable appointment with a specific department/area.
Tardies / Partial Unscheduled Absence

when employee(s) report to work after the scheduled starting time or leave the work area prior to the end of the scheduled shift without giving 16 hours notice. Each department determines the acceptable standard for tardies and partial unscheduled absences. Tardies and partial absences will be tracked.

Separately from unscheduled leave occurrences and an excessive number of tardies or partial absences may result in disciplinary action based on published departmental policy. It is up to department policy as to whether tardies or partial absences may be made up later in the work week.

Teaching Lab specialized space used for teaching, supported by discipline-specific stations for each student.
Teaching Space Computer specialized space used for teaching supported by computer stations for each student.
Technical Manager assigned custodians of IR, provide technical facilities and support services to owners and users of information. Assists Program Management in the selection of cost effective controls to be used to protect information resources are charged with executing the monitoring techniques and procedures for detecting, reporting, and investigating breaches in information asset security.
Temporary Closure

Unit closure expected to last < 7 calendar days

Temporary Income Benefits Weekly compensation benefits based on a percentage of the employee’s average weekly wage as established by State law. An employee may qualify for temporary income benefits if he or she has a disability as a result of a compensable injury and has not reached maximum medical improvement.
Temporary Sign

Temporary signs provide information about services, activities, events, studies, notices and in certain cases emergency messages. A temporary sign includes billboards, decals, notices, placards, posters, banners and any kind of hand held sign. Posting is the means used to display the temporary sign

Temporary Signs

provides information about services, activities, events, studies, notices and in certain cases emergency messages. A temporary sign includes billboards, decals, notices, placards, posters, banners, and any kind of hand held sign. Posting is the means used to display the temporary sign.

Tenant Improvement Allowance a funding source that may be provided by the building lessor that is to be used for design and construction of the space to meet customer-specific requirements. This allowance may be, but is not always, amortized and added to the annual rent bill on a prorated basis over the term of the lease.
Terminal Condition An incurable condition caused by injury, disease, or illness that according to reasonable medical judgment will produce death within six months, even with available life-sustaining treatment provided in accordance with the prevailing standard of medical care.
Test Site Management

The individual(s) within departments/clinics accountable for supervising, training, and ensuring compliance of their personnel with regard to point of care testing policies and procedures.

Texas Resident

A person who:

  1. Physically and lawfully resides within the geographic boundaries of the State of Texas for at least six (6) months prior to the date of the application for a financial discount.
  2. Maintains a permanent residence (e.g., house apartment, trailer, and not just a post office box) in Texas. If the applicant cannot show a permanent physical residence, then a Notarized Letter of Support may be provided.
  3. Claims permanent residency in Texas and can provide two Residence Proofs found in the Proof list.
  4. If the patient is a minor child residing in Texas, at least one parent, Managing Conservator, Guardian and/or other person or entity with primary legal responsibility for the child is a Texas Resident.
  5. If the patient is claimed as a dependent of a parent or guardian, is not an emancipated adult and is enrolled and attending a post-secondary educational institution outside of Texas, maintains permanent residency in Texas and does not claim residency in any other state for tuition purposes; or
  6. Does not claim permanent residency in any other states or country and is not eligible to receive or does not receive any of the following benefits in another state or country including any of the following:

     a. Cannot vote in another state/country unless holding dual citizenship in that country

     b. Does not own a Primary Residence in another state/country, although the ownership of second homes/property is acceptable;

     c. Does not currently pay personal states income tax in another state

     d. Does not receive homestead tax benefits in another state/country. Unless holding dual citizenship in that country

     e. Is registered (or has custodial children registered) and attended elementary or secondary school in another state/country, unless holding dual citizenship in that country; or

     f. Receives in-state or in-country residency tuition benefits in another state/country, unless holding dual citizenship in that country.

The American Disabilities (ADA) Panel The ADA Panel reviews disability documentation for the University provided by the student to verify a disability and the appropriateness of any particular accommodation.
Therapeutic Pass A longer authorized absence from the unit for up to five (5) hours.
Third Party Release Agreeemnt

A document used to authorize the release of a newborn child from the hospital to a designated person or agency.  To be valid, it must be signed by the mother of the newborn child, witnessed by two credible adults, and notarized before a notary public.

Third Party Sexual Harassment Third party sexual harassment occurs when an individual is affected adversely by sexual harassment but is not the target of the adverse behavior
Threat of violence Any behavior, intentional or reckless, that by nature would be interpreted by a reasonable person as intent to harm to another person or damage property. Threats may include but are not limited to oral, written, or communicated through gestures, conventional mail, electronic mail, fax or telephonic means and may be direct or implied.
Threatening Situation an event that has the potential to result in harm to persons or environment. Threatening situations include but are not limited to bomb threats, menacing behavior, terrorist activity, discovery of explosive or suspicious devices, and chemical, biological or radiological contamination.
Time Correction

Any correction to a timecard that results frommissed punches or inaccurately recorded time entries.

Timeliness A Cost Transfer that is timely is one that is limited within the time frames of the Cost Transfer policy.
Tolerance The amount by which salary percentage paid may vary from Effort percentage reported. This tolerance is established by UTMB and is reflected in the Effort Reporting Procedures Manual.
Toluidine Blue Dye (TBD) A 1% aqueous solution that dyes the deep inner epidermis skin cells whose nuclei have been exposed by lacerations/tears. TBD is used for detection of minor injury in the anal-genital area. A deep blue color uptake is considered positive indicating injury.
Total Effort The Effort that an Individual devotes in the aggregate to the professional activities for which he or she receives IBS compensation from UTMB. Specifically excluded from total Effort is time spent on outside consulting activities or other activities for which compensation is received from an entity other than UTMB.
Total Institutional Activities Total Institutional Activities are those activities for which an Individual is paid by the UTMB. Common activities include administrative duties, instruction, patient care, public service, and research.
Total Project Cost (TPC) the complete cost for a project, including professional design fees, construction costs, equipment costs, furniture costs, make-ready costs, move costs, and any miscellaneous cost directly associated with the project.
Training

may include, but is not limited to, completing computer-based training modules, attending instructor-led classroom training, and passing skill assessments

Treatment The provision, coordination, or management of health care related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or for the referral of a patient for health care from one health care provider to another.
Treatment, Payment, and Health Care Operations (TPO)

Three core functions of providing health care to patients.  Treatment involves the administering, coordinating and management of health care services by UTMB for its patients.  Payment includes any activities undertaken either by UTMB or a third party to obtain premiums, determine or fulfill its responsibility for coverage and the provision of benefits or to obtain or provide reimbursement for the provision of health care. Health care Operations are activities related to UTMB’s functions as a health care provider, including general administrative and business functions necessary for UTMB to remain a viable health care provider. For more detailed definitions of TPO, see IHOP Policy 6.2.0, Maintaining Patient
Confidentiality through the Appropriate Use and Disclosure of PHI
.

Unanticipated Outcome A result of a treatment or procedure that differs significantly from what was anticipated.
Unassigned Space

space not assigned to a specific division. All unassigned space belongs to UTMB and any assignment of the space must be approved by the AVP of Facilities Portfolio Management.

Unauthorized form An unauthorized form is a form that has not been approved through the Health Information Management Department, i.e., bootleg, maverick or department created form.
Unclaimed Body

The body of an adult (age 18 years of age or older) who died with no known advance directives in place, or authoried representative, or next of kin, willing and able to make final disposition of the remains.

Undue Hardship

Accommodation that would be unduly costly, substantial, or disruptive, or that would fundamentally alter the nature or operation of a university department, program, service, or activity.

The ADA Coordinator will engage in the interactive process to determine if undue hardship exists.

Unduplicated Headcount Measure that counts all students across an academic year, counting each student only once.
Unit History Number (UH#) (also known as the medical record number) Six digit number with an alpha suffix assigned to a UTMB patient during his/her first visit to UTMB. Each patient is to receive one number and this number is to be used for all future encounters.
Unit Medical Record (UMR)

The official UTMB legal medical record maintained by the Department of Health Information Management (HIM) that contains UTMB’s original/official patient care information.  The UMR is designed to contain the written interpretations of all significant clinical information gathered for a given patient, whether as an inpatient, outpatient, or emergency care patient. The entire patient’s medical record is thus in paper and /or electronic form under one hospital number. UMR’s have a permanent retention schedule.

University Core (UC)

laboratories provide services or technologies essential to the overall mission of UTMB and its investigators.  A University Core should provide service to a minimum of five (5) UTMB Departments or Centers (typically serving a minimum of twenty-five (25) project investigators) or provide unique services, expertise or technology to the community.  A laboratory will be given the University Core designation by consensus of the University Core Development Committee.  Rates are based on direct costs only and can only include internal Core operating costs. Capital equipment depreciation may also be included but only in special circumstances with approval of the Vice President, Financial Accounting and Reporting.

University Facilities

Grounds, buildings, and facilities owned or controlled by UTMB that are maintained and used for programs and activities related to the role and mission of UTMB. See Policy 2.6.2 for specific guidelines regarding Special Use Facilities.

University Owned Vehicle A vehicle to which the University holds title or a vehicle leased by the University for more than one year.
University Service Centers (USC)

provide goods or services to the UTMB community at large and will be established and maintained only when goods or services are needed by a broad base of internal UTMB customers.  The cost base will include internal service center direct operating costs, travel deemed necessary for the operation of the service center, and depreciation on capital equipment and may include allocated space and general administrative costs (Facilities and Administrative [F&A] expenses).

University Time

For faculty, this time is defined by the number of hours per week necessary for the performance of job duties, which include teaching, research, service, and patient care. For some staff this time is defined by a work day with set hours and for other staff this time is defined as a work day with set hours plus on call service as needed.

Unlawful Discrimination

conduct directed at an individual or group that subjects the individual or group to treatment that adversely affects their employment, education, or health care because of their race, color, religion, national origin, sex, age, disability, veteran status, sexual orientation, gender identity, or gender expression.

 

Unlawful Retaliation

any action that adversely affects the employment of an individual that is taken by the institution because the individual has, in good faith, made an allegation concerning a violation of the law,  policy, or procedure, and/or has participated in good faith with an investigation of such allegation.

 Adverse actions do not include petty slights and annoyances,  including, but not limited to: stray negative comments in an otherwise positive or neutral evaluation;, “snubbing” a colleague;, or negative comments or disciplinary actions that are justified by an employee’s work performance, or history.

Employees are not excused from continuing to perform their jobs or follow their Department’s legitimate workplace rules because they have filed a complaint or have participated in an investigation.

Unrecovered Facilities and Administrative Cost The difference between the amount awarded and the amount which could have been awarded under the recipient's approved negotiated facilities and administrative cost rate.
Unscheduled Leave Occurrence unscheduled absence of one or more consecutive workdays. Absences of consecutive work days for the same reason are recorded as one occurrence.
Unsecured PHI PHI that is not made unusable, unreadable, or indecipherable to unauthorized individuals through a technology standard developed or endorsed by a standards developing organization accredited by the American National Standard Institute.
Unusual event an occurrence involving a patient, employee, or visitor which is not consistent with the accepted Hospital/Clinic operation or the routine care of a particular patient, or whenever there is an unusual or unexpected response by the patient to standard treatment or medical intervention. Examples of such occurrences are: • Medication errors • Adverse Drug Events (ADE) • Unusual events that occur to employees (the event involves an employee injury, the WCI process must also be followed) • Patient/visitor falls • Errors related to procedures/treatment/testing • Equipment/supplies/device failure
Unusual Event

Unusual Event - an occurrence involving a patient, staff employee, or visitor which is not consistent with the accepted Hospital/Clinic operations or the routine care of a particular patient, or whenever there is an unusual or unexpected response by the patient to standard treatment or medical intervention.   Examples of such occurrences include:

  1. Medication errors
  2. Adverse Drug Events (ADE)
  3. Unusual events that occur to employees (note: if the event involves an employee injury, the WCI process must also be followed)
  4. Patient/visitor falls
  5. Errors related to procedures, /treatment/, or testing
  6. Equipment, /supplies/, or device failure 
Urgently / Emergently Required Medical Treatment

a medical treatment, procedure or intervention to prevent, alleviate, or reverse a condition or symptoms that, in the absence of immediate medical attention, reasonably could result in jeopardy of the patient's health, serious impairment of the patient's bodily functions, or serious dysfunction of any bodily organ or part.  example:  the administration of blood or blood components.

Use

With respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information that identifies, or reasonably can be used to identify, a patient within UTMB.

Use

A medical treatment, procedure or intervention to prevent, alleviate, or reverse a condition or symptoms that, in the absence of immediate medical attention, reasonably could result in jeopardy of the patient's health, serious impairment for the patient's bodily functions, or serious dysfunction of any bodily organ or part.  Example: the administration of blood or blood components.

UTMB Committee A task force or institution-wide committee appointed by UTMB to oversee the development and implementation of educational programs related to HIV and HBV, and to advise the administration on policies regarding HIV and HBV. It is suggested that the committee include, as a minimum, representation from the faculty, the student body, and administrative areas such as housing services, health services, counseling services, and food service.
UTMB Connect

The following applications are included: Cadence, ADT, Prelude, Resolute Hospital Billing, Resolute Professional Billing and HIM-Coding and Abstracting.

UTMB Expert Review Panel

A panel appointed by the President of UTMB to review instances of HIV or HBV infection in Health Care Workers and to identify exposure-prone procedures and to determine those circumstances, if any, under which a Health Care Worker who is infected with HIV or is HBeAg positive may perform such procedures. The panel should be composed of experts who provide a balanced perspective and might include:

  1. Health Care Worker’s personal physician(s);
  2. An infectious disease specialist w/expertise in the epidemiology of HIV and HBV transmission;
  3. A health professional w/expertise in the procedures performed by the affected Health Care Worker;
  4. A member of UTMB’s infection control committee, preferably a hospital epidemiologist; and
  5. An occupational health specialist.
UTMB official with a legitimate educational interest may include a person employed by UTMB in an administrative, supervisory, academic, or support staff position (including law enforcement unit and health staff); a person or company with whom UTMB has a contract or affiliation; a member of the UTMB Board of Regents; or a person assisting another UTMB official in performing his or her tasks who needs to review an education record in order to fulfill his or her professional responsibility.
UTMB Personnel All faculty and staff.
UTMB Personnel Any faculty, staff, student, volunteer, or any other contractors or agents of UTMB.
UTMB Procurement Card Program

Purchase of non-restricted goods or services costing up to $2,000 or less through use of the UTMB issued procurement card. 

UTMB Workforce

All level of employees, contract workers and students

UTMB-sponsored social media online content posted by or on behalf of a recognized UTMB department, program or organization.
Vacant (Vacated) Space

space that is not occupied. It can be assigned or unassigned. All vacant space shall be reported in the annual space survey by the department to which the space is assigned.

Vaccine preventable diseases diseases included in the most current recommendations of the Advisory Committee on Immunization, Practices of the Centers for Disease Control and Prevention.
Values Define the culture and guide every interaction
Vehicle Equipment of a motorized, vehicular nature, which requires a State driver’s license to operate. This does not include riding lawnmowers or other vehicles that normally operate off public thoroughfares, except for incidental crossing of a public roadway.
Vendor

any individual or company that has sold, currently sells, or may sell goods and/or services to UTMB.

Verified Address

an address for an individual that UTMB has reasonably confirmed is accurate.

Vision A statement of the organization’s aspirations.
Voluntary Uncommitted Cost Sharing refers to costs of a project not funded by the sponsor and which were not committed in the proposal or award.
Waived Test Waived tests are approved by the FDA for home use and employ methods that are straightforward and accurate such that the likelihood of erroneous results or patient injury is negligible.
Weapon a firearm, illegal knife, club, explosive device, etc
Web accessibility the degree of flexibility built into a web site or web application to meet the different needs, preferences, and situations of many different users, including individuals with disabilities. The intent is to increase accessibility by reducing or eliminating technological or design barriers that impede access or use of otherwise public content and information.  
Weekday Monday through Friday, excluding any day that is an official holiday of the component institution or when regularly scheduled classes are suspended due to emergent situations.
Wheeled Items in Use

These are items that are on wheels and attended at least once every 30 minutes, necessary for the operations of the area and include such items as trash carts, linen carts, housekeeping carts, delivery carts, computers on wheels, etc.  This definition is specifically applicable to Healthcare areas.

Wholesale Acquisition Cost (WAC)

The price paid by a wholesaler (or direct purchaser) in the United States for drugs purchased from the drug’s manufacturer or supplier. Publicly available WAC lists do not represent actual transaction prices and do not include prompt pay or other discounts, rebates, or reductions in price.

Witnesses

In any circumstance in which the Texas Advance Directives Act requires the execution of  an advance directive to be witnessed:
      (a) each witness must be a competent adult; and
      (b) at least one of the witnesses must be a person who is
not:

1. a person designated by the declarant to make a treatment decision;
2. a person related to the declarant by blood or marriage;
3. a person entitled to any part of the declarant’s estate after the declarant’s death under a will or codicil (i.e., a  supplement or appendix to a will) executed by the declarant or by operation of law;
4. the attending physician;
5. an employee of the attending physician;
6. an employee of  UTMB if the employee is providing direct patient care to the declarant or is an officer, director, partner, or business office employee of UTMB or any parent organization of UTMB; or
7. a person who, at the time the written advance directive is executed or, if the directive is a non-written directive issued under the Advance Directives Act, at the time the non-written directive is issued, has a claim against any part
of the declarant’s estate after the declarant’s death.

Work Days Monday through Friday, excluding any day that is an official UTMB holiday.
Workforce

Employees, volunteers, trainees, and other persons whose conduct, in the performance of work for UTMB, or a business associate, is under direct control of UTMB or a business associate, even if they are not paid by UTMB or the business associate.

Working Groups

Includes committees, faculty bodies, etc. (Example: CAPP Committee, Council of Deans, and Faculty Senate).

Workplace includes all University facilities and off-campus locations where faculty, staff, agents or contractors are engaged in University Business
Workplace Violence

Threatening and/or violent behavior that can include but is not limited to:

  • Physically assaulting an individual, by slapping, hitting, punching, pushing, poking or kicking; or physical threats to inflict physical harm;
  • Arson, sabotage, equipment vandalism, damaging or destroying property, throwing or hitting objects;
  • Displaying a weapon or an object which appears to be a weapon in a threatening manner; carrying a firearm of any kind onto University owned or controlled property; except parking lots and garages, or using a weapon to harm someone;
  • Intimidating or threatening gestures, bullying or hazing;
  • Intimidating, threatening, hostile or abusive language directed toward another person that communicates the intention to engage in violence against that individual and leads a reasonable individual to expect that violent behavior may occur;
  • Stalking another individual
Written Declaration a signed document indicating the reason for declining a vaccine. The acceptable reasons for declination include medical contraindications or for reasons of conscience, including religious beliefs.

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