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The University of Toledo Policy Websiteis a compilation of relevant policy, operational procedures, governing documents and handbooks of The University of Toledo. The purpose of the policy website is to ensure faculty, staff, and students have ready access to policies. It is the responsibility of the UT community, including faculty, staff, and students, to familiarize themselves with the policies and comply with the University policies that affect them.
Policy Review and Approval Process
Draft policies are posted on the Policies Posted for Comment page for a thirty day period, during which time the campus community has an opportunity to offer comments or suggestions about the draft policy. Comments submitted for review are answered by the policy’s responsible agent.
An email notification of updates and additions to the Policies Posted for Comment is distributed to all University faculty and staff.
The University of Toledo approves, issues, and maintains policies using a consistent process and format. Please see the 3364-10-01 Formulation and issuance of policies for the standard format, vetting, and approval process for the policies.
The Policy Committee is charged with ensuring that the University’s policies are accessible, appropriately disseminated, and current. The committee does not decide the appropriateness or validity of policies.The committee is comprised of membership from the Provost’s Office, Faculty Senate, Internal Audit and Compliance, Legal Affairs, University Archives, and the UT Medical Center.
Contact Annette Hyttenhove, at annette.hyttenhove@utoledo.edu (419.530.4043) or Assistant General Counsel, Adam Motycka at adam.motycka@utoledo.edu (419.530.8418) for more information about University policies.
NOTE: The University’s policies ultimately become a part of the Ohio Administrative Code. The Administrative Code is written in lower case. As each UT policy comes due for review, it will be formatted according to the Ohio Legislative Service Commission Drafting Manual. Many words that normally would be capitalized will not be capitalized in the text of the policy. For example – university of Toledo, president of the United States, supreme court, holidays such as Christmas day (Christmas is capitalized but day is not). The Drafting Manual includes many other grammatical guidelines. The header box and the signature box do not need to comply with these rules. Please do not send comments asking to revise capitalization, outline format, grammar, etc.
College of Medicine and Life Sciences - 1 policy
Policy Name:3364-81-29 Medical student housing for offsite required clinical clerkship rotations ٱپDz:(New policy)This policy defines the requirements and expectations for housing accommodations
for offsite locations.
DZ: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-81-29
Academic - 1 policy
Policy Name:3364-72-12 Administrator assuming a faculty position ٱپDz:(Minor revisions to policy)The revisions clarify and provide detail to this policy.
DZ: All University of Toledo Campuses
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-72-12
Graduate Medical Education - 3 policies
Policy Name: 3364-86-008-00 Appeal process for all eligible corrective action ٱپDz:(Major revision of policy)The Resident will request an appeal by emailing the Associate Dean for GME. After
submitting the appeal request the Resident has seven (7) calendar days to provide
additional documentation supporting their case to the Associate Dean for GME. The
Associate Dean for GME or his/her designee will review the information provided on
the Corrective Action and the response from the Resident. The Associate Dean for
GME will render a summary decision. Removal of Remediation Report and previous Remediation
template that is being revised and reduced into three pages.
DZ: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-86-008-00
Policy Name:3364-86-026-00 USMLE Step 3 or equivalent examination timing ٱپDz:(Minor/technical revision of existing policy)Grammar edit – “from another training program” has been removed from a sentence.
DZ: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-86-026-00
Policy Name:3364-86-045-00 Semi-annual evaluations ٱپDz:(Minor/technical revision of existing policy)The semi-annual evaluations are to be completed no later than December 31st of the academic year, and end of year evaluations are to be completed no later than
June 30th.
DZ: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-81-29
University of Toledo Medical Center – 16 policies
Policy Name: Description:(Minor revision of existing policy) Under therapy animal restricted areas, added Intensive Care Units are restricted
unless permitted by Chief Nursing Officer to improve patient outcomes.Under references,
there are date changes and updated resource links.
DZ:University of Toledo Medical Center and its Medical StaffComment Period: January 17, 2025 through February 17, 2025
Comment on this policy:
Policy Name: Description:(Minor revision of existing policy) Under policy statement, changed preventing the transmission of Creutzfeldt-Jakob
Disease removed from one person to another and added the healthcare setting. Under
procedure, added the acronym CJD for Creutzfeldt-Jakob Disease, and added three forms
of Creutzfeldt-Jakob Disease to include sporadic, familial and iatrogenic with definitions.
Under low infectivity, placenta was added.
New reference link was added to transmission prevention. Omitted words the, and person
to person under transmission. Under Operating and Autopsy Rooms, added method of
disposal equipment to include destruction of heat-resistant surgical instruments that
encounter high-infectivity tissues is the safest method. Under references, there
are date changes and updated resource links.
DZ:University of Toledo Medical Center and its Medical StaffComment Period: January 17, 2025 through February 17, 2025
Comment on this policy:
Policy Name: 3364-109-EQP-301 Sterility Assurance of Patient Care Items Description:(Minor revision of existing policy) Under procedure, added that items will be stored in a manner to protect the integrity
of the packaging. Under references added amendments.
DZ:University of Toledo Medical Center and its Medical StaffComment Period: January 17, 2025 through February 17, 2025
Comment on this policy:
Policy Name: Description:(Major revision of existing policy) Under policy statement, changed from accepts to allows facsimile machines as acceptable
form of transmission of patient information. Also, updated language that after HIM
release of information is verified, HIM can transmit data on substance abuse, HIV
or psychiatric diagnosis and they should not be faxed by operational users. Also,
updated language stating that transmission of health information for the reporting
of results, and continuity of care should be minimal for these diagnoses. Under preventing
error’s, word change from would necessitate to requires completion of UTMC’s online
incident report.
DZ:University of Toledo Medical Center Comment Period: January 17, 2025 through February 17, 2025
Comment on this policy:
Policy Name: 3364-133-119 340B Program Description:(Minor revision of existing policy) Changed instances of drug dispensed to drug administered to reflect Epic conversion.
Under policy statements on pandemic response – added qualifying clinics before they
appear on the Medicare cost report. Changed titles of responsible staff to reflect
current titles (Sr. Hospital Administrator from Chief Pharmacy Officer). Added Primary
Contact to instances of Administrative Official to accurately reflect that the Primary
Contact may add/change items in OPAIS. Changed pricing structure from GPO to WAC cost
of goods. Other formatting and grammatical revisions.
DZ:University of Toledo Medical Center Comment Period: January 17, 2025 through February 17, 2025
Comment on this policy:
Policy Name: 3364-133-17 Medication Control and Distribution Description:(Minor revision of existing policy) Under Transfers, the transfer reconciliation may occur on paper or electronically
has been removed. For discontinuing a drug order- “resume Previous Orders” has been
changed to not a valid order. Administering of medications: Administration of Medications
policies in nursing policies has been removed. Administering of medications: Self-administration
of patient home medications in outpatient encounters outside of the scope of the visit
are at the discretion of patient and provider. Under automatic stop orders “Z Pak
Dosing” has been removed as an exception. Other formatting and grammatical updates.
DZ:University of Toledo Medical Center and its Medical StaffComment Period: January 17, 2025 through February 17, 2025
Comment on this policy:
Policy Name: 3364-100-50-38 Patient safety event including sentinel eventsٱپDz:(Major revision of existing policy)Title updated to include sentinel events policy. Sentinel event definition was
updated to include death caused by self-inflicted injurious behavior with new criteria
to include while in a health care setting, and within 7-days of discharge from an
inpatient, emergency department, behavioral health, day treatment program, partial
hospitalization program, residential, group home or transitional supportive living.
Under safety reporting, added words upon discovery, prior to the word determination
of sentinel event, to clarify when the event support team is initiated.
DZ: The University of Toledo Medical Center and its medical staff
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:3364-100-50-38
Policy Name:3364-100-45-19 Pediatric patientsٱپDz:(Major revision of existing policy)Title updated to encompass all pediatric patients. Policy, purpose, and scope changed
to Management of pediatric patients in elective surgery and emergency care with definition
of pediatric patient, under the age of 16 years. New patient criteria have been added
related to eligibility and admission criteria. Pre-operative evaluation and preparation
was added. Emergency Department Management evaluation and stabilization added. Transfer
for ineligible patients added. Ohio Code added as a reference.
DZ: The University of Toledo Medical Center and its medical staff
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:3364-100-45-19
Policy Name:3364-100-01-20 Management of UTMC inpatients requiring radiation therapy at the Eleanor
N. Dana Cancer CenterٱپDz:(Major revision of existing policy)Under patient populations, added ICU and Non-ICU patient instructions into the policy.
Under procedure, added details about vented patients, how to transport, and with whom
should accompany them, to ensure patient safety. Removed all language related to
radiation staff responsibility for transport. Added documentation requirements during
patient transport to be manually written and scanned into patient record. Added instructions
for patients who have a cardiopulmonary arrest during transport and during treatment.
DZ: The University of Toledo Medical Center
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:3364-100-01-20
Policy Name:3364-100-01-01 Admission, discharge and transfer
Description: (Major revision of existing policy)Under Intra-Unit and Inter-Unit Transfers, added section on transfer from the intensive
care unit to step-down or med-surg units; specifically, transfer instructions for
the ICU, Medical ICU and Surgical ICU teams. The ICU team will inform the nurse supervisor
of intent to transfer, notify receiving team of pending transfer, provide verbal hand-off;
and a written hand-off to the receiving team for patients with ICU stay over 72 hours.
Added ICU team responsibility for placing the patient in the primary team list. Added
Medical ICU will provide care of transferred patients until 7am the following day.
Added the Surgical ICU will provide care until transferred patient can physically
leave the unit. Other minor grammatical and formatting changes.
DZ: The University of Toledo Medical Center
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:3364-100-01-01
Policy Name: ٱپDz:(Minor revision of existing policy)Under policy statement, added Emergency Medical Screening and Transfer (EMTALA)
for reference to regulations. Under procedure, added exempt location clarification.
Changed documentation log to Epic Report to document emergency care. Removed attachments
due to form changes, updates and/or future updates.
DZ: The University of Toledo Medical Center
Comment Period: February 7, 2025 through March 10, 2025
Comment on this policy:
Policy Name:3364-100-50-33 Cardiopulmonary resuscitation competency, ACLS and PALS certifications ٱپDz:(Major revision of existing policy)Changed name of policy to include type of required certifications; ACLS and PALS.
Under procedure, added clarification of the acceptable competency training bodies
and required frequency for recertification. Provided clarification on continued employment
status or job modification if employee is unable to fulfill requirements.DZ: The University of Toledo Medical CenterComment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-100-50-33
Policy Name:3364-135-056 Nuclear medicine administration ٱپDz:(Minor revision of existing policy)For clarification, added identifying acronym to Radioisotope Committee (RSC).Under
procedure, added requirement for a list of current authorized users and their approved
use for medical use radioactive materials. Added resource for questions in the Radiation
Safety Office. Added requirements for approval from authorized users, criteria and
documentation. Other minor grammatical changes.
DZ: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-135-056
Policy Name:3364-135-091 Radiopharmaceutical administration, oral directive and revisions to written
directives ٱپDz:(Minor revision of existing policy)Under procedure, added requirement for a list of current authorized users and their
approved use for medical use radioactive materials. Added resource for questions
in the Radiation Safety Office. For clarification, added identifying acronym to Radioisotope
Committee (RSC) and Authorized Users (AU). Minor grammatical changes.
DZ: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-135-091
Policy Name:3364-135-092 Radiopharmaceutical medical event
ٱپDz:(Minor revision of existing policy) Under procedure, minor grammatical changes, and update to reporting language. DZ: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-135-092
Policy Name:3364-135-136 Quality control of nuclear medicine equipmentٱپDz:(Minor revision of existing policy)Updated policy statement to include optimal image quality and compliance with regulations
involving radioactive materials (RAM). Under purpose of policy added clarification
to incorrect prescribed radiopharmaceutical activity and added departments instead
of procedures. Under procedures, added criteria for equipment that fails quality checks
and required action taken. Changed dose calibrator to dose calibrator systems. Added
other testing criteria for equipment and frequency. Added qualitied individuals who
may perform preventative maintenance. Added CT to quality check language. Removed
section on annual evaluation by a medical physicist.
DZ: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-135-136
Policy Name:3364-100-01-09 Admission and discharge criteria for intensive care unitsٱپDz:(Major revision of existing policy)Under procedure, updated ICU vital sign criteria, clinical and diagnosis related
criteria. Added Step down unit responsibility and criteria for respiratory, vital
signs and clinical and diagnosis related criteria. Conflict resolution was updated
to require discussion for admission and intra-hospital transfers to be held with pulmonary/critical
care fellow and attending. Minor structural and grammatical changes.
DZ: The University of Toledo Medical Center and its medical staff
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:3364-100-01-09