Policy Terms and Definitions

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.

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.

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.

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

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

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.

ADA Amendments Act of 2008

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

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

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

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.

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).

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

Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants.

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.

Environmental conditions that cause the risk of harm such as weather emergencies and other disasters.

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.

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.

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.

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.

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.

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

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.

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

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.

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.

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.

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

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.

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.

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.

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

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

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.)

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

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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

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).

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

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.”

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.

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.

The party who makes a compliant or allegation against another party.

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

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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

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.

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.

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.

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.

• Members of the Regular Armed Forces – duty during deployment of the member with the Armed Forces to a foreign country; or
• Members of the Reserve components of the Armed Forces – duty 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.

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.

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.

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.

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

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

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.”

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

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.

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

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

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.

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.

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

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

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.

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

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

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

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.

  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.

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

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.

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

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.

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.

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.

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

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 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.

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.

the department initiating a new or revised medical record form.

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

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

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.

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.

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

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.

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. 

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.

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.

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.

(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.

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.

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

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.

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

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.

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

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

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.

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.

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

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.

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.

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.

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.

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).

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.

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).

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.

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.

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

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.

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.

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.

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.

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

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.

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

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

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

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.

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

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.

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.

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.

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 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.

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

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.

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. These individuals 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.

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.

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

A panel of three faculty members, composed of two faculty members from the accused student’s school and one faculty member from the alternative UTMB schools, selected by the Provost of the Provost's delegate from a predetermined pool to hear disciplinary charges, make findings of fact, and, upon a finding of responsibility, impose an appropriate sanction(s).

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.

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.

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

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

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

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.

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.

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. 

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.

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

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.  
 

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.

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.

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.

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.

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.

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.

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.

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

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).

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

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

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.

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

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.

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.   

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.

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.

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.

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.

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.

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.

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. 

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.

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

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.

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.

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.

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.

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.

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

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. 

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.

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.

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.

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)

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

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.

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.

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.

2. 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.
3. 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.

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.

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

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

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.

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.

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.

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). 

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.

• 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.

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

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.

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

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.)

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.

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.

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.

Fabrication, falsification, plagiarism, in proposing, performing, or reviewing research or in reporting research results. (a) Fabrication is making up data or results and recording or reporting them. (b) Falsification is manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research. (c) Plagiarism is the appropriation of another person’s ideas, processes, results, or words without giving appropriate credit. (d) Research Misconduct does not include honest error or differences of opinion. 

(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.

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.

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.
    

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

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.

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.

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).

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

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.

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

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

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

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.

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

• 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).

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.

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).

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

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.

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.

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.

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.

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.

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.

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.

• 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.
 

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.

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

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.

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.

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.

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.

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 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.

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.

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

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

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.

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

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.

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

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.

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.

A period of six months for a new UTMB employee. The period begins with the first day of appointment to a regular position

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.

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.

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.

Art that is displayed in public spaces.

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

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.

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.

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.

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:  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

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.

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.

• 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

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.

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.

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

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.

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.

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.

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

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.

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.”

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.

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

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

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.

A systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge (45 CFR 46.102(d)) or, under FDA regulations, an activity that (1) involves a drug, other than use of a market drug in the course of medical practice, or (2) the use of a device to evaluate safety and effectiveness of that device, and (3) data from the activity will be submitted to, or held for inspection by, the FDA in support of a marketing or research application for an FDA-regulated product.  If the activity is designed to improve internal practices, it is not research.

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.

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.

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.

The party against whom a compliant or allegation has been made or filed.  The party accused of wrong doing.

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.

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.

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.

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

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.

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

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.

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.

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.

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.

A patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity or harm). 

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.

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.

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 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 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 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.

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

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

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.

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.)

4. 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.
5. 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.
6. 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

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.

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.

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

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.

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.

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.

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.

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. 

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.

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
• School of Public and Population Health (SPP) – Associate Dean for Student Affairs

This may be referring to the appointed Associated Dean's delegee.  When necessary to avoid delays in the investigation or adminstration of academic conduct and discipline cases, the appointed Student Affairs Officer may delegate this authority to a fellow faculty member. 

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

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. 

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.

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.

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.

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

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).

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

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

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.

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.

Unit closure expected to last < 7 calendar days

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

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.

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.

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.

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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 

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.

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.

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.

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

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.

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

All level of employees, contract workers and students

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.

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

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

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.

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.

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.

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.

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

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