06.A.12 – Health Care Clinics Managed and Operated by University of Houston System or Its Universities
Section: Academic Affairs
Area: General
1. PURPOSE
Health Care Clinics enhance opportunities for students, faculty, and staff to learn, teach, and practice a wide variety of medical and health disciplines and specialties, including focusing on preventing and improving poor health with the goal of eliminating health disparities in urban and rural areas, as well as underserved communities. Health Care Clinics provide an environment where students can receive the highest medical training from our faculty in order to provide comprehensive health care. Health Care Clinics also provide an opportunity to deliver health care to patients of all ages and socioeconomic backgrounds. It is imperative that the Health Care Clinics created, managed, and run by the University of Houston System (UHS) and its universities:
A. Support UHS's mission and strategic priorities;
B. Adhere to a high standard of professionalism, patient care, and excellence;
C. Provide students with training and mentoring to maximize their success in the classroom, laboratory, and clinic; and
D. Strengthen the teaching, research, and service activities of their corresponding core academic disciplines.
2. SCOPE AND APPLICABILITY
A Health Care Clinic is any facility, building, room, place, or establishment on or off campus managed and operated by UHS or its universities where physical and health examinations, health consultations, organized medical services, including offering diagnostic, therapeutic, or preventative outpatient services, and/or the care or treatment of people is provided or made available outside a hospital setting. A Health Care Clinic may involve students, faculty, and staff, as well as scholarly and academic collaboration and research. A Health Care Clinic may be identified primarily with one medical and health discipline and specialty, be multi-disciplinary, may support interaction involving teaching, research, or exchange of students, faculty, and staff, and may involve more than one university.
3. POLICY
3.1. Each university is responsible for having in place policies regarding the development, approval, and operation of its Health Care Clinics. Such policies shall address the existence of appropriate fiscal controls, adequate oversight of the provision of health care services, as well as the academic quality of the clinic instruction. Moreover, the university policies shall ensure that its Health Care Clinics conform to applicable state and federal law and Board and UHS policies, including this policy, and specifically address the following:
3.1.1. Initial assessment of proposed Health Care Clinics, including but not limited to support of the UHS mission, benefits and costs, sustainability, and compliance;
3.1.2. Creation and approval of Health Care Clinics;
3.1.3. Financial operation and business practices in operating and managing Health Care Clinics, including any regulatory requirements such as necessary permits, licenses, and certifications;
3.1.4. Privacy and security measures to protect individually identifiable health information;
3.1.5. Administrative organization of Health Care Clinics, including reporting relationships; and
3.1.6. Periodic review of Health Care Clinics, including achieving compliance as well as their overall effectiveness in fulfilling its purposes and the UHS mission.
3.2. Before any Health Care Clinic is created, the university president or their designee must approve the creation, existence, and purposes of the Health Care Clinic; or in the case of a UHS Health Care Clinic (which includes a Health Care Clinic involving more than one university), the Chancellor or their designee must approve the creation, existence, and purposes of the Health Care Clinic. First, a proposal containing the elements set forth in Section 3.4 below must be submitted by the appropriate dean to and approved by the university's Provost in the case of a Health Care Clinic or UHS Provost in the case of a UHS Health Care Clinic. Second, once approved by the appropriate Provost, then the proposal will be forwarded to the Office of General Counsel for review and approval, prior to the third step which is review and approval by the university president or their designee, or the Chancellor or their designee for any UHS Health Care Clinic.
3.3. Any Health Care Clinic currently existing and in operation as of the effective date of this SAM 06.A.12 must submit the information contained in Section 3.4 below, to the Office of General Counsel within ninety days of the effective date of this SAM.
3.4. Information required for proposals for new Health Care Clinics and already existing Health Care Clinics, as applicable:
3.4.1. Purpose and mission of the Health Care Clinic, including projected start date and location;
3.4.2. Anticipated number of staff, students, faculty, and licensed professionals involved in the operation of the Health Care Clinic;
3.4.3. Daily operations of the Health Care Clinic, including utilization of a medical record filing system, scope and frequency of services to be provided, patient eligibility for services, and other entities involved in the operations of the Health Care Clinic including departments, colleges, universities, and community agencies;
3.4.4. Training and education required for staff, students, faculty, and any other entities or licensed professionals involved in the operation of the Health Care Clinic;
3.4.5. Projected and secured funding, associated fees for services, forms of payment accepted, billing and coding practices, and oversight of the billing and coding practices for the Health Care Clinic;
3.4.6. Applicable regulatory and licensing requirements for the Health Care Clinic, including professional licensing boards;
3.4.7. Any and all policies, procedures, or patient forms drafted specifically for the Health Care Clinic; and
3.4.8. Identification of a director and/or manager of the Health Care Clinic, as well as the person responsible for overall compliance for the Health Care Clinic.
Issued: 05/10/2023
Last Reviewed/Revised:
Responsible Office(s): Academic Affairs