Implementation Guidelines for Compliance

Effective November 19, 2009, the University of Kentucky (UK) Tobacco Policy is changed to create a tobacco-free campus that encompasses the entire Lexington campus and all properties owned, operated, leased, or controlled by UK in Fayette County, Kentucky. These guidelines are intended to assist employees, students, and medical trainees (house staff) in the implementation of this change. The new policy states:

University of Kentucky Tobacco Policy, Administrative Regulations 6:5

For areas located within Fayette County, Kentucky, the use of all tobacco products is prohibited on all property that is owned, operated, leased, occupied, or controlled by the University, …“Property” for purposes of this paragraph includes buildings and structures, grounds, parking structures, enclosed bridges and walkways, sidewalks, parking lots, and vehicles, as well as personal vehicles in these areas.

Violation of the Policy is defined as using any tobacco products, including e-cigarettes and other non-combustible tobacco products, within the prohibited areas.

Successful implementation of the Policy will engage everyone in creating a culture of compliance. Employees, student leaders, and medical trainees will be trained to provide clear, compassionate yet firm messages to communicate the policy. Using scripted messages, employees and students will courteously remind any employee, patient, student, visitor, vendor or contractor violating the Policy that the University prohibits the use of all tobacco products on the University of Kentucky property.

Employees in supervisory roles, Human Resources Employee Relations (HR ER), Deans of Colleges, the Dean the Students, and medical center security are responsible for responding to reported violations of the Policy.

I. Employees

Employees are defined as persons employed by the University of Kentucky (faculty, staff, student, and temporary). All UK employees will be informed of the University of Kentucky Tobacco Policy.

An employee who violates the Policy will be subject to corrective action under the Human Resources Policies and Procedures or other applicable University regulations or policies.

II. Students and Medical Trainees

During the admission and enrollment process, all students and medical trainees will be informed of the University of Kentucky Tobacco policy and receive informative material relating to the policy. Students and medical trainees may also be referred to University Health Services for access to smoking cessation treatment programs or to manage symptoms and/or treat tobacco dependence as appropriate.

a) Undergraduate and Graduate Students. Undergraduate and Graduate Students who violate the Policy will be reported to the Dean of the appropriate college or the Dean of Students. Students who violate the Policy in student housing areas will be reported to the Office of Residence Life. Students who violate the Policy will be subject to corrective action according to the applicable disciplinary code (i.e., the Student Code of Conduct (http://www.uky.edu/StudentAffairs/Code) and/or the Health Care Colleges Code of Student Professional Conduct (http://www.uky.edu/Provost/APFA/Policy_Protocol/HCCSPBC.pdf)).

b) Health Care College Students. Students who violate the Policy who have a UK HealthCare ID will be reported to the Health Care College listed on their UK HealthCare ID or to the Dean of Students. Students who violate the Policy will be subject to corrective action according to the applicable disciplinary code (i.e., the Student Code of Conduct (http://www.uky.edu/StudentAffairs/Code/) and/or the Health Care Colleges Code of Student Professional Conduct (http://www.uky.edu/Provost/APFA/Policy_Protocol/HCCSPBC.pdf)).

c) Medical Trainees (housestaff). Medical Trainees (housestaff) who violate the Policy will be reported to the Office of Graduate Medical Education, who will notify the appropriate program director. Trainees who violate the Policy will be subject to corrective action according to the applicable disciplinary code (i.e., the Student Code of Conduct (http://www.uky.edu/StudentAffairs/Code/) and/or the Health Care Colleges Code of Student Professional Conduct (http://www.uky.edu/Provost/APFA/Policy_Protocol/HCCSPBC.pdf), or the Graduate Medical Education (GME)
Resident/Fellow handbook and the Policies and Procedures for Graduate Medical Education (http://www.mc.uky.edu/gme/0809GMEResidentHandbook.pdf)).

d) Dual Student/Employee Status. Some students, such as Postdoctoral Scholars, Postdoctoral Fellows, and Teaching Assistants, may have dual status as a student and an employee. These students who violate the policy should be reported to the Dean of their college, or the Dean of Students. These students may be subject to corrective action according to the applicable disciplinary code (i.e., the Student Code of Conduct (http://www.uky.edu/StudentAffairs/Code/), the Health Care Colleges Code of Student Professional Conduct (http://www.uky.edu/Provost/APFA/Policy_Protocol/HCCSPBC.pdf), the Human Resources Policies and Procedures, or other applicable University regulations or policies.).

III. In-Patients

During the admission process, all patients will be informed of the UKHC Tobacco-free policy and receive a brochure. During admission and orientation to the inpatient unit, patient care staff will review the tobacco policy with the patient and family. Patients will be assessed for tobacco use and provided treatment to manage symptoms and/or treat tobacco dependence as appropriate.

Tobacco use by an in-patient will be reported to the appropriate patient care unit.

Inpatients: First Violation of Tobacco-Free Policy

Who Responsible	Action
Patient Care Manager	Notify Attending Physician Document all actions Complete reportable occurrence form (online) and send copy to Security Notify Security
Attending Physician	Visit with patient to emphasize importance of compliance with policyand advise of potential consequences including discharge Offer nicotine replacement therapyor prescription medication if appropriate to situation andpatient’s condition. Document actions in patient chart
Security	Visit patient Remind patient of the policy Notify Tobacco Treatment Consult Service Determinevisitor restriction if contributing to the problem, with input with clinical staff Sendcopy of reportable occurrence form to Tobacco Treatment Consult Service
Tobacco Treatment Consult Service	Visit patient, assess motivation to quit smoking, offer appropriate tobacco treatment Discuss policy and potential consequences, and urge use of medications if appropriate Document all actions in chart

Repeat Violation of Tobacco-Free Policy

Who Responsible	Action
Patient Care Manager	Contact Risk Management for strategy to achieve compliance Complete reportable occurrence form (online). Notify Attending Physician. Notify Security
Attending Physician	Confer with Risk Management regarding plan of action and the Chief Medical Officer if emergency intervention. Visit with patient and inform of necessary action to be taken including discharge. Offer nicotine replacement therapy or prescription medication if appropriate to situation and patient’s condition. Document actions in patient chart.
Security	Visit patient Determine visitor restriction if contributing to the problem, with input from clinical staff. Notify Tobacco Treatment Services. Notify Risk Management. Send copy of security report to Tobacco Treatment Consult Service, Risk Management and Chief Medical Officer. If emergency intervention (impending discharge), page Chief Medical Officer and Tobacco Treatment Consult Service.
Tobacco Treatment Consult Service	Visit patient, follow up with bedside consultation for tobacco treatment. Document all actions in chart.

IV. Out-patients and Visitors

Before and during the registration process, all outpatients and visitors who accompany the patient will be informed of the UKHC Tobacco-free policy and patients will receive a brochure on-site. Tobacco use violations by any person will be reported to UK Healthcare Security. Outpatients and visitors who violate the Policy may be asked to leave the tobacco-free area by Security.

V. Campus Visitors and Guests

Visitors and Guests will be notified of this policy through on-campus signage, notification on the UK website, and notification provided by the University department that is responsible for their visit. Visitors and guests who pre-register for a visit will be informed of the Tobacco-free policy at the time of registration or prior to the visit. Tobacco use violations by any person will be reported to the university department that is responsible for their visit. Guests and visitors who violate the Policy may be asked to leave campus.

VI. Vendors and Contractors

Vendors and contractors will be informed of the University of Kentucky Tobacco Policy in the bid or contract documents. Violations of the Policy by vendors or contractors or any of their employees or agents, including subcontractors, will be considered a breach of contract.

Tobacco use by a vendor or contractor will be reported to appropriate campus contact, Physical Plant Division, Purchasing, Project Managers, Food Services, etc. The name or description of the individual and location should be provided. Follow up will be handled by the Facility Project Manager.