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HUMAN RESEARCH PROTECTION MANUAL

CHAPTER 3

 

3.0.1 Principal Investigators and Research Team

UTEP policy requires training for all faculty, faculty advisors, principal investigators and students who conduct human subject research. This requirement extends to external researchers from other institutions. All people listed as members of the research team that interact with participants must complete human subjects training. To comply with the policy, UTEP affiliates with the Collaborative Institutional Training Initiative (CITI) Program.

All training requirements are updated regularly, as determined by the IRB Chair and AVP of RCRS. Please refer to the IRB website, to review specific training requirements.

Researchers may collaborate with partners from non-academic settings when performing community-engaged research. These partners also need human subjects training, as determined by the IRB Chair and AVP of RCRS. Please refer to the IRB website, to review specific training requirements.

Training compliance will be verified as all submissions are screened and processed. Submissions will not be finalized until training requirements are met.

3.0.2 IRB Members and Staff

A vital component of a comprehensive human research protection program is an education program for the IRB Staff, IRB Chair, Vice Chair and members. UTEP is committed to providing training and an on-going educational process for IRB members and the staff of the IRB Office, related to ethical concerns and regulatory and institutional requirements for the protection of human subjects.

IRB members, their alternates, the IRB Chair, and Vice-chair must complete the required CITI Program IRB member training upon being appointed to the IRB and every three years for the duration of their membership.

Initial training consists of completion of modules relating to their service as IRB members. A IRB staff member will schedule an in-person meeting to provide orientation information (meeting schedules, locations, etc.), discuss member duties and meeting processes.

To ensure that oversight of human research is ethically grounded and the decisions made by the IRB are consistent with current regulatory and UTEP policy requirements, training is continuous for IRB members throughout their service on the IRB.

In addition to initial training requirements, the IRB Chair, Vice Chair, Members, and Staff must also satisfy continuing education requirements on an annual basis. UTEP uses the following activities as a means for offering continuing education to IRB members, Research Compliance Manager, and IRB staff:

  • In-service training at IRB meetings that include current hot topics
  • Training workshops, webinars, and conferences
  • Identification and dissemination by the IRB Office staff of new information that might have affected the human research protection program, including laws, regulations, policies, procedures, and emerging ethical and scientific issues to IRB members via email, or during IRB meetings

Staff must document that they have completed the IRB member CITI Program training. Attendance at regional and national meetings (e.g., PRIM&R) is encouraged and supported. IRB staff are encouraged to attend any additional training, such as webinars offered by the Office for Human Research Protections (OHRP) and to obtain IRB Certification (Certified IRB Professional (CIP) as they become eligible.

3.1.1 Principal Investigators

The following are the PI responsibilities and are not all inclusive:

  • Assure that all personnel listed on the research protocol have completed the human subject research training.
  • Assure that all covered individuals listed as research personnel on non-exempt protocols have submitted a Conflict-of-Interest Disclosure.
  • Submit protocols for IRB review and approval of proposed research activities prior to commencing the research activities.
  • Employ sound study design in accordance with standards of the PI’s discipline.
  • Assure that adequate time and resources are present before conducting a research study to assure participant protections.
  • Maintain appropriate oversight of each research study, as well as research staff, and appropriately delegate research responsibilities and functions.
  • Ensure that the research is conducted according to the protocol, any signed agreements, in compliance with all applicable laws and regulations and organizational policies and procedures with the highest ethical standards.
  • Submit for review and approval all proposed protocol and consent form changes prior to implementing the changes in the protocol except where necessary to eliminate apparent immediate hazards to human subjects.
  • Obtain legally effective informed consent from subjects prior to commencement of research activities, unless the requirement is waived by the IRB.
  • Ensure the rights, safety and welfare of research subjects are upheld and protected.
  • Follow reporting requirements for problems that require prompt reporting.
  • Submit requested data at specified times for continuing review of ongoing research activities.
  • Upon completion of a study, honor all commitments that were agreed to as part of the approved research, e.g., providing information about the study results to research subjects or honoring commitments for reimbursements to subjects.
  • Submit a Closure Report to the IRB upon completion of a study.
  • Disclose any conflicts of interest.
  • Retain records as required by regulations, the sponsoring entity, and local policy for the appropriate period.
  • When PI is the lead researcher for a multi-site study, applications must include information about the management of information that is relevant to the protection of research participants, e.g., interim results; protocol modifications; how unanticipated problems involving risks to participants or other unanticipated problems will be managed.; how communication of unanticipated problems to all sites will occur; how protocol modifications will be managed; is there a formal agreement in place delineating each site’s roles and responsibilities.
  • If the PI holds an Investigational New Drug (IND)/Investigational Device Exemption (IDE), adhere to sponsor responsibilities in addition to investigator responsibilities as per 21 CFR Parts 312/812.
  • If appropriate, assure that applicable clinical trials and National Institutes of Health (NIH) sponsored clinical trials are registered on the governmental database at ClinicalTrials.gov.
  • Address research participants’ concerns, complaints, or requests for information.

3.1.2 Faculty Principal Investigators for Student Research

UTEP requires all research to be conducted under the guidance of a qualified Principal Investigator. Students will be engaged in conducting research as an integral part of their educational experience. Faculty who assumes advisory responsibility for student-led research involving human subjects must be willing to provide oversight for the research activities and assume full responsibility for the conduct of the research. The Faculty Advisor must be actively involved in the research, from protocol design to data analysis and report preparation. In many cases, it may be the student's first experience with formal research. The success of the student's experience will be measured not only in the outcome of their projects, but also in what they learn from the faculty advisor. These experiences will help form their perception of scientific research, and in some cases, determine whether a career in academic research is right for them. The following are the Faculty Advisor responsibilities and are not all inclusive:

  • Advise the student on the content and preparation of their research proposal. Understand the research hypothesis, goals, and methodology. Guide and interact with the student throughout the research project.
  • Assist the student with the preparation of the IRB application. As the PI on the project, submit the application to the IRB. Ensure the student obtains all necessary approvals (i.e., IRB) before initiating the project, implementing any changes in the research activities and continuing the research activities after the approval period has expired.
  • Assume full oversight of the IRB protocol and ongoing when the student leaves the institution prior to completing the research protocol.
  • Ensure that the student is provided with, or has access to, information on University policies relating to administration of their protocol.
  • Ensure the student understands the underlying ethical principles for conducting research with human subjects and the applicable research regulations and local policies and procedures. Stay abreast of the status of the protocol and ensure on-going compliance with federal regulations and institutional policies and procedures relating to human subject research and IRB required reporting.
  • Advise and assist students with the preparation of poster presentations and papers, as applicable.
  • Ensure that all study documents and data are archived at the end of the study in accordance with federal, state and local policy and regulations.
  • Be available to the student during the active research period.

3.1.3 Institutional Official

The Vice President for Research & Innovation is designated by the University President as the Institutional Official to have responsibility for the Human Research Protection Program with the authority to delegate activities as may be necessary to fulfill the following responsibilities:

  • Ensure compliance with institutional policies and all applicable regulations for the protection of human research subjects.
  • Is legally authorized to represent the institution in matters regarding human subject research and is the signatory authority for all Federal-Wide Assurance (FWA) to the Office for Human Research Protections (OHRP).
  • Responsible for review and evaluation of reports on HRPP performance and QI activities.
  • Periodically evaluates the resource needs of the HRPP in collaboration with the AVP of RCRS, Research Compliance and Regulatory Services. Responsible for further institutional review or disapproval of research approved by the University IRB (neither the IO nor any other University official can approve research that was disapproved by the IRB).

3.1.4 Institutional Review Board (IRB)

IRB main responsibilities in safeguarding the rights and welfare of subjects are as  follows and are not all inclusive:

  • Conduct review of initial protocol submissions, continuing reviews, and all revisions to protocols of human subject research conducted by the University researchers.
  • Approve, require modifications to secure approval, defer (table), or disapprove research activities overseen and conducted under the auspices of the University, regardless of location of the research activities.
  • Systematically analyze protocols for benefits to subjects and importance of knowledge to be expected and assess the potential benefits in relation to the potential risks involved in the research.
  • Report in writing the findings and actions of the IRB to the PIs, IO, and, when applicable, to federal regulatory agencies or departments, as necessary.
  • Determine the interval at which ongoing studies need to be reviewed by the IRB.
  • Determine which studies need verification from sources other than the researchers that no material changes have occurred since the previous IRB review.
  • Observe, or have a third party observe, consent processes and/or the conduct of research.
  • Ensure prompt reporting of any changes in research activities to the IRB by researchers.
  • Ensure prompt reporting (within 30 days of the determination), by PIs, to the IRB and/or federal agencies or departments (where applicable) of:
    • Unanticipated problems involving risks to subjects or others.
    • Serious or continuing non-compliance with regulations.
    • Suspension or termination of IRB approval.
  • Determine if studies involving drugs need an investigational new drug (IND) number designated by the FDA.
  • Determine if studies involving investigational devices pose significant or non-significant risk and whether an investigational device exemption (IDE) is required.
  • Suspend or terminate approval of research not being conducted in accordance with IRB requirements or that has been associated with unexpected serious harm to subjects.
  • If applicable, act as the Privacy Board for research involving the use of PHI.

3.1.5.1 IRB Chair and Vice Chair

IRB Chair and Vice Chair main responsibilities are as follows and are not all inclusive:

  • Serve as public spokesperson for the IRB
  • Chair full board meetings of the IRB
  • Ensure adequate expertise for review and determination
  • Assure a quorum is present for all meetings
  • Review protocols, continuing review reports, unanticipated problems and deviation reports, and other documentation submitted to the IRB
  • Obtain an individual vote on all IRB actions (For, Against, Abstain)
  • Vote on each IRB action
  • Delegate review responsibilities as necessary and applicable
  • Maintain up-to-date knowledge of human subjects regulations and pertinent events
  • Consult with investigators as necessary
  • Suspend the conduct of research when individuals are placed at an unacceptable level of risk
  • Collaborate with IRB staff to provide continuing education for IRB members
  • Collaborate with the IRB staff to resolve IRB-related issues with faculty or subjects
  • Recognize and support partnership with IRB to assure IRB efficiency and effectiveness

3.1.5.2 IRB Members

IRB members responsibilities are as follows and are not all inclusive:

  • Be familiar with IRB policies and procedures and federal, state, and local regulations policies or guidelines relating to human subject research.
  • Review submitted proposals assigned by the Chair or Chair’s designee.
  • Review meeting documents in advance of IRB meetings and be prepared for discussion of submitted protocols.
  • Act as a primary or secondary reviewer of protocols when assigned.
  • Maintain confidentiality of IRB proceedings.
  • Disclose conflicts of interest, if applicable.
  • Attend a minimum of 75% of scheduled meetings.
  • Maintain current human subjects training.
  • Actively engage in continuing education related to human subject research.

3.1.6 Clinically Responsible Investigator

If research procedures involve clinical elements and the PI is not qualified in the appropriate clinical area, does not hold an applicable license, or does not have privileges to practice where the research will occur, a licensed and institutionally credentialed clinician appropriately qualified by education, training, experience, and background and appropriate privileges must be designated as the Clinically Responsible Investigator.

The Clinically Responsible Investigator must manage or appropriately delegate all clinical elements of the research such as physical examination, psychological testing, providing counseling services, conducting any drug administration, follow-up examinations, evaluating lab values, test results and reviewing all adverse events.

Clinical elements of a study are considered any event, procedure, test, or intervention that would require performance by a licensed/credentialed professional in a non-research setting.

During review of human subject research, the IRB can determine that a Clinically Responsible Investigator must be identified. The Clinically Responsible Investigator should be noted by name in the research proposal and listed as research personnel in the electronic protocol system. A copy of the Clinically Responsible Investigator’s Curriculum Vitae should be uploaded in “Other Attachments” in the project. The Clinically Responsible Investigator’s contact information should also be included in the informed consent document(s).

3.2 Project Compliance Verification

In accordance with 21 CFR 56.108(a)(2) (FDA) and 45 CFR 46.109(g) (OHRP), a duty of the IRB is to assure itself, by whatever method it deems appropriate, that the rights and welfare of human subjects are being protected. This applies to transnational research and research taking place in other states and in Texas. The IRB may determine that it is appropriate to use sources other than reports from the investigator to verify that no material changes in the protocols have occurred since their most recent review, and that investigators are conducting the research in compliance with all regulations, laws (domestic and international), policies, and guidelines. Also, the IRB may determine that the consent process for some higher risk protocols should be observed.

To assess whether there have been no material changes in the protocols as stated above, the IRB may request that members of the IRB and/or IRB staff conduct an observational visit for a specific protocol. This review will help ensure that investigators are not implementing protocol changes prior to IRB review and approval, except when necessary to eliminate apparent immediate hazards to subjects.

As a part of an ongoing Quality Improvement (QI) program, monitoring reviews may be initiated in other ways:

  • The Post Approval Verification & Education (PAVE) staff may randomly select protocols from a list of currently approved protocols.
  • The PI or the PI’s department may wish to have research protocols reviewed proactively for compliance.
  • The IRB may determine that verification of compliance is required and may request a For Cause Evaluation.

Upon completion of the PAVE visit, the results will be reported to the AVP of RCRS and IRB Chair. The PI will be asked for a response to the findings of the visit, if applicable. The report and, if requested by the IRB, the PI’s responses will be brought to the IRB at a full board meeting for discussion and action.

3.3 Questions, Comments, Complaints or Concerns           

All questions, comments, complaints, or concerns about the HRPP, IRB, or IRB staff or feel they may have been subjected to or have observed instances of, coercion or undue influence in aspects of human subject research may contact:

IRB Office

Kelly Hall, 4th Floor

Email: irb@utep.edu

Phone: 915-747-6590

Website: https://www.utep.edu/research/human-subjects-research/  

All IRB, HRPP or IRB staff questions, comments, complaints, concerns or other input and any allegations of coercion, undue influence or non-compliance are thoroughly investigated, and corrective actions taken when needed.

The AVP of RCRS is responsible to assure that all concerns, complaints, and allegations have been addressed appropriately and that input and suggestions related to the HRPP are considered when reviewing the program. The IRB staff will seek to resolve any complaints, in collaboration with the PI as needed.

Further inquiry will follow procedures in Section 20 if the concern/complaint could be an incident of non-compliance. Unanticipated problems involving risks to subjects or others will be reviewed according to Section 9 of this manual.

3.4.1 HRPP

The IRB Administrator, with input from the IRB Chair, will periodically review the composition of the IRB and determine whether it is appropriate for the volume and types of research being reviewed to ensure thorough and timely IRB review. Recommendations for the appointment of new members and removal of members will be forwarded to the IO. The AVP of RCRS will annually consider whether the resources and personnel being provided in support of the HRPP are adequate and advise the IO as necessary. Additionally, the AVP of RCRS will evaluate allocated space, personnel resources to support the HRPP, the availability of legal counsel and the process of assuring that all applicable personnel involved in the HRPP have completed the required training and submitted financial interest disclosures.

The AVP of RCRS will periodically review HRPP policies and procedures and adjust as necessary. Comments from research faculty and staff regarding the HRPP will be reviewed as they are received by the IRB Chair, Vice-Chair, AVP of RCRS, and, if necessary, the IO. If applicable, modifications to the HRPP will be made and implemented, and the effectiveness of the implemented changes monitored and discussed at appropriate intervals.

Oversight of the HRPP includes implementation of a quality improvement function to continually assess compliance and effectiveness of the HRPP, and the IRB. The goal of this program is to ensure the HRPP is functioning in full compliance with applicable regulations using processes and procedures that are effective and efficient so that the system facilitates the highest quality of research.

This assessment process includes the following components:

  • Defining at least one objective for achieving or maintaining compliance and at least one objective for enhancing quality, efficiency, or effectiveness.
  • Defining at least one measure of compliance and at least one measure of quality, efficiency, or effectiveness.
  • Describing the methods to assess compliance and make improvements, as needed, and methods to assess quality, efficiency, or effectiveness to make improvements.

Examples of assessing compliance might include:

  • Evaluating IRB meeting minutes for compliance with quorum requirements, accurate documentation of votes and recusals, and accurate documentation of regulatory findings.
  • Assessing IRB reviews and corresponding documentation to ensure the appropriate review
  • category has been determined, regulatory criteria for approval are appropriately met, and appropriate documentation is maintained.
  • Assessing IRB reviews of research with additional sponsor requirements or vulnerable populations to ensure requirements are met and documented appropriately; and
  • Reviewing study documentation and reliance agreements for compliance with policies and procedures.
  • Examples of assessing quality, efficiency and effectiveness might include:
  • Determining whether IRB time-to-approval is within institutionally identified goals and comparing with AAHRPP accredited peers.
  • Evaluating the amount and quality of IRB feedback provided to researchers; and
  • Evaluating research community and IRB member needs for training and guidance.

The AVP of RCRS and the PAVE Administrator are responsible for identifying objectives and measures for quality assurance and quality improvement (QA/QI). The outcomes of QA/QI (PAVE) efforts are documented and reviewed via QA reports and periodic HRPP progress reports.

3.4.2 IRB Members and IRB Staff

The IRB Administrator, in consultation with the IRB Chair, periodically reviews IRB Members, IRB member feedback, and any input from outside the IRB and provides recommendation(s) to the IO regarding the recruitment, retention, or dismissal of members. This review includes examination of attendance, specialty, expertise, education, affiliation, and diversity. A summary of the evaluations and member comments will be submitted through the Associate Vice President of Research Compliance and Regulatory Assurances to the IO.

3.5 Community Outreach

IRB dedicates a webpage for current and future research participants. This webpage will contain useful research process information for participants and is updated as needed.

3.6 Records Retention

To allow a reconstruction of a complete history of IRB actions related to the review and approval of protocols, the IRB records include copies of:

  • Protocol applications, research protocols, consent documents, recruitment materials, investigator brochures, and all other documents submitted for review of proposed human subject research
  • Scientific evaluations, when provided by an entity other than the IRB
  • IRB meeting minutes
  • Progress reports submitted by researchers
  • Reports of injuries to participants
  • Data and safety monitoring reports, if any
  • Modifications to previously approved research
  • Records of continuing review activities
  • Unanticipated problems involving risks to subjects or others
  • Documentation of non-compliance
  • Significant new findings
  • All correspondence between the IRB and researchers
  • IRB reliance records, including agreements, local context documents, and documentation of the rationale for not utilizing a single IRB for cooperative research when subject to federal requirements.

IRB records document all IRB determinations including, but not limited to, those required by laws, regulations, codes, and guidance. IRB records for initial and continuing review of research by the expedited procedure include the justification for using the exempt and expedited procedure and actions taken by the reviewer.

Records are accessible for inspection and copying by authorized representatives of federal agencies or departments at reasonable times and in a reasonable manner.

All research records are retained for at least three years after completion of the research. If a protocol is canceled without participant enrollment, IRB records are maintained for at least three years after cancellation.

UTEP Records Retention Schedule (https://www.utep.edu/purchasing-and-general-services/pgs-departments/records-management/retention-schedule.html) is certified by the Texas State Library and Archives Commission. It has been adopted as an administrative rule of the University. All official state records (paper, microform, electronic, or any other media) listed on the schedule must be retained for the minimum period designated. Once official University records have met their retention periods, they must be disposed of in accordance with the policies and procedures of Records Management.