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Human Research Protections & Institutional Review Board

The Presbyterian Healthcare Services’ (PHS) Human Research Protections Program (HRPP) exists to promote high quality, ethical research. The HRPP does this by serving as the advocate for the rights and welfare of persons who participate in research programs conducted under the auspices of PHS. Research oversight at PHS is the responsibility of the Institutional Review Board.

The Human Research Protections Program at Presbyterian Healthcare Services (PHS)

Presbyterian Healthcare Services (PHS) has established a human research protections program which (in partnership with its research community) is responsible for ensuring the ethical and equitable treatment of human subjects in research conducted under the auspices of PHS. Research under the auspices of the organization includes research conducted at PHS, conducted by or under the direction of any affiliated investigator (including students or residents) in connection with his or her organizational responsibilities, conducted by or under the direction of any approved unaffiliated investigator proposing to use any PHS property, facility, patient/employee population, or non-public information for research purposes.

PHS fosters a research environment that promotes respect for the rights and welfare of individuals participating in research. In reviewing and conducting research, PHS adheres to the principles described in the Ethical Principles and Guidelines for the Protection of Human Subjects in Research (commonly known as the “Belmont Report”) by the National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research. In addition to upholding these principles, PHS research activities conform to all applicable federal, state, and local laws and regulations, as well as PHS organizational policy.

The PHS Human Research Protections Office is responsible for implementing and managing the human research protections program.

Human Research Protections Office

The mission of the PHS Human Research Protections Office (HRPO) is to advance the ethical treatment of research participants and ensure the responsible conduct of research by (1) safeguarding the rights, privacy, and welfare of human participants in research projects conducted under the auspices of PHS; and (2) facilitating a culture of respect, integrity, responsibility, and trust; and (3) providing timely and high quality education, review, and monitoring for human research projects.

The PHS HRPO provides administrative and technical support to researchers, and to the PHS Institutional Review Board (IRB). Learn more about the IRB.

Contact Us

If you have questions about conducting research at Presbyterian, please contact the HRPO.

Phone: 505-841-1436
Email: PHSResearch@phs.org
Hours: Monday – Friday, 8:00 a.m. to 5:00 p.m. ​

Policies, Procedures, and Guidelines

The Presbyterian Healthcare Services (PHS) human research protections program operates under the organizational authority of two policies: “Human Research Protections Program” (IRB.PHS-E.002), and “Human Research Protections and Institutional Review Board Policies and Standard Operating Procedures” (IRB.PHS-E.001).  These policies can also be accessed from IRBNet.

Applicable regulatory guidance and standard operating procedures specific to the PHS human research protections program are available below, and may also be found on IRBNet.

Federal Wide Assurance

The federal regulations require that federally-funded human subject research only be conducted at facilities covered by a Federal Wide Assurance (FWA) approved by the U.S. Department of Health and Human Services’ (DHHS) Office for Human Research Protections (OHRP). An FWA is an organization’s assurance to the federal government that human subject research conducted at that site is in compliance with federal regulations pertaining to the protection of human subjects. The FWA designates the Institutional Review Board (IRB) that will review and oversee the research, specifies the ethical principles under which the research will be conducted, and names the individuals who will be responsible for the proper conduct of the research.

Presbyterian Healthcare Services (PHS) has an OHRP-approved FWA (#00006178), and has designated one IRB (registration # IRB00001091) to review all human research plans. In its FWA, PHS has opted to limit the application of the FWA to non-exempt human subject research conducted or supported by DHHS or federal agencies that have adopted the Common Rule.

Regulatory and Institutional Authority

The Presbyterian Healthcare Services (PHS) human research protections program derives its regulatory authority from the following:
  • Code of Federal Regulations (CFR) Title 45 Part 46 (45 CFR 46): “Protection of Human Subjects” (aka the “Common Rule”)

The Presbyterian Healthcare Services (PHS) human research protections program operates under the organizational authority of two policies: “Human Research Protections Program” (IRB.PHS-E.002), and “Human Research Protections and Institutional Review Board Policies and Standard Operating Procedures” (IRB.PHS-E.001).  These policies can also be accessed from IRBNet.

Institutional Review Board

The Presbyterian Healthcare Services' (PHS) Institutional Review Board approves, monitors, and reviews all research involving human participants that is conducted under the auspices of PHS.

What is an Institutional Review Board (IRB)?

An Institutional Review Board (IRB) is a committee established to review and approve research involving human subjects. PHS has established an on-site IRB to ensure the protection of the rights and welfare of human research subjects through review and oversight of safe and ethical research. The IRB discharges this duty by complying with the requirements of federal and state regulations, the FWA, and organizational policies.  All non-exempt research conducted under the auspices of PHS must be reviewed and approved by the PHS IRB or another designated IRB prior to the initiation of the research unless it has been determined that PHS is not engaged in the research.

The PHS IRB derives its authority from federal regulatory sources (45 CFR 46.107).

IRBs have the authority to:

  1. Approve, require modifications to secure approval, or disapprove all human subjects research activities overseen and conducted under the auspices of the PHS;
  2. Require that informed consent be obtained and documented in accordance with regulatory requirements unless the criteria for the waiver or alteration of such requirements has been satisfied and approved by the IRB.  The IRB may require that information, in addition to that specifically mentioned in the regulations, be given to the subjects when in the IRB's judgment the information would meaningfully add to the protection of the rights and welfare of subjects;
  3. Conduct continuing review of research at intervals appropriate to the degree of risk of the research, but not less than once per year;
  4. Suspend or terminate approval of research not being conducted in accordance with the IRB’s requirements or that has been associated with unexpected serious harm to participants;
  5. Observe, or have a third party observe, the consent process; and
  6. Observe, or have a third party observe, the conduct of the research.

IRB members are volunteers who represent the specialty areas that encompass most of the research performed at the PHS, as well as the interests of the community. In addition to regular and alternate members, the PHS IRB has two elected officers: Chair and Vice Chair. The IRB functions independently of, but in coordination with, other organizational committees and officials and must remain free from the influence of financial and other organizational interests. However, the IRB makes its independent determination to approve or disapprove a research plan based upon whether or not human subjects are adequately protected.

Membership on the IRB

The PHS Human Research Protections Office (HRPO) accepts nominations and applications on a continuous basis from individuals interested in serving on the IRB. HRPO staff, along with the IRB Chair, review all completed applications with consideration for maintaining the diversity and specialty requirements as mandated by federal regulations. Recommended applications are then sent for formal institutional approval. Members are appointed to a two-year renewable term.

If you are interested in serving on the PHS IRB as a scientific, non-scientific, or community member, please complete the IRB member application form and submit to PHSResearch@phs.org.

Attending IRB Meetings as a Guest

Guests wishing to attend IRB meetings must request permission in advance from the HRPO, and must complete a confidentiality agreement.

Does My Project Need IRB Review?

The responsibility for initial determination of whether an activity constitutes human subject research rests with the investigator. The investigator should make this determination based on the definitions of “human subject” and “research” below. Because they will be held responsible if the determination is not correct, investigators are urged to request a confirmation from the Presbyterian Healthcare Services’ (PHS) Human Research Protections Office (HRPO) that an activity does not constitute human subject research. The request may be made by email or through a formal written communication. All requests must include sufficient description of the activity and the rationale for the investigator’s initial determination.

The PHS Institutional Review Board (IRB) has assured federal regulatory agencies that the institution will review and approve all research that meet the federal definition of human subjects’ research.

Determining whether or not a project meets the federal definition of human subjects’ research is a two-step process. The investigator must determine if the project meets the federal definition of research and, if so, determine if the project includes human subjects. The information below will help you assess whether IRB review is required.

Step One: Is it Research?

Federal regulations regarding the protection of human subjects in research are codified at 45 CFR Part 46, subparts A through D (also known as the “Common Rule”). The Common Rule defines research as “a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” IRB review is not required if your project does not match the definition of research. You do not need to submit an application. If your project matches the definition of research, go to Step Two below.

Step Two: Does it Involve Human Subjects?

The Common Rule defines human subjects as “…a living individual about whom an investigator (whether professional or student) conducting research obtains (1) data through intervention or interaction with the individual, or (2) identifiable private information.”

If your activity is research but does not involve human subjects as defined in the regulations your activity does not fall under the purview of the IRB. You do not need to submit an application.

If you have determined that your research does meet the federal definition for human subjects research, you will need to apply for IRB review and approval before you begin (the IRB will not review projects retrospectively).

Who Can Conduct Research?

In order for a study to be eligible for review by the Presbyterian Healthcare Services (PHS) Institutional Review Board (IRB), the principal investigator (PI) or a co-investigator must be affiliated with PHS.

An Affiliated investigator is any individual who is qualified by experience, education, and training to conduct research at PHS, and who falls into one of the following categories:

  • A physician or advanced-practice clinician with clinical privileges at a PHS facility;
  • A private-practice physician on the PHS medical staff who does not have clinical privileges;
  • A paid employee of PHS, including an employee currently enrolled as a student in an academic program related to the study;
  • An employee of a PHS-contracted service (e.g., Tricore Labs, Radiology Associates of Albuquerque); or
  • A resident who is participating in a program which has a clinical affiliation agreement with PHS.

An Unaffiliated investigator is any individual who

  • Does not meet the above affiliation criteria (for example, a resident participating in a program which does not have a clinical affiliation agreement program with PHS or a private-practice physician without clinical privileges); and
  • Proposes to conduct research using any PHS property, facility, patient/employee population, or non-public information.

Approval is required when a PI is not affiliated with PHS or is not covered under the IRB of another institution. Any human research activities being proposed by an unaffiliated PI may be covered under the PHS FWA only in accordance with a formal, written agreement stating a commitment to abide by PHS’s policies/procedures and IRB oversight.

Principal Investigator

Conducting research with humans is a privilege and carries with it ethical and legal responsibilities. The PI is the individual responsible for writing an accurate protocol to utilize human subjects. Ultimately, the PI assumes the responsibility for the ethical conduct of the project and for the welfare of the human subjects. This responsibility includes the intellectual conduct of the project, fiscal accountability, administrative aspects, and the project’s adherence to relevant policies and regulations.

Student Investigators

Student investigators must be paid PHS employees in order to initiate a research project at PHS. Student investigators must also identify a study mentor who will provide guidance and oversight of the proposal development/submission process and the conduct of the research. Study mentors must formally approve and sign off on student applications.

Required Training and Education

Anyone who is significantly involved in the design, conduct, or publishing of research (e.g., investigators, study coordinators, study nurses, etc.) is considered an investigator and must complete required training, including the Collaborative Institutional Training Initiative (CITI) course in the ethical use of human subjects in research.

Individuals who are assisting with the study in an administrative capacity or who are ancillary to the study (e.g., data entry clerks, phlebotomists, technicians, etc.) are not considered to be co-investigators and are not required to take CITI training.

Investigators should choose the appropriate CITI curriculum depending on their research focus (social-behavioral or biomedical). New study applications and requests for continuing review will not be processed until all key study personnel have completed CITI training. Re-training is required every three years and requires completion of CITI refresher modules.

How Do I Submit a Research Project to the IRB for Review?

New Principal Investigators (along with at least one other member of the study team) who are seeking IRB review of research projects are required to register with IRBNet, PHS’s web-based electronic submission system.

Investigators must submit completed study applications along with ALL relevant materials via IRBNet. No hard copy or email attachments will be accepted.

Study activities may not begin until notification of approval from the IRB has been received.

Types of Review

The federal regulations, Title 45 CFR Part 46, describe three levels of IRB review (see below). Please note that the Presbyterian Healthcare Services (PHS) Institutional Review Board (IRB) will make the final determination whether your application is appropriate for full, expedited, or exempt review. The IRB may request additional information or revision of materials or procedures before approval. A quicker response time is dependent, in part, on whether the application is neatly and completely filled out, avoids the use of jargon, and includes copies of all pertinent materials attached in a logical order.

Exempt Studies

All research using human subjects must be approved by the PHS IRB. However, under federal regulations (45 CFR 46.101(b)), certain categories of human subject research are exempt from IRB approval. Exempt research is subject to review for determination of exemption status, and exemptions are determined or granted, rather than approved. Although exempt research is not covered by the Common Rule [45 CFR 46], this research is not exempt from ethical considerations, such as honoring the principles described in “The Belmont Report.” The IRB does not conduct continuing reviews of exempt research but any changes to the exempted project should be reviewed by the IRB to ensure the exemption still applies.

In order to obtain an exemption determination, investigators must submit a completed “Request for Determination of Exempt Status” form (available for download from IRBNet). The IRB Chair or designee review all requests for exemptions and determine whether the request meets the criteria for exempt research. Exempt determination letters do not include a termination date. However, studies receiving an Exempt classification by the IRB will be required to submit a one-page “Study Update Form Exempt/Ceded Review” each year in order to keep the study open. It is the responsibility of the Principal Investigator to inform the PHS IRB of any changes in the study scope or design prior to implementation of the changes to ensure that the study continues to meet the exempt criteria. Investigators must also notify the Human Research Protections Office (HRPO) when an exempt research project is complete so that the organization can maintain an accurate database of active research.

Expedited Review

Expedited review is a process by which certain types of minimal risk research may be reviewed and approved without convening a meeting of the IRB. Expedited reviews are not “quicker” or conducted with less rigor, but fewer reviewers are required for approval. There are several types of research that may be reviewed in an expedited manner. Research activities that (1) present no more than minimal risk to human subjects, and (2) involve only procedures listed in one or more of the categories listed in and authorized by 45 CFR 46.110 and 21 CFR 56.110 may be reviewed by the expedited review procedure.

Full Review

All research that poses greater than minimal risk to research participants will be reviewed at a convened meeting of the IRB.

All studies submitted for Expedited and Full Board review will first be pre-reviewed by the HRPO/IRB Coordinator who will check for completeness and accuracy. Only complete submissions will be placed on the IRB agenda for review. The investigator will be informed either by e-mail, phone, or in person of missing materials and the necessary date of receipt for inclusion on the agenda.

If an investigator is submitting for the first time or is not well-versed in the submission procedures, a consultation can be arranged with HRPO/IRB staff.

Study activities may not begin until notification of approval from the IRB has been received.

What Dates/Deadlines Should I Be Aware Of?

All new study submissions need to be complete and received in the Human Research Protections Office (HRPO) by the 10th day of the month to be considered for inclusion on the next IRB agenda. The workload of the HRPO necessitates that all study submissions received after midnight on the 10th will be assigned to the next month’s agenda. The IRB meets on a regular basis throughout the year (typically on the fourth Tuesday of the month). The schedule for the IRB may vary due to holidays or lack of quorum.

Frequently Asked Questions

IRBNet is PHS’s web-based electronic submission system. Principal Investigators (along with at least one other member of the study team) who are seeking IRB review of research projects are required to register with IRBNet. All study applications and study related materials must be submitted via IRBNet. No hard copy or email attachments will be accepted.

An IRBNet basic training module is available below. HRPO staff members are also available for one-on-one training.

Yes. Both student projects conducted by PHS employees, and projects conducted by residents who are participating in affiliated programs need IRB approval, if the project fits the definitions of "research" and "human participants" as described above. Students and residents are required to identify a study mentor to oversee study activities.

Case studies generally involve the description of medical treatment in a single patient or a few patients with a unique treatment, disease course, or outcome based on a retrospective review of medical records, or they can involve a description of a unique diagnostic finding or uncommon presentation. No predetermined hypothesis or research question guides case studies and publication of the information about the patients’ medical care is not planned prior to or during the patients’ treatment. In addition, case studies are usually prepared by clinicians who have personally provided care to those patients.

Case studies usually do not require IRB review since they do not meet the Common Rule definition of research.

Yes, if your research project involves active data collection. Federal regulations and PHS policy require that ALL research involving intervention or interaction with human participants, regardless of whether or not identifying information is being collected, must be submitted for review prior to beginning the research study.

However, if your research project involves use of existing information collected from human participants (e.g., secondary datasets, existing biological samples), but there are not any identifiers linking individuals to the data/samples, then the activity may not require IRB review. Please see the Decision Tree or contact the HRPO staff for further guidance.

Under federal regulations [45 CFR 46.101(b)], certain categories of human subject research are exempt from IRB approval. Exemptions are determined or granted, rather than approved. The significance of exempt status is that the research activity is not monitored by the IRB (assuming the project does not change). However, even though exempt studies are not covered by the federal regulations, such research is not exempt from ethical considerations, such as honoring the principles described in The Belmont Report.

The criteria and processes for determining "exemption" from IRB review are outlined in the Human Research Protections Program Policies and Standard Operating Procedures manual.

In order to have a research project recognized as exempt, investigators will need to submit a “Request for Exempt Determination” form (available for download from IRBNet), along with other study related materials (e.g., consent forms, surveys, questionnaires, interview scripts/outlines, etc.) via IRBNet.

If you are affiliated with PHS and you are the person responsible for the conduct of the study (PI), you must get PHS IRB approval to conduct your research regardless of where the research takes place. Investigators should contact the IRB office whenever collaborative research is occurring. Separate applications for each institution may be necessary; however, in order to avoid duplicate review, an IRB Reliance Agreement may be arranged with the other institution to establish one IRB as the designated IRB to review and approve the research.

You must receive written approval from the PHS IRB before beginning participant recruitment, data collection, or data analysis. An e-mail will be sent to you via IRBNet when your project has IRB approval.

That depends on the nature of your study and the characteristics of the people you intend to recruit. Research projects that involve only minimal risks are eligible for expedited review, for which you should allow at least 3 weeks for IRB review.

All new study submissions need to be complete and received in the Human Research Protections Office (HRPO) by the 10th day of the month to be considered for inclusion on the next IRB agenda. The workload of the HRPO necessitates that all study submissions received after midnight on the 10th will be assigned to the next month’s agenda. The IRB meets on a regular basis throughout the year (typically on the fourth Tuesday of the month). The schedule for the IRB may vary due to holidays or lack of quorum.

Please consult the current year’s IRB meeting calendar for exact meeting dates.

No. There is no provision in the federal regulations that allow for IRB approval of research that has already been conducted. If data was collected for purposes that the IRB determines to be non-research, IRB approval can be sought for the data analysis going forward.

Fees

It depends. Fees are assessed for IRB review of human research projects according to the following schedule:

IRB Review Fees

Commercially Sponsored/Federally Funded Studies (Full Board or Expedited Review)

New Study Review:
Continuing Review:
Amendment (major changes):
Informed Consent Revision (major changes):
Minor Changes
(recruitment/advertising materials, PI change, etc.):

Unfunded or Investigator Initiated Studies
New Study Review (flat fee):

Other Services
Exempt Determination:
Request for Waiver to External IRB:
Late Continuing Review Submission:
Serious Adverse Event Reporting:
DSMB/Sponsor Reports:
Emergency Use or Expanded-Access Use:
Study Closure:
Student-Initiated Projects:

$1,750
$700
$350
$250
$100



$500


$750
$700
$350
No Charge
No Charge
No Charge
No Charge
No Charge

The Application Process

Every new study application submitted to the IRB must include a protocol and a completed application form, along with all required materials. For more information about the submission process and the types of documents that need to accompany your application form, please consult the Human Research Protections Program Policies and Standard Operating Procedures manual.

A research protocol is a document that describes the background, rationale, objectives, design, methodology, statistical considerations, and organization of a clinical research project. Every application submitted for review by the PHS IRB must be accompanied by a protocol.

The IRB also encourages researchers to consult with colleagues and other professionals in their field who have done research for advice on preparing research protocols.

No investigator conducting research under the auspices of PHS may involve a human being as a subject in research without obtaining the legally effective, written informed consent of the subject or the subject’s legally authorized representative unless a waiver of consent has been approved by the PHS IRB. The IRB will evaluate both the consent process and the procedures for documenting informed consent to ensure that adequate informed consent is obtained from participants. Consent forms must comply with federal regulatory requirements. The Office for Human Research Protections (OHRP) provides guidance on developing informed consent processes and documents.

The Office for Human Research Protections (OHRP) provides guidance on how to develop informed consent processes and documents.

The PHS Human Research Protections Office provides additional guidance on how to ensure readability when writing for a general audience.

A consent form template is also available for download from IRBNet.

Continuing Review

The IRB will conduct a continuing review of ongoing research at intervals that are appropriate to the level of risk for each research plan, but not less than once per year. At the time of initial review and at continuing review, the IRB will make a determination regarding the frequency of review of the research study. If IRB approval of the human research expires, all study procedures related to the protocol under review must cease, including recruitment, advertisement, screening, enrollment, consent, interventions, interactions, and collection of private identifiable information. IRB approval is considered to have lapsed at midnight on the expiration date of the approval (i.e., the expiration date is the last day research can be conducted). Continuing human research procedures is a violation of federal regulations. You need to receive continued approval from the IRB in order to continue research.

It is the responsibility of the principal investigator to ensure continued approval of his or her human participant research study. As a courtesy, the Human Research Protections Office will send reminder emails to the principal investigator 60, 30, and 14 days in advance of project expiration. If no response is received to the reminders, a notice indicating the approval for the study expired may be sent after the approval expiration date.

The approval date and approval expiration date are clearly noted on IRB determination letters and must be strictly adhered to. Investigators should allow sufficient time for development and review of continuing review submissions.

“Continuing Review Report” forms are available for download from IRBNet.

For more information about the continuing review process, please consult the Human Research Protections Program Policies and Standard Operating Procedures manual.

Closing a Study

Studies may be closed when the involvement of human subjects ceases (interventions, interactions, observations, and the gathering, use, study, and analysis of identifiable private information, including specimens, are all complete). Studies may be closed when the only remaining research activity involves the analysis of unidentifiable individual level data, or aggregate data sets.

Investigators should submit study closures to the IRB on a “Study Closure Report” form (available for download from IRBNet). With closure submissions, the investigator must provide a summary of the research activity and any findings available at that time.