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Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of CareTITLE:                Safety Management Plan...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care      4. Significant findings, discrepancies...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care             A.     The level of safety know...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care             e. CODE STORM: Severe Weather W...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care                    HAMILTON COMMUNITY HEALT...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care                 HAZARD SURVEILLANCE/RISK AS...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care                  HAZARD SURVEILLANCE/RISK A...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care                                 HAMILTON CO...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care                    HAMILTON COMMUNITY HEALT...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care                                            ...
Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care                                 HAMILTON CO...
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Ex environmentofcare-safetymanagementplan-100113002448-phpapp02 (1)

  1. 1. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of CareTITLE: Safety Management PlanREFERENCES: Joint Commission on Accreditation of Healthcare Organization’s Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) 2000 Standards EC.1.3 & EC.2.2OBJECTIVE: To effectively manage the components of the organization’s safety management systems and to minimize risks to People and Property. It is expected that there will be compliance to relevant Joint Commission standards.PROCEDURE(S): 1. A Safety Committee will be comprised of representatives from each department and administrative personnel. The CEO appoints all members of the Safety Committee. The chair of the Safety Committee is the Safety Officer. The Safety Committee will meet at least quarterly and perform the following functions: A. Keep minutes of meetings. B. Conduct and review periodic hazard surveillance and risk assessments. C. Evaluate the effectiveness of the organization in the performance of fire and other emergency-preparedness drills. D. Respond to safety-related incident reports. 2. Responsibility for implementation of the Safety Management plan rests with the Director of Operations. The Safety Committee is responsible for the supervision and day-to-day execution of the Safety Management Plan. Each Safety Committee member will be assigned one of the areas of responsibility listed below: A. Safety B. Life Safety C. Emergency Preparedness D. Security E. Utilities Systems F. Medical Equipment G. Hazardous Materials and Waste H. Infection Control 3. Pre-appointed Safety Committee members will conduct monthly/quarterly/ periodic hazard surveillance and risk-assessment inspections. The attached checklist will be used for this periodic inspection, and will be filed with the Safety Officer.May, 2005, Hamilton Community Health Network, Inc. Page 1
  2. 2. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care 4. Significant findings, discrepancies, or observations will be reviewed by the Safety Committee, which will develop a corrective action plan. This plan will be reported to the QI committee. 5. Risk assessments will be performed on an ongoing basis by department coordinators/ managers. Serious problems will be reported by work order to the Safety Officer, for immediate correction by the appropriate individual. Problems of a less immediate nature will be forwarded to the Safety Committee, which will proactively evaluate the impact of the situation on patient, staff and public safety. 6. All incidents of property damage, and patient or visitor injury will be reported immediately to administration. Staff witnessing the event will encourage the injured patient or visitor to be seen by a Provider, will complete the appropriate documentation and forward it to the Director of Operations. Responsible administrative staff will determine HCHN liability and subsequent billing. All Incident Reports will be forwarded to the Safety Committee for review and analysis. The Safety Committee will determine whether corrective action needs to be taken and will look for patterns, which suggests a need for system improvement. 7. Incidents of staff injury or occupational illness will be reported immediately to the supervisor. Affected staff must complete an Incident Report form, which must be sent to the Safety Officer and forwarded to the Human Resources Department so that a Workman’s Compensation claim can be initiated as appropriate. For needlestick injuries, see Policy for Exposure to Bloodborne Pathogens. 8. Ongoing surveillance of the building, grounds, and equipment will be carried out by all department coordinators/managers, but will be the ultimate responsibility of the Director of Operations. 9. All products recalls will be reported in writing to the Safety Officer who will present the information at the next scheduled Safety Committee meeting. 10. Safety policies are distributed to new employees upon hire, discussed at Orientation, and reviewed via supervisors at departmental meetings. The Board will review the effectiveness, scope, objectives, and performance annually. 11. New employee orientation and ongoing in-service education will incorporate all relevant elements of this Safety Plan. 12. The overall performance of the agency in meeting the objectives of the Safety Management Plan will be assessed at least annually, and will include assessment of:May, 2005, Hamilton Community Health Network, Inc. Page 2
  3. 3. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care A. The level of safety knowledge and skill of the staff, as determined by post- instruction quizzes, and documented performance in safety and disaster drills. B. A review of staff participation on the Safety Committee. C. Timely completion of all safety inspections, including the reporting of deficiencies. D. A review of incident reporting procedures, and analysis of the reported incidents. E. Inspection, testing and maintenance of all safety equipment and systems. 13. All supervisors, Safety officers and department heads are authorized to intervene whenever conditions pose an immediate threat to life or health, or threaten damage to equipment or buildings. 14. The following are safety codes that will be used by Hamilton Community Health Network, Inc.: a. CODE WHITE: Intruder With Weapon or Disruptive Behavior Staff in the immediate vicinity of the security incident will act to protect other staff, patients, and visitors. The intercom system will be used to call for assistance. If necessary, the local police/emergency service will be called using 911. Following the incident, an Incidence Report will be executed and delivered to the Safety Officer. b. CODE SEARCH: Bomb Threat This is the only code that will not be announced over the intercom/paging system. If you receive a bomb threat call, you should gather all the information you can (time of call, attitude of the caller, background noises, etc.).This information will be used to assist emergency response authorities in their investigation. Try to keep the caller on the line as long as possible and discreetly have another personnel member notify the operator via another extension of the bomb threat call. c. CODE RED: Fire – See Life Safety Management Plan. d. CODE BLUE: Cardiac Arrest / Medical Emergency The center has an established a Code Blue response team consisting of personnel trained to respond to this type of emergency. If you are a part of this team, you will be notified by your supervisor and should respond to the area announced upon hearing this code. If you are not a part of this team, you should continue your current job task. Note: It is the policy of this organization to stabilize patients in Cardiac Arrest using basic life saving techniques and to transport as soon as possible using available ambulance and EMT services.May, 2005, Hamilton Community Health Network, Inc. Page 3
  4. 4. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care e. CODE STORM: Severe Weather Warning Upon hearing this code announced, staff should assist other personnel members in your area by moving all patients and visitors into areas of safety (away from glass windows and exterior walls) and wait for further instructions. f. CODE BLACK: Utility Failure: This procedure is discussed in the Utilities Management section and Section 208 of the Environment of Care Policy and Procedure Manual. However, if electricity is the failure and the lighting system has been compromised, you must immediately secure a flashlight from designated sites and assist patients (particularly those in exam rooms), personnel, and visitors to a well-lit area. Medication in the refrigerator should be placed in the larger cooler located in the conference room kitchen and transported to the Main location. g. CODE SPILL: Chemical Spill Upon hearing this code announced, you should report immediately to your supervisor, who upon receiving instructions from the Safety Officer will determine whether evacuation of patients will be necessary. Staff on the scene of the spill will immediately clear the area and determine the risks involved with this specific spill. Cleaning the spill area will follow the procedures identified in the Hamilton Community Health Network health center’s Hazardous Materials and Waste Management Plan. h. CODE MANPOWER: Everyone help Upon hearing this code announced, you should report immediately to the given location, staff will act to protect other staff, patients, and visitors. The intercom will be used to call for assistance. If necessary, the local police/emergency service will be called using 911. Following the incident, an Incidence Report will be executed and delivered to the Safety Officer.May, 2005, Hamilton Community Health Network, Inc. Page 4
  5. 5. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care HAMILTON COMMUNITY HEALTH NETWORK, INC. HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM TO BE COMPLETED EVERY SIX MONTHSDate: Site:Program Hazard Surveillance/ Yes No Comments & Risk Assessment Item ResolutionSafety 1. Are grounds clean & free of hazards?Management 2. Are floors clean, dry, in good repair, & free of obstructions? 3. Are mechanisms for access (i.e. ramps, handrails, door opening mechanisms, etc.) operational? 4. Is the parking area free of potholes or other hazards?Security 1. Are doors functioning & locked asManagement appropriate? 2. Are medical records centrally located and accessible ONLY to authorized personnel. 3. Are alarms functioning, tested, and maintained in accordance with manufacturer’s specifications. 4. Are systems/mechanisms in place to quickly notify officials or other staff quickly in the event of a security related problem.Hazardous 1. Are OSHA Hazard Communication andMaterials & Exposure Control Documents available?Waste 2. Have all biohazard and toxic substancesManagement been identified? 3. Are MSDS sheets quickly available for all identified toxic substances? 4. Are all waste contaminated with blood/body fluid considered and handled as infectious? 5. Are sharps containers puncture resistant and in accordance with require safety standards? 6. Are sharps and disposable syringes placed in approved Sharps containers? 7. Are all engineering, personal protective equipment & workplace controls in effect.October 2004, Hamilton Community Health Network, Inc. Page 5
  6. 6. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM Continued (Page 2)Program Hazard Surveillance/ Yes No Comments & Risk Assessment Item ResolutionEmergency 1. Is there an updated disaster plan in thePreparedness department?Management 2. Has an non-fire related emergency drill been performed in the past six months? 3. Are staff aware of at least three different types of potential non-fire emergencies and their role in eliminating or reducing the risk to patients, staff and property? 4. Are staff aware of the primary and secondary exits from the facility?Life Safety 1. Is the evacuation plan posted and can staffManagement demonstrate knowledge of the plan. 2. Are fire extinguishers located in accordance with NFPA standards? 3. Are fire extinguishers inspected monthly and documented on/near the extinguisher? 4. Are smoke/fire alarm systems functioning, tested, and maintained in accordance with manufacturers specifications? 5. Are egress hallways well lit & obstacle free? 6. Is emergency exit lighting operational and tested in accordance with NFPA standards? 7. Are fire/smoke doors operating effectively? 8. No smoking policies are in effect and signs are posted appropriately?Medical 1. Is there a unique inventory of all medicalEquipment equipment in the facility?Management 2. Is all equipment evaluated & prioritized 0(Form EC 1.8) prior to use? 3. Has all equipment been tested/maintained according to manufacturer’s specifications? 4. Are maintenance records complete, (i.e. do they record the results of both electrical safety as well as calibration, as appropriate? 5. Are systems/mechanisms in place to respond appropriately to a medical equipment failure?October 2004, Hamilton Community Health Network, Inc. Page 6
  7. 7. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM Continued (Page 3)Program Hazard Surveillance/ Yes No Comments & Risk Assessment Item ResolutionUtility 1. Are the lights, emergency lights, and powerManagement plugs operational and in working order? 2. Does the water/sewage system appear to be working properly and has the water quality been tested within the past year? 3. Is the telephone system operational?Infection 1. Are all staff utilizing Universal PrecautionsControl (i.e. utilizing appropriate PPE,Monitoring handwashing, etc.) in the performance ofIssues their job duties? 2. Are cleaning solutions secured, mixed, and utilized appropriately throughout the facility? 3. Are potentially “infectious patients” aggressively identified and processed in a manner which would minimize the risk of infection of staff and other patients? 4. Can staff intelligently describe their role in infection control within the organization?Other Key 1. Are Utility Rooms locked, clean and clearSafety of debris?Monitoring 2. Are Storage Rooms secure, clean, and freeIssues of flammables? 3. Is the breakroom clean and clear of debris and flammables? 4. Are all medications, including samples, secured and accounted for by lot number?Additional Findings:Inspection Conducted By: Date:Reports Noted: Date: Safety OfficerOctober 2004, Hamilton Community Health Network, Inc. Page 7
  8. 8. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care HAMILTON COMMUNITY HEALTH NETWORK, INC. ANNUAL COMPREHENSIVE RISK ASSESSMENT REPORT FORMDirections: Assess and comment on any aspects of the environment of care that could potentially place patients, staffor the public at risk. Suggest corrective actions that might reduce such risk. Address at least the following areas:Buildings:Grounds:Equipment:Occupants:Internal Physical Systems:Other:Inspection Conducted By: Date:Reports Noted: Date: Safety OfficerOctober 2004, Hamilton Community Health Network, Inc. Page 8
  9. 9. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care HAMILTON COMMUNITY HEALTH NETWORK, INC. HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM TO BE COMPLETED MONTHLYDate: Site: Program Hazard Surveillance/ Yes No Comments & Risk Assessment Item Resolution Safety 1. Are grounds clean & free of hazards? Management 2. Are floors clean, dry, in good repair, & free of obstructions? 3. Is the parking area free of potholes or other hazards? Security 1. Are doors functioning & locked as Management appropriate? 2. Are alarms functioning, tested, and maintained in accordance with manufacturer’s specifications. 3. Are systems/mechanisms in place to quickly notify officials or other staff quickly in the event of a security related problem. Hazardous 1. Have all biohazard and toxic substances Materials & been identified? Waste 2. Are all waste contaminated with blood/body Management fluid considered and handled as infectious? 3. Are sharps and disposable syringes placed in approved Sharps containers? 4. Are all engineering, personal protective equipment & workplace controls in effect? Emergency 1. Is there an updated disaster plan in the Preparedness department? Management 2. Are staff aware of at least three different types of potential non-fire emergencies and their role in eliminating or reducing the risk to patients, staff and property? 3. Are staff aware of the primary and secondary exits from the facility? Life Safety 1. Is the evacuation plan posted and can staff Management demonstrate knowledge of the plan. 2. Are fire extinguishers located in accordance with NFPA standards? HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORMOctober 2004, Hamilton Community Health Network, Inc. Page 9
  10. 10. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care Continued (Page 2) Program Hazard Surveillance/ Yes No Comments & Risk Assessment Item Resolution 3. Are fire extinguishers inspected monthly and documented on/near the extinguisher? 4. Are smoke/fire alarm systems functioning, tested, and maintained in accordance with manufacturers specifications? 5. Are egress hallways well lit & obstacle free? 6. Is emergency exit lighting operational and tested in accordance with NFPA standards? Utility 1. Are the lights, emergency lights, and power Management plugs operational and in working order? 2. Does the water/sewage system appear to be working properly and has the water quality been tested within the past year? 3. Is the telephone system operational? Infection Control 1. Are all staff utilizing Universal Precautions Monitoring (i.e. utilizing appropriate PPE, hand Issues washing, etc.) in the performance of their job duties? 2. Are cleaning solutions secured, mixed, and utilized appropriately throughout the facility? Other Key 1. Are Utility Rooms locked, clean and clear Safety of debris and flammables? Monitoring 2. Is the break room clean and clear of debris Issues and flammables? Additional Findings: _________ ________________ _________ _________ Inspection Conducted By: Date: _ _____ ___ Reports Noted: Date: ___ Safety OfficerOctober 2004, Hamilton Community Health Network, Inc. Page 10
  11. 11. Hamilton Community Health Network, Inc.Policy and ProcedureEnvironment of Care HAMILTON COMMUNITY HEALTH NETWORK, INC. MONTHLY COMPREHENSIVE RISK ASSESSMENT REPORT FORMDirections: Assess and comment on any aspects of the environment of care that could potentially place patients, staffor the public at risk. Suggest corrective actions that might reduce such risk. Address at least the following areas:Buildings:Grounds:Equipment:Occupants:Internal Physical Systems:Other:Inspection Conducted By: Date:Reports Noted: Date: Safety OfficerOctober 2004, Hamilton Community Health Network, Inc. Page 11

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