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NORTHERN COCHISE COMMUNITY HOSPITAL
SAFETY PLAN
DEPARTMENT: Safety
SUBJECT: Safety Plan
Reviewed By:
| Review Date:
| Committee
| 07/20/17
| Med Staff
| 08/28/17
| Governing Board
| 09/26/17
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REFERENCES: OSHA, CMS, and all Federal, State and Local Codes related to Safety.
SCOPE: All NCCH Staff.
POLICY: Safety Plan
PROCEDURE:
The policy of Northern Cochise Community Hospital is to provide a safe and healthy workplace in which applicable health and safety laws and regulations are observed. We constantly strive to find sound and innovative methods to reduce the impact of our activities on the environment.
Northern Cochise Community Hospital complies with all applicable workplace health, safety, and environmental laws and regulations. All employees are expected to handle materials according to established control, storage, and disposal procedures. All employees are expected to follow established security policies and report any unusual activity.
Purpose:
The hospital, Sulphur Springs Medical Center, and Sunsites Medical Center Safety Plan provides a framework in which to manage safety issues. The plan works in conjunction with performance improvement and risk management programs in accordance with Arizona state standards. This program monitors and evaluates non-clinical safety issues in an attempt to reduce the safety risks to patients, visitors, and personnel.
Objectives:
The objectives of the safety plan are to reduce the risk of injury to patients, visitors, and personnel as follows:
- Conducting formal and informal surveillance rounds for cleanliness, safety, appropriate maintenance, and care of the internal and external environment.
- Coordinate an effective product recall program.
- Develop and update safety programs, policies, and procedures as well as review and guide departmental specific policies and procedures.
- Conduct fire drills, and provide regular testing and preventative maintenance of the fire alarm system.
- Provide regular input to renovation and construction projects with special consideration of Life Safe Codes, and state and federal regulations including the American with Disabilities Act, CMS, MEDICARE.
- Conduct regular hazard surveillance assessments of the facility and take reasonable action when opportunities to improve safety are found.
- Evaluate the occurrence screening program for performance improvement issues, active teams, and improve areas identified as potential safety problems.
- Protect against clinical equipment failure or user error by monitoring preventative maintenance and inspection procedures, providing education for use of equipment and establishing user competency.
- Aggregate and analyze data related to non-clinical safety issues to establish indicators and thresholds for performance improvement opportunities.
- Provide general safety and hazardous material safety training to all personnel on a regular basis, to include new employee orientation and annual training.
- Conduct Quarterly Safety Training for all staff.
- Implement and maintain an emergency preparedness program.
- Facilitate efforts to correct safety problems as they occur.
Authority and Responsibility
The authority for the plan rests with the Board of Directors. The Board of Directors has delegated the authority to implement and maintain the activities described herein to the Chief Executive Officer (CEO) and/or his or her respective designee(s) who shall report quarterly on safety issues to the Board of Directors. The Safety Committee, Safety Officer, members of management, and medical staff shall all work together to implement an effective safety program. The Chairman of the Safety Committee (the Safety Officer) shall have the authority to take action in situations that require immediate intervention to avoid risk to patients, visitors, and personnel.
The Safety Committee, under the leadership of the Safety Officer, has been authorized to oversee development, implementation, and monitoring of safety management. The committee provides a multidisciplinary forum for the analysis and dissemination of information and formulation of corrective and preventative actions to manage risks to patients, visitors, and personnel. The committee will review and evaluate the effectiveness of safety programs, policies, and procedures annually. The activities of the Safety Committee will be documented in a format that reflects discussion, conclusions, recommendations, actions taken, and evaluation of actions taken.The committee will disseminate information and recommendations to the medical staff, and administrative committees, or other individuals as appropriate.
Committee members shall consist of the following as appointed by the CEO upon recommendation of the executive committee:
Physician Advisor
Safety Officer
EVS
Quality
Case Management
Human Resources
Information Services
Ancillary Services
Rural Health Clinics
Business Office
IC
Risk
Administration
Medical Staff Services
Compliance Officer
DON, Hospital
Nursing Executive
Appointees will serve for two years and may be re-appointed.
Safety Officer:
The Safety Officer shall be selected by the CEO and will automatically become chairperson of the Safety Committee. The Safety Officer is responsible for gathering information from all applicable safety laws, regulations and rules in order to assist the committee in identifying safety risks to patient, visitors, and personnel. He/she will provide reports on safety issues including actions and recommendations of the Safety Committee to management, medical staff, and the Board of Directors. The Safety Officer will conduct the semi-annual hazard surveillance rounds and assign the responsibility of compliance to the Safety Committee members from each department or area. He/she will accompany the various building inspectors on Environment of Care tours. In the absence of the Safety Officer, the required duties will be assigned to the Safety Committee, the Director of Risk Management, and/or the Director of Plant Operations.
Management and Medical Staff
Management and medical staff are responsible for implementing relevant parts of the safety program in their respective departments. Department managers and medical staff members are responsible for ensuring that employees under their direction receive relevant information including the actions and recommendations of the Safety Committee. Management and medical staff shall ensure that all employees under their direction participate in relevant safety education and training programs. Department managers are responsible for developing departmental policies and procedures in accordance with safety programs. All staff members will cooperate with the Safety Committee in its efforts to implement standards relating to life safety, general safety, utility management and equipment management programs.
Aggregating, Analyzing, and Reporting Data
Aggregation and analysis of safety data will be coordinated by the Safety Committee and will address the various aspects of the Environment of Care. The data will be summarized and reported to the committee on a regular basis and presented in a format that will allow the committee to analyze trends, outcomes, and benchmark with national or industry standards. The data will assist in the selection of measurable indicators or opportunities for improvement that address the seven aspects of the Environment of Care. Examples of data aggregated include:
- Summary statistics regarding safety education training.
- Occurrence Reports
- Hazardous materials and waste management monitors.
- Hazard surveillance of construction sites.
- Hazard surveillance of building and grounds.
- Fire alarm system testing.
- Fire drills and evacuation.
- Preventative maintenance and testing data for biomedical equipment.
- Preventative maintenance and testing data for utility systems.
- Evaluations of utility failures.
- Reports from performance improvement, infection control, and risk management.
- Reports regarding security issues.
- Reports from regulatory agencies.
The quarterly reports produced by the Safety Committee will show the data utilized to determine the indicators of the seven aspects of the care environment. These indicators will generate further analysis and actions to improve the safety of patients, visitors, and personnel. The report will be made to the Quality Committee and Board of Directors with information disseminated to the managers and medical staff as needed.
Coordinating with Performance Improvement and Risk Management
In order to ensure protection of confidentiality, information relating to safety issues only will be shared with the Safety Committee. In matters relating to performance improvement, safety information and processes will be shared with the Quality Committee through the Quality Director to accept and approve improvement plans of action.In matters relating to Risk Management, the committee will share occurrence review and investigation information, which is protected under Arizona statutes. All occurrence reports are sent to Risk Management, who in turn will report summaries and trends of non-clinical issues to the Safety Committee. The Quality/Risk Management Director shall attend Safety Committee meetings to facilitate information sharing.
Educational Programs
Educational activities coordinated through the safety program represent a primary means by which the Safety Committee will effect improvement in the safety of patients, visitors, and personnel. Education programs are based on industry standards and literature reviews and are continually revised to reflect organizational experience and relevant safety issues as defined by the Safety Committee. In addition, the effectiveness of the educational program will be evaluated by the employee's knowledge, participation in drills and safety programs.
Members of management are responsible for ensuring that employee under their direction participate in relevant educational programs. Safety Committee members will be available to assist in the development of specialized education and training programs and to assist in the implementation of such programs. All new employees will attend the orientation program to receive the initial safety training. Thereafter, each employee must show evidence of participation in Quarterly Safety Training annually.
SAFE-PLAN-013-1
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