PRESENTED BY APRIL 18, The University of Texas MD Anderson Cancer Center Houston, Texas

Transcription

1 PRESENTED BY APRIL 18, 2018 The University of Texas MD Anderson Cancer Center Houston, Texas

2 Management Systems for Healthcare Environmental, Health and Safety Matt Austin, CIH, Occupational Safety Manager, Mayo Clinic

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4 Your system is perfectly designed to give you the results you re getting.

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7 Tradition A professional virtue is self sacrifice, the willingness to risk one's other relationships, as well as health and even life that are threatened in and by the care of patients. Ethical Challenges of Physician Executives: Bioethics Primer American College of Physician Executives, September

8 Culture of Safety 2009 [Heathcare and Social Assistance] is burdened by the historical and entrenched belief that patient care issues supersede the personal safety and health of workers and that it is acceptable for HCSA workers to have less than optimal protections against the risks of hazardous exposures or injuries. Identification of Research Opportunities for the Next Decade of NORA: State of the Sector Healthcare and Social Assistance. NIOSH Publication No June 2009

9 More obese patients requiring lifting, dementia related altercations driven by an aging patient population, and an older workforce are contributing to a disproportionate number of employee injuries and losses at hospitals and nursing homes.

10 "It is unacceptable that the workers who have dedicated their lives to caring for our loved ones when they are sick are the very same workers who face the highest risk of work related injury and illness.

11 Safety pioneers like James Reason long ago made the case for a systems approach to safety in healthcare. Yet the healthcare industry still lags behind other sectors of the economy in recognizing the importance of managing staff safety. For example, while most healthcare organizations have processes in place to investigate the root causes of preventable harm to patients, we rarely see similar efforts made when workers are harmed.

12 Management System A management system is the framework of processes and procedures used to ensure that an organization can fulfill all tasks required to achieve its objectives

13 Procedure vs Process vs System Procedure set of instructions (static) focus on compliance Process execution stream of a procedure (dynamic) includes feedback: input process output System summation and interrelation of all organizational procedures and processes focus on performance

14 An organizations management system

15 OH&S Management System An OHSMS is part of a management system used to achieve the OH&S policy (policy = statement of intent by top management)

16 Healthcare safety drivers: What are they?

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18 Reason to Celebrate? Safety Culture

19 Unequivocally, no! Safety Culture

20 Improving Patient and Worker Safety Opportunities for Synergy, Collaboration and Innovation Health Care Workers Unprotected November 19, 2012 Insufficient Inspections and Standards Leave Safety Risks Unaddressed July 17, 2013 Leading a Culture of Safety: A Blueprint for Success: July 2017 Caring for Our Caregivers Safety and Health Management Systems: A Road Map for Hospitals September 2013

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23 SMS Common Elements Management commitment & leadership Policy Risk Assessment and control Objectives and targets Roles and responsibilities Education, training Communication Employee participation Documentation and documentation control Operational control Monitoring and measuring Incident investigation Preventive and remedial action System audit Management review Continuous improvement

24 Source: JCAHO_comparison_508.pdf

25 SMS in Action: A Peak into the Mayo Clinic SMS

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27 Mayo Clinic Today 5 STATES MAIN CAMPUSES Rochester, Minnesota 5 SCHOOLS 63,000 EMPLOYEES 1.3 million 12billion UNIQUE PATIENTS from every state & 137countries ENTERPRISE REVENUE all income reinvested Phoenix/ Scottsdale, Arizona Jacksonville, Florida

28 Outpatient Clinics Warehouses Loading Docks Research Laboratories Trash Compactors Animal Care Power Plants Incinerator Paint Shops Hyperbaric Chambers Machine Shops Grounds/Landscaping Clinical Laboratories Kitchens Biosafety Level 3 Compounding Pharmacies Proton Beam Construction EtO Sterilizers Sharps Material and Patient Handling Tissue Storage Offices Surgical Suites Fitness Center Transportation Radiology Chemical Distribution Transportation Students/Patients/Visitors Helipads Mechanical Floors Cyclotrons Chemical Hygiene Plan Potent Compounds Recycling Center Linen Management BBP Plan Nursing Home Infectious Diseases Confined Spaces Print Shop Autopsy Mobile Workforce

29 Baseline Self Assessment Pockets of excellence Accreditation focused Comprehensive hazard inventory Consistency R&R, Accountability Document control system(s) Relationship/Person vs System dependency Governance clarity (e.g., management review) Balanced performance measures Thorough audit(s) Branding and Communication Internal safety team integration Talent & Knowledge Management

30 Safety Management System

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32 Safety Management System Framework Identification of Hazards/Risks & Controls Hazards, real or potential, concerns and the associated risk that have the potential to create a negative impact on Mayo Clinic require documented controls. Mayo Clinic s Environmental Health and Safety Committee (MCEHSC) acts as the governing body for assessing risk and publishing Enterprise Policy. MCEHSC Policy defines Scope, Purpose as well as key Statements. These Statements are Mayo Clinic requirements. Each Entity performs assessments to identify additional hazards that may exist and require control, which are not addressed by MCEHSC requirements. The results of the assessment are communicated to MCEHSC for consideration as MCEHSC requirements.

33 Safety Management System Framework Development of Entity Procedures, Processes and Programs Each Entity assesses the applicability of Policy requirements and develops documented Procedures to meet both the requirements of the Policy and any Entity specific regulatory requirements. Guidance on interpretation of Policy requirements is provided by MCEHSC. Entity documentation indicates where responsibility for implementation resides. Additionally, documentation should be supported by tools and resources to assist with implementation.

34 Safety Management System Framework Monitoring and Measurement Monitoring and measurement is achieved through a variety of techniques conducted as part of business as usual throughout an annual cycle. Monitoring and measurement activities and the amount of resource allocated should be based on a consideration of risk and Entity needs (e.g., regulatory requirements, accreditation). Each Entity produces an annual Control Plan, or equivalent, detailing how local safety programs will be assessed for compliance/conformance with requirements. A summary of the Control Plan, including methodology, frequency, timescales, and results must be maintained and available.

35 Safety Management System Framework Improvement Planning On an annual basis as part of the planning phase, MCEHSC will identify Enterprise improvement plans with objectives and targets. Entities must also examine local needs along with emerging issues to identify additional areas for continual improvement. Entity specific improvement plans are developed, including measurable objectives and targets. Focusing on a few prioritized plans with well defined targets and anticipated outcomes is the most effective way to continually improve and promote cross Entity learning/best practices.

36 Safety Management System Framework Preventive and Remedial Action Preventive Action: Where proactive efforts identify a change that could negatively impact Entity employee safety and health, preventive action is taken. Preventive action requires a documented plan, including responsible party, which will be implemented to mitigate the potential for negative impact. Remedial Action: Where monitoring and measurement activities reveal system deficiencies, the root cause must be identified, the deficiency corrected, and actions taken to prevent recurrence. This information must be tracked according to local procedures and documented as a remedial action. Note: Only systemic or substantive remedial actions should be recorded. One off findings should be handled and recorded locally as appropriate.

37 Safety Management System Framework Education Communications Regulatory and Entity Changes Emerging Risks Education: Levels of occupational safety and health knowledge, competence, and general employee awareness need to be commensurate with risk. Each Entity s training and awareness programs must be documented, communicated, and assessed for effectiveness. Communications: Procedures for internal and external communications must exist so that requirements and information relating to employee safety and health are effectively communicated to employees and other interested parties (e.g., Unions, contracted workforce). Regulatory and Entity Changes: Entities need to establish a process for staying up to date on regulatory changes and emerging Entity concerns. A documented process should be available that identifies the mechanisms used to meet this requirement. Emerging Risks: Regulatory and Entity Changes may create an emerging risk. These risks should be documented, including an assessment of impact and reported as part of Management Review. Emerging risks may lead to a Preventive Action.

38 Safety Management System Framework Management Review Each Entity conducts a periodic Management Review with MCEHSC to ensure the adequacy, effectiveness and quality of MCSMS elements, including improvement plans, control plans, remedial actions, etc. Each Entity also conducts Management Review meetings with Entity leadership and/or oversight committee(s) for the purpose of providing system updates, seeking input for improvement plans, identifying Entity changes, etc.

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41 Purpose Management Review is a key element of an SMS, providing an opportunity for leadership (i.e., top management ) to determine the suitability, adequacy and effectiveness of the system Environmental Health and Safety Subcommittee = top management Agenda Improvement Plan Status 3 rd Party/Independent Review Remedial Actions Control Plan Emerging Risks Preventive Actions Successes Future Improvement Plans

42 Lessons Learned Safety professionals can sell the value of a management system Set the stage for change; Perform and report the results of a management system self assessment Design a system that aligns with your culture, versus forcing the adoption of a given system standard Leverage improvement plans to close management system element gaps Management review drives alignment, visibility and engagement Measure and report on overall performance, not just compliance (or accreditation readiness) Prepare for a marathon, not a sprint

43 Thank You