Management Systems for Healthcare Environmental, Health and Safety

Transcription

1 Management Systems for Healthcare Environmental, Health and Safety Danial Bravard, Senior Consultant and Head of Healthcare Services, BSI EHS Services and Solu=ons Ma> Aus=n, CIH, Occupa=onal Safety Manager, Mayo Clinic

2 Overview Introduc=on to Management Systems and Safety Management Systems Founda=on: Basis for the Safety Management Systems Core Components Quality and Safety a Cri=cal Synergy Misconcep=ons GeNng Started SMS in Ac=on: A Peak into the Mayo SMS Q&A

3 Safety Management System (SMS) What is it? Safety Management System is the formal, top-down, organiza=on-wide approach to managing safety risk and assuring the effec=veness of safety risk controls. It includes systema=c procedures, prac=ces, and policies for the management of safety risk. SMS s provide: A structured means of safety risk management decision making A means of demonstra=ng safety management capability before system failures occur Increased confidence in risk controls though structured safety assurance processes An effec=ve interface for knowledge sharing between organiza=onal members A safety promo7on framework to support a sound safety culture Federal Avia@on Administra@on

4 What is a Safety Management System? A systema=c, explicit and comprehensive process for managing safety risks that provides for goal senng, planning and measurement of performance against defined criteria A formal method of measuring and evalua=ng individual and organiza=onal safety performance with an emphasis on con=nuous improvement Na@onal Safety Council

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6 Safety Management System: Reduces the risk of workplace incidents, injuries and fatali=es through data-driven measurements and improvements Involves engaging people and working in partnership to make safety a shared responsibility, recognizing the value of cross-level teamwork Is organized and structured to ensure organiza=ons are able to achieve and maintain high standards of safety performance Is proac=ve, preven=ve and integrated into the culture of your organiza=on Na@onal Safety Council

7 Core Components A structured means of safety risk management decision making A means of demonstra=ng safety management capability before system failures occur Increased confidence in risk controls though structured safety assurance processes An effec=ve interface for knowledge sharing between organiza=onal members A safety promo7on framework to support a sound safety culture Federal Avia@on Administra@on

8 SMS Common Elements Management commitment & leadership Policy Risk Assessment and control Objec=ves and targets Roles and responsibili=es Educa=on, training Communica=on Employee par=cipa=on Documenta=on and documenta=on control Opera=onal control Monitoring and measuring Incident inves=ga=on Preven=ve and remedial ac=on System audit Management review Con=nuous improvement

9 Quality Management Systems and Safety Management Systems: Two worlds but interconnected QMS and SMS Common Methods and Techniques, but different primary Objec=ves: QMS Objec=ve is Customer Sa=sfac=on SMS Objec=ve is Safety Focused QMS and SMS should complement each other, and organiza=onal efforts should be made to avoid conflicts

10 Safety Leadership Thought Leadership Respond to events that have already happened! Ac=vely seeks iden=fica=on of hazardous condi=ons through the analysis of the organiza=ons processes. Analyses system processes and environment to iden=fy poten=al or future problems

11 Your system is perfectly designed to give you the results you re genng.

12 OSHA Incidents / 200,000 Hours OSHA Total Recordable Rates, Ambulance Services Nursing & Residental Care Facili=es Hospitals - Psychiatric/Substance Abuse Hospitals - General Medical/Surgical Private Industry - Average

13 Management Systems for Healthcare OSHA Environmental, DART Rates, Health and Safety DART Cases / 200,000 Hours Days Away, Restricted or Transferred Ambulance Services Nursing & Residental Care Facili=es Hospitals - Psychiatric/Substance Abuse Hospitals - General Medical/Surgical Private Industry - Average

14 A professional virtue is self-sacrifice, the willingness to risk one's other rela=onships, as well as health and even life that are threatened in and by the care of pa=ents. Ethical Challenges of Physician Execu=ves: Bioethics Primer American College of Physician Execu=ves, September 2006 h>p://net.acpe.org/interact/ethics/bioethicsprimer.pdf

15 Culture of Safety [Heathcare and Social Assistance] is burdened by the historical and entrenched belief that pa=ent care issues supersede the personal safety and health of workers and that it is acceptable for HCSA workers to have less than op=mal protec=ons against the risks of hazardous exposures or injuries. Iden=fica=on of Research Opportuni=es for the Next Decade of NORA: State of the Sector Healthcare and Social Assistance. NIOSH Publica=on No June 2009

16 Risk Tolerance Is Changing More obese pa=ents requiring liping, demen=a-related alterca=ons driven by an aging pa=ent popula=on, and an older workforce are contribu=ng to a dispropor=onate number of employee injuries and losses at hospitals and nursing homes.

17 "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. Dr. David Michaels, Assistant Secretary of Labor for OSHA

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19 Healthcare safety drivers: What are they?

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21 Reason to Celebrate? Safety Culture

22 Unequivocally, no! Safety Culture

23 Improving and Worker Safety Opportuni=es for Synergy, Collabora=on and Innova=on Health Care Workers Unprotected November 19, 2012 Insufficient Inspec=ons 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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25 Source: h>ps://

26 SMS in A Peak into the Mayo SMS

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28 Outpa=ent 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 Construc=on EtO Sterilizers Sharps Material and Pa=ent Handling Tissue Storage Offices Surgical Suites Fitness Center Transporta=on Radiology Chemical Distribu=on Transporta=on Students/Pa=ents/Visitors Helipads Mechanical Floors Cyclotrons Chemical Hygiene Plan Potent Compounds Recycling Center Linen Management BBP Plan Nursing Home Infec=ous Diseases Confined Spaces Print Shop Autopsy Mobile Workforce

29 Baseline Self-Assessment Pockets of excellence Accredita=on focused Comprehensive hazard inventory Consistency - R&R, Accountability Document control system(s) Rela=onship/Person vs System dependency Governance clarity (e.g., management review) Balanced performance measures Thorough audit(s) Branding and Communica=on Internal safety team integra=on Talent & Knowledge Management

30 Safety Management System

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32 Safety Management System Framework of Hazards/Risks & Development of Requirements Hazards, real or poten=al, concerns and the associated risk that have the poten=al to create a nega=ve impact on Mayo Clinic require documented Policies, Procedures, etc., in order to demonstrate how risk is controlled and to promote posi=ve outcomes. Mayo Clinic s Environmental Health and Safety Commi>ee (MCEHSC) acts as the governing body for assessing risk and publishing Enterprise requirements. Each En=ty assesses the applicability of MCEHSC requirements and develops implementa=on processes. En=ty documenta=on should indicate where responsibility for implementa=on resides. Addi=onally, documenta=on should be supported by tools and resources to assist with implementa=on. Each En=ty performs assessments to iden=fy addi=onal hazards that may exist and require control, which are not addressed by MCEHSC requirements. The results of the assessment are communicated to MCEHSC for considera=on as MCEHSC requirements.

33 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 ac=vi=es and the amount of resource allocated should be based on a considera=on of risk and En=ty needs (e.g., regulatory requirements, accredita=on). Each En=ty 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, =mescales, and results must be maintained and available. Improvement Planning On an annual basis as part of the planning phase, MCEHSC will iden=fy Enterprise improvement plans with objec=ves and targets. En==es must also examine local needs along with emerging issues to iden=fy addi=onal areas for con=nual improvement. En=ty specific improvement plans are developed, including measurable objec=ves and targets. Focusing on a few priori=zed plans with well-defined targets and an=cipated outcomes is the most effec=ve way to con=nually improve and promote cross-en=ty learning/best prac=ces.

34 Safety Management System Framework and Remedial Where proac=ve efforts iden=fy a change that could nega=vely impact En=ty employee safety and health, preven=ve ac=on is taken. Preven=ve ac=on requires a documented plan, including responsible party, which will be implemented to mi=gate the poten=al for nega=ve impact. Remedial Ac@on: Where monitoring and measurement ac=vi=es reveal system deficiencies, the root cause must be iden=fied, the deficiency corrected, and ac=ons taken to prevent recurrence. This informa=on must be tracked according to local procedures and documented as a remedial ac=on. Note: Only systemic or substan=ve remedial ac=ons should be recorded. One-off findings should be handled and recorded locally as appropriate.

35 Safety Management System Framework Regulatory and Changes Emerging Risks Levels of occupa=onal safety and health knowledge, competence, and general employee awareness need to be commensurate with risk. Each En=ty s training and awareness programs must be documented, communicated, and assessed for effec=veness. Communica@ons: Procedures for internal and external communica=ons must exist so that requirements and informa=on rela=ng to employee safety and health are effec=vely communicated to employees and other interested par=es (e.g., Unions, contracted workforce). Regulatory and En@ty Changes: En==es need to establish a process for staying up-to-date on regulatory changes and emerging En=ty concerns. A documented process should be available that iden=fies the mechanisms used to meet this requirement. Emerging Risks: Regulatory and En=ty 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 Preven=ve Ac=on.

36 Safety Management System Framework Management Review Each En=ty conducts a periodic Management Review with MCEHSC to ensure the adequacy, effec=veness and quality of MCSMS elements, including improvement plans, control plans, remedial ac=ons, etc. Each En=ty also conducts Management Review mee=ngs with En=ty leadership and/or oversight commi>ee(s) for the purpose of providing system updates, seeking input for improvement plans, iden=fying En=ty changes, etc.

37 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 adop=on 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 accredita=on readiness) Prepare for a marathon, not a sprint

38 Thank You