Applying Lean Principals to the Environment of Care
|
|
- Preston Foster
- 5 years ago
- Views:
Transcription
1 Applying Lean Principals to the Environment of Care Russ Harbaugh, CHEP Accreditation Coordinator EOC/Life Safety/Disaster Preparedness St. Luke s Health System Boise Idaho EOC Purpose The environment of care is a broad term for a wideranging group of factors in the healthcare environment; however, it encompasses a large body of checkpoints that accrediting bodies use to determine a facility s quality. We talk about the environment of care as referring to the elements and factors that contribute to creating the way the environment works for the patient, family, staff and others in the healthcare delivery system, in terms of certain key elements. 1
2 Environment of Care Some important aspects of the environment addressed in the standards include the following: Safety and Security Hazardous materials and waste Fire safety Medical equipment Utilities Objectives: This presentation is organized around the concepts of planning, implementing, and evaluating, and evaluation of results. Also to hard-wire compliance with Environment of Care regulations and standards. Environment of Care 2
3 Environment of Care Background The Hospital s Environment of Care program previously has not been effective in ensuring a continual state of regulatory readiness. Internal surveillance as well as findings from on-site surveys consistently revealed opportunities for improvement in the following areas with organizational performance for October 2010-February 2011 as indicated below: Under sink storage (73%) Expired supplies (65%) High dusting (77%) Clean vs. dirty separation (89%) Linen supply carts (80%) Wall mounted sharps containers (86%) Multi-dose vials (90%). Develop a Core Team for Support Executive Sponsors Team Leader EOC/ Life Safety Accreditation Infection Prevention Employee Safety/ IH Consultant Document Management 3
4 Goals Implement an effective Environment of Care framework to improve compliance with EOC regulations Hard-wire compliance with Environment of Care regulations and standards. Providing a Safe Environment? Code compliance? 4
5 Code compliance? Current State Current State Wastes People- Underutilizing FTEs available at the unit-level People- Over-utilizing Accreditation FTEs to audit and follow-up on continued non-compliance Inventory- over ordering of supplies due to expiration Impact: Under sink storage- infection prevention Expired supplies- patient safety/financial impact High dusting- infection prevention/hcahps performance with cleanliness question Clean vs. dirty separation- infection prevention/patient safety Linen supply carts infection prevention Wall mounted sharps containers- employee safety/osha Multi-dose vials- patient safety 5
6 Opportunities Lack of identified environment of care champions outside of the Unit Services Supervisors role. Site-based EOC Committee lacks authority and scope to ensure continual environment of care compliance Lack of standardized environment of care expectations Lack of subject matter environment of care experts Opportunities cont. Lack of best practice spread throughout the organization Lack of hard-wired processes to facilitate continuous compliance Lack of sustainability and accountability at the local level when opportunities are identified Develop an audit process that ensures the collection of statistically relevant data needed to validate improvement Next Steps Finalize the list of EOC Champions Finalize the EOC Champions Manual Initiate System EOC Committee Implement VSURVEY Audit Process Deploy EOC Boot Camp Deploy Kamishibai Pilot Develop and Deploy Best Practices Library Implement EOC Annual Education Update Process 6
7 Targeted Champions Boot Camp Our Goal is to promote a safe, functional, and supportive environment within the hospital so that quality and safety are preserved. The Boot Camp will help educate individuals to identify the risks within their environment, including those associated with safety and security, fire, hazardous materials and waste, medical equipment and utility systems. Benefits Benefits Heightened awareness and support for hardwired continual regulatory readiness with the environment of care standards Trained over 220 champions through standardized education. Improved champion understanding by 90% 7
8 Environment of Care Champions Manual Prepared by Russ Harbaugh, CHEP EOC/Life Safety Officer Please send all feedback for future revisions to Russ Harbaugh at or Current Revision: 1/6/2012 SINGLE POINT LESSON TOPIC/SUBJECT AREA/DEPT PREPARED BY APPROVED BY Eye Wash Stations Environment of Care Russ Harbaugh EOC Committee 1. Where are eye wash stations located? Eye wash stations are installed in work areas where hazardous substances (i.e. chemicals, disinfectants) are used and/or there is potential of blood or body fluid exposure. Eye Wash signs identify the locations. Eye wash stations are located where they can be reached from the hazardous substance location within 10 seconds. Note: Contact Safety Officer to determine proper location for an eye wash station. 2. Who should know how to operate an eye wash station? All employees who might be exposed to a chemical splash will be trained in the use of the eye wash. 3. How often are eye wash stations tested? Eye wash stations are tested weekly. Weekly eye wash apparatus testing will be documented on a log sheet and kept in the vicinity of the eye wash. The department director or manager will select a person(s) to be responsible for the weekly testing requirement. All eye wash stations shall be inspected annually by a building services plumber to ensure they meet ANSI Z358.1 requirements. Assure that that water stream is crossing at the peak. Regulatory Standards: 29 CFR OSHA/ANSI Eye Wash Station Requirements The American National Standards Institute (ANSI) developed the ANSI standard Z OSHA (c) NFPA St. Luke s Policy: Eye Wash Safety (EC037) Infection Prevention, Facility-wide (IP054 TV) Blood borne Pathogens Exposure Control Plan (IP055 TV) 23 SINGLE POINT LESSON TOPIC/SUBJECT AREA/DEPT PREPARED BY APPROVED BY Construction Areas Environment of Care Russ Harbaugh EOC Committee 1. Who can visit construction sites within the hospital? Only trained, qualified, competent tradespeople are permitted to be within construction sites during construction and shall be trained in the hazards that might exist. All others wishing to visit the construction site will require approval and an escort. 2. What is the process for approved tours of construction sites? When construction or remodel work is in progress and a walk-through or tour is desired, either during or after normal work hours, by St. Luke s employees, tenants, physicians, donors, board members, or any other non-construction personnel, the following steps must be followed: A walk-through or tour will be managed in a safe, organized manner that meets all Construction Department and OSHA standards for safety and compliance. The tour will be conducted by qualified construction personnel only. Proper clothing and personal protective equipment (e.g., hard hats) are required. The Construction Department reserves the right to refuse visits and tours for nonconstruction personnel due to feasibility or safety concerns. 3. How can departments ensure construction/ remodel areas are safe and secure? Departments must review and assess the need to implement additional safety measures to ensure compliance with the following: Barriers to prevent accessibility by unauthorized persons, staff, and the public. Special attention should be given to controlling areas that children might access. Signage to alert and direct people away from the construction/ renovation area. Appropriate storage of equipment not in use. Appropriate closure of construction/renovation sites at the end of the work day to prevent accessibility by unauthorized individuals. Regulatory Standards: LS The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction St. Luke s Policy: Non-Construction Personnel Visitation to Construction Sites (EC076 TV) Interim Life Safety Measures (ILSM) (EC024 BMW) 24 8
9 Accomplishments Identified EOC Champions and alignment with key stakeholder groups Development and implementation of EOC Champions manual Held sessions of EOC Boot Camp Scheduled Quarterly EOC Boot Camps Shared educational tools with system partners through the newly established System Environment of Care Committee Created Kamishibai Environment of Care templates Developed a deployment plan for Kamishibai Card implementation across the continuum of care Implemented Kamishibai Cards on 14 inpatient nursing units and 1 clinic Implemented process to gather data on key project goals with reporting transparency Kamishibai Have you experienced: Improvements that do not sustain the gain Missed quality audits Work overload Difficulty balancing your work activity Too many activities happening to remember where you have been Kamishibai Kamishibai is a systematic approach to organize and balance repeatable tasks using time frequencies to trigger the event Kamishibai is a Tool used to sustain the process improvements from foundational tools of Lean House 9
10 Kamishibai Transform Healthcare Continuous Improvement Staff Focused Just in Time Built in Quality Patient Centered 5S Workplace Organization Problem Solving Culture of Accountability Standardization Visual Management Kamishibai Origin - Japanese card play (traditional children's story card game) Cards deliver a pictorial message, which in turn prompts an action to explain the picture and tell a story - similar to charades Link to Lean - elimination of unevenness (Mura), overburden (Muri) and waste (Muda) that has been identified in the development of the process improvement systems Too much to remember Repeated unnecessary tasks Differing workloads, hour by hour, day by day Differing workloads person by person Applications Overview Kamishibai is a system that can be used to audit on a random, a time based or count based interval. The interval used is determined by needs of the application being audited. This tool can be applied to ensure Safety, Quality, Productivity, Cost, etc. 10
11 Safety The Kamishibai system is used to audit safety in a random fashion, although there will be sets of cards to complete. A process review from management can be performed on a regular basis to be proactive for accident prevention. Quality Quality is audited by the team with the cards ensuring all check intervals are properly maintained. Supervisors can audit the cards that are being performed by the assigned staff. In addition, they can randomly audit the services by performing the check themselves; noting compliance. Standardized Work Sheets can be audited to confirm that each staff member is following the proper sequence of events Tools and Concepts of Kamishibai Board - Depends on size or frequency of tasks Card - Listing tasks and frequencies Paperless - No check lists or ticks in boxes Visual Aid - Quick reference of tasks Periodical - To be utilized on a set frequency Standard Procedure- Follow standards 11
12 Board Key Requirements Board layout must contain: Planning Rack Audit Rack Single Point Lesson Action Item List Cards Board Example Kamishibai Board Single Point Lesson Action Item List Planning Rack Completed Audit Board Example 12
13 Kamishibai Requirement Guidelines When Daily, Weekly, Monthly activities Who Everybody at all levels Why Helps remember Day to Day audits Where Anywhere that you have regular tasks Standards Stable and standardized conditions Types of Kamishibai Cards Every card in the system is one of two types: Task - Performing duties to meet standards Audit - Verifying tasks Card Handling Standards As a standard, there are three places a card may be: 1. On the board it has been completed 2. In your hand you are completing it 3. In the zone post it is not yet completed 13
14 Sup Central Rx Audit Sup Central Rx Audit Daily: Environment of Care Daily: Environment of Care Trip Hazards: No trip or slip Hazards exist. Area Clutter: Storage area and other areas are clean, orderly, free of trash, and well lighted. Carts in Proper Location Container Rack in Proper Location Area Security: No doors held open by people/equipment. Damaged manifolds noted properly Red Tape Zones: All Alarm pull boxes and fire extinguishers are tapped off and clear of any items Decon rounds board up to date Area free of slip hazards and water on the floor Area Organized & Clean During Shift End of Shift #1 During Shift End of Shift #2 Two Sides Each card has two sides Red side ~ abnormality occurred Green side ~ standard is met Upon completion of an audit or task card, the side turned outward indicates the current condition. If the red side is left outward, an action item must be created to countermeasure the issue identified. Sup Central Rx Audit Sup CSPD Audit Daily: Environment of Care Daily: Environment of Care During Shift During Shift End of Shift #1 End of Shift #2 14
15 Color Standards The Audit tasks interval color code. Daily Task Weekly Task Monthly Task Red side out ~ abnormality occurred and observed Green side out ~ standard is met How to Respond Any identified abnormality at any level requires response. Use of the action item list initiates and tracks countermeasure to completion. Also supported by a standardized problem solving methodology. Action Item List Operation An action item is created when an issue is raised. When the issue is completed, the person who completes it strikes a line through it. Should an issue carry to the next week, a red dot is placed at the end of its row. This indicates it has been outstanding and needs a higher level of focus, support or resources 15
16 FY10 Compliance Rate FY11 Compliance Rate 10/07/2012 Kamishibai Benefits Accountability adds responsibility Standardized process - disciplined, requires rules Promotes teamwork - all involved - collective responsibility Process driven Supports work balance Eliminates complacency Flexible - dynamic can add or take away Visual - easy to view and interpret status or adherence Environment of Care & Life Safety Identified EOC Champions and alignment with key stakeholder groups Development and implementation of EOC Champions manual Held sessions of EOC Boot Camp Quarterly EOC Boot Camp sessions scheduled on an ongoing basis Shared educational tools with system partners through the newly established System Environment of Care Committee Created Kamishibai Environment of Care templates Developed a deployment plan for Kamishibai Card Implementation across the continuum of care Implemented Kamishibai Cards on 14 inpatient nursing units and 1 clinic Implemented process to gather data on key project goals with reporting transparency. Sharps Containers: Are sharps containers unobstructed and less than 89.9% 92% 2/3 full? Wall-Mounted Sharps Containers: Are wall mounted sharps containers 95.8% 96% 52" to 56" high? Identification Badges: Are staff wearing their identification badges? 98.6% 90% Facility Security: Are critical areas of the department appropriately 97.0% 97% secured and accessed only by those authorized? Medication/Syringe Security: Are syringes and pharmaceuticals locked, within line of sight, or within a secure unit (surgical services, 88.4% 90% critical care, etc.)? Warming Cabinets: Are warming cabinets set below 105 degrees for 81.1% 99% liquids and 130 degrees (+/-) for blankets? Crash Carts: Are crash cart logs complete with no missing dates? 77.1% 95% Hazardous Chemicals: Are hazardous/flammable materials properly 99.1% 98% stored and labeled? Housekeeping Closets: Are housekeeping closets and other chemical 97.3% 99% storage areas locked if not within a secure unit? Eyewash Stations: Are eyewash stations available and tested at least 84.4% 96% weekly? Ceiling Tiles: Are ceiling tiles present and free from stains, scuffing, 63.4% 81% visible dirt, cracks, and breaks? Kitchen Cleanliness: Are kitchen appliances (refrigerators, 94.7% 91% microwaves, etc.), including those used by patients, clean? Under Sink Storage: Are only non-porous items (cleaning supplies and 83.1% 88% flower vases) stored under sinks? Expired Items: Are patient care supplies and medications (PYXIS, 33.6% 67% refrigerator, and floor stock items) in date? Refrigerators: Do refrigerators only contain appropriate items? 94.7% 97% Temperature Logs: Are refrigerator temperature logs maintained and 85.1% 93% actions taken if out of compliance? Clean vs. Dirty: Is there appropriate separation of clean and dirty 97.2% 92% supplies? Linen/Clean Supply Carts: Are linen/clean supply carts covered and do 97.6% 95% the carts have a solid bottom? High Dusting: Is high dusting completed regularly? 79.7% 76% FY 10 Compliance vs FY11 Out of 28 areas surveyed under the EOC inspection process there were: 17 areas improved 8 areas slipped back by a small percent 3 areas stayed neutral Egress: Are exit signs available and illuminated? 97.7% 100% Corridors: Are corridors free of equipment and clutter (food carts, beds, etc.)? Hallways: Do hallways have 4-6 feet of clearance with equipment 94.6% 98% 97 0% 99% Slips, Trips, Falls The Slip/Trip/Fall incident rate has dropped below the One Standard Deviation Improvement level as of March 31 st (1/2 through the fiscal year). We are currently at 1.16 events per 100 FTE and the 1 StndDev goal is (Note: Hours worked were based on Jan 2012 hours-worked until the injury scorecard is released it might lower the rate even more). 16
17 Slips, Trips, Falls Departments who have implemented the Kamishibai Audit cards for Identification of STF hazards have seen a 61% reduction in STF total events (based on projection of same rate for next 6 months). Summary Kamishibai originated from a card play game Kamishibai is a systematic approach to organize and balance repeatable standardized tasks using time frequencies to trigger the event Displays clearly (visually) status of completion real time Can be applied to any area and any level within an organization - fully flexible Like any system requires discipline to be effective! 17
SAMPLE: Environmental Rounds and Safety Assessment Tool
SAMPLE: Environmental Rounds and Safety Assessment Tool Area/Department Evaluated: Date: Security and Incident Management Y N N/A Comments 1. Are emergency telephone numbers posted by all stationary phones?
More informationAdministrative Policies and Procedures
Administrative Policies and Procedures Originating Venue: Environment of Care Policy No.: EC 2007 Title: Environment of Care Management Program Cross Reference: EC 2001 Date Issued: 04/14 Authority Environmental
More informationTJC Corrective Actions. Nursing Education January, 2015
TJC Corrective Actions Nursing Education January, 2015 TJC Finding Normal Saline fluids stored in the warmer did not have the revised expiration dates. Normal Saline fluids stored in the warmer had a temperature
More informationPersonal Protective Equipment Program. Risk Management Services
Personal Protective Equipment Program Services Table of Contents I. Program Goals and Objectives... 2 II. Scope and Application... 2 III. Responsibilities... 2 IV. Procedures... 3 V. Training... 5 VI.
More informationProfiles in CSP Insourcing: Tufts Medical Center
Profiles in CSP Insourcing: Tufts Medical Center Melissa A. Ortega, Pharm.D., M.S. Director, Pediatrics and Inpatient Pharmacy Operations Tufts Medical Center Hospital Profile Tufts Medical Center (TMC)
More informationPACKAGING, STORAGE, INFECTION CONTROL AND ACCOUNTABILITY (Lesson Title) OBJECTIVES THE STUDENT WILL BE ABLE TO:
LESSON PLAN: 7 COURSE TITLE: UNIT: II MEDICATION TECHNICIAN GENERAL PRINCIPLES SCOPE OF UNIT: This unit includes medication terminology, dosage, measurements, drug forms, transcribing physician s orders,
More informationEAST CAROLINA UNIVERSITY INFECTION CONTROL POLICY
EAST CAROLINA UNIVERSITY INFECTION CONTROL POLICY Department: Neurology (Hemby Lane) Date Originated: 2/20/14 Date Reviewed: 6.5.18 Date Approved: 6/3/14 Page 1 of 7 Approved by: Department Chairman Administrator/Manager
More informationWhitehouse Primary School. Health & Safety Policy
Whitehouse Primary School Health & Safety Policy To be accepted if agreed Sept. 2016 Review Date Sept. 2018 Overview Whitehouse Primary School s Health and Safety Policy is to provide and maintain safe
More informationInfection Control Policy and Procedure Manual. Post-Anesthesia Care Unit (Recovery Room) Page 1 of 6
(Recovery Room) Page 1 of 6 Purpose: The purpose of this policy is to establish infection prevention guidelines to prevent or minimize transmission of infections in the. Policy: All personnel will adhere
More informationLaboratory Safety Coordinator Meeting. Fall 2011
Laboratory Safety Coordinator Meeting Fall 2011 Last Meeting- LSC Summer Interactive Different groups within EHS presented services to the labs Fischer Sci: Gathering lists of PPE and other common items
More informationNational Association of Rural Health Clinics
National Association of Rural Health Clinics A Virtual Walk Through of a Rural Health Clinic October 17, 2017 Kate Hill, RN VP Clinical Services Inc. Tom Terranova Chief Operating Officer Who Is In The
More informationLaboratory Safety Chemical Hygiene Plan (CHP)
Laboratory Safety Chemical Hygiene Plan (CHP) The Occupational Safety and Health Administration s (OSHA) Occupational Exposure to Hazardous Chemicals in Laboratories standard (29 CFR 1910.1450), referred
More informationAdministration OCCUPATIONAL HEALTH AND SAFETY
ACCREDITATION STANDA RDS OCCUPATIONAL HEALTH AND SAFETY The accreditation standards relating to occupational health and safety include those most critical to staff safety in the non-hospital setting; however,
More informationCHEMICAL HYGIENE PLAN
SAMPLE WRITTEN CHEMICAL HYGIENE PLAN For Compliance With 29 CFR 1910.1450 Wyoming General Rules and Regulations Wyoming Department of Workforce Services OSHA Division Consultation Program ACKNOWLEDGEMENTS
More informationInfection Prevention and Control and Isolation Authored by: Infection Prevention and Control Department
Infection Prevention and Control and Isolation 2015 Authored by: Infection Prevention and Control Department Objectives After you complete this Computer-Based Learning (CBL) module, you should be able
More informationPortiuncula Hospital Ballinasloe Hygiene Services Quality Improvement Plan September 2013
Portiuncula Hospital Ballinasloe Hygiene Services Quality Improvement Plan September 2013 This Quality Improvement Plan (QIP) was developed following the HIQA unannounced monitoring assessment in Portiuncula
More informationRHC COMPLIANCE AND REGULATIONS
RHC COMPLIANCE AND REGULATIONS ROBIN VELTKAMP HEALTH SERVICES ASSOCIATES OBJECTIVES Participants will gain an understanding of the basic Federal RHC Regulations. Participants will gain an understanding
More informationEXPOSURE CONTROL PLAN
BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN SALT LAKE COMMUNITY COLLEGE October 2011 ~ 1 ~ POLICY Salt Lake Community College is committed to providing a safe and healthful work environment for our entire
More informationSelf Assessment Guide for an Effective Safety and Health Program
Self Assessment Guide for an Effective Safety and Health Program The revised Rural Electric Safety Achievement Program provides the frame work for cooperatives to develop safety and health programs that
More informationA Health and Safety Tip Sheet for School Custodians. Did you know? Step 1. Identify job hazards. Step 2. Work towards solutions
A health and safety tip sheet for INSPECTION Health for SCHOOL Custodians and CHECKLIST Safety Committees SCHOOL MAINTENANCE custodians of STAFF safety: A Health and Safety Tip Sheet for School Custodians
More informationInfection Prevention and Control Checklist for LTCHs Suggestions for Use
s Suggestions for Use This checklist is designed to assist you to complete an Infection Prevention and Control walkabout in your facility. Some suggestions for use include: Set aside an hour to tour your
More informationTopic 3 Contribute to safe work practices in the workplace 43
Contents Before you begin vii Topic 1 Follow safe work practices 1 1A Follow workplace policies and procedures for safe work practices 2 1B Identify existing and potential hazards, and report and record
More informationCertified Healthcare Safety Environmental Services (CHS-EVS) Examination Blueprint/Outline
Certified Healthcare Safety Environmental Services (CHS-EVS) Examination Blueprint/Outline Exam Domains 100-130 1. Safety Management 38-50 (38%) 2. Hazard Control 38-50 (38%) 3. Compliance & Voluntary
More informationGeneral Health and Safety Information for Victoria University. An outline of any further Health and Safety Training you may require.
Directed by: Health and Safety Officer Physical Plant Updated: March 2017 General Health and Safety Information for Victoria University. General Health and Safety Information for the task and work you
More information7.0 Joint Occupational Health and Safety Committee Occupational Health and Safety Forms
Sect 7.0 -i- 7.0 Joint Occupational Health and Safety Committee Occupational Health and Safety Forms 7.0 JOHSC Report/Form Index.... Sect 7.0 - i - 6.1.A Concern/Complaint Report (Section 6.1)...Sect 7.0-1-
More informationACCIDENT PREVENTION POLICY August 2018
ACCIDENT PREVENTION POLICY August 2018 Dalton State College (DSC) is committed to establishing and maintaining a safe and healthful work environment. The commitment involves the development, implementation
More informationMODULE 22: Contingency Planning and Emergency Response to Healthcare Waste Spills
MODULE 22: Contingency Planning and Emergency Response to Healthcare Waste Spills Module Overview Present examples of contingencies related to HCWM Describe steps in developing a contingency plan Describe
More informationCORPORATE SAFETY MANUAL
CORPORATE SAFETY MANUAL Procedure No. 27-0 Revision: Date: May 2005 Total Pages: 9 PURPOSE To make certain that our employees are duly aware of the hazards of blood exposure or other potentially infectious
More informationBloodborne Pathogens Cumru Township Fire Department 02/10/2011 Policy 10.5 Page: 1 of 7
Policy 10.5 Page: 1 of 7 Purpose: The Cumru Township Fire Department is committed to providing a safe and healthful work environment for our entire staff, both career and volunteers. In pursuit of this
More information2016 Kentucky Rural Health Clinic Summit. Kate Hill, RN VP Clinical Services
2016 Kentucky Rural Health Clinic Summit Kate Hill, RN VP Clinical Services Operational excellence leads to clinical excellence Focusing on day-to-day operations can DECREASE COSTS while INCREASING QUALITY
More informationDuties of a Principal
Duties of a Principal 1. Principals shall strive to model best practices in community relations, personnel management, and instructional leadership. 2. In addition to any other duties prescribed by law
More informationPenticton & District Community Resources Society. Child Care & Support Services. Medication Control and Monitoring Handbook
Penticton & District Community Resources Society Child Care & Support Services Medication Control and Monitoring Handbook Revised Mar 2012 Table of Contents Table of Contents MEDICATION CONTROL AND MONITORING...
More information250- PERSONAL PROTECTIVE EQUIPMENT PROGRAM
250.1 PURPOSE A. To set forth procedures for the use, care, and maintenance of personal protective equipment (PPE) required to be used by employees for the prevention of injuries. 250.2 SCOPE A. Applies
More informationCertified Healthcare Safety Long Term Care (CHS-LTC) Examination Blueprint/Outline
Certified Healthcare Safety Long Term Care (CHS-LTC) Examination Blueprint/Outline Exam Domains 100-130 1. Safety Management Principles 31-40 (31%) 2. Hazard Control Concepts 46-60 (46%) 3. Compliance
More informationDepartment of Public Health Infection Control Survey
Patient Care Services, uality and Safety Being Ready for Every Patient Every Day Department of Public Health Infection Control Survey Resource Guide for Patient Care ssociates Excellence Every Day The
More informationUsing Body Mechanics
Promotion of Safety Using Body Mechanics Muscles work best when used correctly Correct use of muscles makes lifting, pulling, and pushing easier Prevents unnecessary fatigue and strain and saves energy
More informationFacilities Department Accident Prevention Plan
Prepared By: Facilities Management team Revision Date: 2/12/18 1.0. PURPOSE The management of Edmonds Community College is committed to preventing accidents and ensuring the safety and health of our employees.
More informationObjectives Top Ten Cited Deficiencies for Acute Care Facilities April 21, 2015
2014 Top Ten Cited Deficiencies for Acute Care Facilities April 21, 2015 Michele Kala, MS, RN Director of Accreditation and Certification Objectives Understanding of the top scored deficient HFAP standards
More informationRESEARCH LABORATORIES CONDUCTING HIV/HBV RESEARCH AND PRODUCTION
RESEARCH LABORATORIES CONDUCTING HIV/HBV RESEARCH AND PRODUCTION A. Definition of HIV/HBV Research and Production Laboratories Research laboratory means a laboratory which produces or uses research laboratory
More informationChild Health and Safety
1. Responding to Emergency Staff will be trained on emergency procedures such as but not limited to CPR, basic first aid, and medication administration. Emergency procedures will be posted in classrooms.
More informationSUBCHAPTER 31. MANDATORY PHYSICAL ENVIRONMENT
SUBCHAPTER 31. MANDATORY PHYSICAL ENVIRONMENT 8:39-31.1 Mandatory construction standards (a) No construction, renovation or addition shall be undertaken without first obtaining approval from the Department,
More informationBLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN School Name: Eastern Local School District Date of Preparation: August 2, 2000 (Revised August 22, 2002) In accordance with the PERRP Bloodborne Pathogens standard,
More informationThe Joint Commission and Facility Design: A Partnership for Patient Safety and Quality Care
The Joint Commission and Facility Design: A Partnership for Patient Safety and Quality Care A Webinar Presentation for the AIA AAH 8 January 2013 1 Topic 1: Driving Safety through Good Design Presenter:
More informationINJURY AND ILLNESS PREVENTION SELF-ADMINISTERED TRAINING BOOKLET REV 1.1
INJURY AND ILLNESS PREVENTION SELF-ADMINISTERED TRAINING BOOKLET REV 1.1 Office of Environmental Health & Occupational Safety 2009 INTRODUCTION Welcome to California State University, Northridge (CSUN).
More informationRegional Healthcare Hygiene and Cleanliness Audit Tool
Regional Healthcare Hygiene and Cleanliness Audit Tool Organisation Name: Area Inspected/ Speciality: Auditors: Date: Contents Guidance 4 Audit Tool 4 Scoring 5 Section 0 - Organisational Systems and Governance
More information13 SUPPORT SERVICES OVERVIEW OF SUPPORT SERVICES
1 13 SUPPORT SERVICES OVERVIEW OF SUPPORT SERVICES The organisation may employ its own personnel to provide support services, such as laundry, housekeeping and catering or support services may be outsourced,
More informationPharmacy Sterile Compounding Areas
Approved by: Pharmacy Sterile Compounding Areas Corporate Director, Environmental Supports Environmental Services/ Nutrition Food Services Operating Standards Manual Number: Date Approved June 17, 2016
More informationAssessment: Physician Office/Clinic
Assessment: Physician Office/Clinic Location: Site director: Date of Evaluation: Date of last Eval: Reviewer: No. of exam/treatment rooms: Type of facility: Medical Director: Number of Providers Physicians
More informationYukon Government s. Telework Guidelines. February 2010 Policy, Planning & Communication Branch, PSC
Yukon Government s Telework Guidelines Table of Contents Telework Guidelines 1 Appendix A: Telework Agreement Template 6 Appendix B: Health & Safety Checklist 10 These guidelines are intended to be read
More informationINCIDENT INVESTIGATION PROGRAM
INCIDENT INVESTIGATION PROGRAM 1.0 PURPOSE The purpose of this program is to prevent the recurrence of an incident and to eliminate or minimize the risks associated with the incident. 2.0 SCOPE This procedure
More informationInfection Control Checklist for Dental Settings Using Mobile Vans or Portable Dental Equipment. Guiding Principles of Infection Control:
Guiding Principles of Infection Control: PRINCIPLE 1. TAKE ACTION TO STAY HEALTHY PRINCIPLE 2. AVOID CONTACT WITH BLOOD AND OTHER POTENTIALLY INFECTIOUS BODY SUBSTANCES PRINCIPLE 3. MAKE PATIENT CARE ITEMS
More informationENVIRONMENTAL HEALTH AND SAFETY STANDARDS
Adopted: January 8, 1985 Revised: March 12, 1991 February 8, 1999 October 12, 2009 July 22, 2013 (no change) Contact Person: Health and Safety Coordinator POLICY 407 ENVIRONMENTAL HEALTH AND SAFETY STANDARDS
More informationSection 5 General Policies Work, Health and Safety Policy. The Gums Childcare Centre Policies
The Gums Childcare Centre Policies Section 5 General Policies 3.14 Work, Health and Safety Policy Background 1. The Gums Childcare Centre is committed to ensuring a safe and healthy working and learning
More informationOSHA Compliance Update for Long Term Care
OSHA Compliance Update for Long Term Care Alabama Nursing Home Association June 2011 What/Who is OSHA? Occupational Safety and Health Administration Created under the OSH Act of 1970 Initiated in 1971
More informationTOP 10 ASC COMPLIANCE FAQs
TOP 10 ASC COMPLIANCE FAQs January2013 Read the 10 most common compliance issues from real ASCs in more than 40 states and our tips on how to solve them. www.pss4asc.com Q 1: When and how often should
More informationThere were 40 residents on 28/07/2007. The Nursing Home is currently fully registered for 50 residents.
Nursing Home Inspectorate, HSE Dublin North East Area, Kells Business Park, Cavan Rd., Kells, Co. Meath. Tel No: 046-9282629/9282524 Fax No: 046-9282561 Tuesday, 9 th October 2007 Mowlam Healthcare Ltd.,
More informationPOLICY & PROCEDURES MEMORANDUM
Policy No. *SF-1373.6 POLICY & PROCEDURES MEMORANDUM TITLE: BLOODBORNE PATHOGENS: EXPOSURE CONTROL PLAN (ECP) EFFECTIVE DATE: November 25, 2002* (*ORM Regulations Update 9/24/12; Title Updates 5/7/05)
More informationBLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN School Name: MSAD #33 Date of Preparation: March 1993 In accordance with the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030, the following exposure control
More informationHEALTH & SAFETY EDUCATION FOR THE WORKPLACE
HEALTH & SAFETY EDUCATION FOR THE WORKPLACE Pamela L. Smith, Consultant and Facilitator Safety Consultant and Facilitator 1 INTRODUCTION TO HEALTH & SAFETY FOR SMALL BUSINESS TOPICS Workplace Safety Basic
More informationBest Practice Guidelines - Storing and Handling Clean Linen in Healthcare Facilities
Best Practice Guidelines - Storing and Handling Clean Linen in Healthcare Facilities Target Audience: All employees who handle clean linen in a healthcare facility. Purpose: To ensure healthcare linen
More informationHealth and Safety Policy Statement
Health and Safety Policy Statement Author: Michelle Bingham Date of Issue: 16 th September 2017 Review date: 16 th September 2018 At Brookside Preschool, we believe that the health and safety of children
More informationPreparing for Life Safety Code Surveys with the Joint Commission - Part 2. Florida Hospital Association. Wednesday, May 2, 2018 WELCOME!
Preparing for Life Safety Code Surveys with the Joint Commission - Part 2 Florida Hospital Association 1 WELCOME! Thanks for joining us! 2 Florida Hospital Association 1 Part 1 Review Understand how The
More informationPERSONAL PROTECTIVE EQUIPMENT (PPE) Standard Operating Guidance
Revision Date: 27OCT2014 Hazard ID: P/H Incident EBOLA Annex A 1 PPE Revised By: PERSONAL PROTECTIVE EQUIPMENT (PPE) Standard Operating Guidance Use By: Response personnel required to don and doff PPE
More information11/16/17. Annual Survey Watch Report. Surveyors. Keeping you in the know in the ASC industry CMS. Accreditation
Keeping you in the know in the ASC industry Annual Survey Watch Report Crissy Benze, MSN, BSN, RN Progressive Surgical Huddle November 20, 2017 Surveyors CMS Accreditation 1 Governance Governing Body failed
More information(Company name) Health and Safety Plan
(Company name) Health and Safety Plan 1 Index I II III IV V VI VII VIII IX Safety Policy Statement Accident/Injury Analysis Component Safety Program Record keeping Component Health and Safety Education
More informationStandard EC Elements of Performance for EC The hospital manages fire risks.
Standard EC.02.03.01 The hospital manages fire risks. Elements of Performance for EC.02.03.01 1. The hospital minimizes the potential for harm from fire, smoke, and other products of combustion. 2. If
More informationEAST CAROLINA UNIVERSITY INFECTION CONTROL POLICY
EAST CAROLINA UNIVERSITY INFECTION CONTROL POLICY Department: Pediatrics-Hem/Onc-Module F Date Originated: 03/6/2012 Date Reviewed: 6/14, 9/12/17 Date Approved: 6/5/12 Page 1 of 8 Approved by: Department
More informationHEALTH AND SAFETY POLICY 2010
April 2008 CONTENTS Page No ii 1 GENERAL STATEMENT OF POLICY 2 2 DELIVERING HEALTH AND SAFETY 3 2.1 Management 3 2.2 Policy and Procedures 3 2.3 Training 4 2.4 Communication and Involvement 4 2.5 The Working
More informationFacility Information. Overview of Visit. Report Summary
Team Advocacy Inspection for December 15, 2015 Miles Residential Care Inspection conducted by Nicole Davis, P&A Team Advocate, and Bethany Schweer, Volunteer Facility Information Miles Residential Care
More informationHazardous Materials and Waste Management Plan
Hazardous Materials and Waste Management Plan EC 01.01.01 EP 5; EC 02.02.01; EC 04.01.01 I PURPOSE MCG Health, Inc. (MCGHI) is a leader in health care for the state of Georgia and provides a full spectrum
More informationPHARMACEUTICALS AND MEDICATIONS
DESCHUTES COUNTY ADULT JAIL CD-10-17 L. Shane Nelson, Sheriff Jail Operations Approved by: December 6, 2017 POLICY. PHARMACEUTICALS AND MEDICATIONS It is the policy of Deschutes County Sheriff s Office
More information2017 Annual Mandatory Education. Sarasota Memorial Health Care System
2017 Annual Mandatory Education Sarasota Memorial Health Care System Self-Study Module Questionnaire The goals of Annual Mandatory Education are to provide employees with information pertinent to their
More informationSupplemental Information for SECOR Submissions
Supplemental Information for SECOR Submissions Enform» Supplemental Information for SECOR Submissions 2 Introduction This document has been developed to provide supplemental information to SECOR holders
More informationCertified Healthcare Safety Nursing (CHSN) Examination Blueprint/Outline
Certified Healthcare Safety Nursing (CHSN) Examination Blueprint/Outline (Effective October 1, 2017) Exam Domains 135 Items 1. Patient Safety Fundamentals 54 Items/40% 2. Healthcare Safety Management 54
More informationHealth and Safety Policy
Introduction Health and Safety Policy BSB is committed to ensuring health and safety good practice across all areas of school life. We take our responsibility for the health and safety of staff, pupils,
More informationPRESENTED BY APRIL 18, The University of Texas MD Anderson Cancer Center Houston, Texas
PRESENTED BY APRIL 18, 2018 The University of Texas MD Anderson Cancer Center Houston, Texas Jim Shelton, CAS Houston North Area Office OSHA and Healthcare Healthcare encompasses several NAICS codes and
More informationHealthcare Associated Infection (HAI) inspection tool
Healthcare Associated Infection (HAI) inspection tool Hospital: Ward/Department: Inspector: Date: Guidance note: This tool is designed to assist HEI inspectors assess NHS boards compliance with NHS Quality
More informationA Sharper Phlebotomy Service
A Sharper Phlebotomy Service Preparing for the future Submission for the 2014 Canterbury DHB Quality Improvement and Innovation Awards Megan Harris, Karen Heatley, Linda Boyce, Jaine Duncan Canterbury
More informationIs clearly identified which type of inspections should be carried out:
3. PLANNED INSPECTIONS (75) 3.1. Inspection Guidelines (20) 3.1.1. Is clearly identified which type of inspections should be carried out: general (housekeeping inspections)? (1) middle and senior management
More informationCommon Conditions in Decision Reports. Christine Grusys OHP Program Supervisor
Common Conditions in Decision Reports Christine Grusys OHP Program Supervisor Objective: Review the most common sections of the OHPIP Standards where there are outstanding conditions following Committee
More informationEAST CAROLINA UNIVERSITY INFECTION CONTROL POLICY
EAST CAROLINA UNIVERSITY INFECTION CONTROL POLICY Family Medicine Physical Therapy Date Originated: February 25, 1998 Dates Reviewed: 2.25.98, 2.28.01 Date Approved: February 28, 2001 3.24.04; 9/10/13
More informationREGULATORY COMPLIANCE: HOW READY IS YOUR HEALTHCARE SYSTEM?
REGULATORY COMPLIANCE: HOW READY IS YOUR HEALTHCARE SYSTEM? POP QUIZ: CAN YOU ANSWER THESE 10 QUESTIONS? 1. Is a bloody tissue considered trash or regulated medical waste? 2. What is the proper mix of
More informationSchool Safety Audit Checklist
School Safety Audit Checklist Based on work done by Virginia State Education Department and modified by the New York State Police as a resource for school personnel. Components of the Audit Process School
More informationChapter 4 - Employee First Aid, Medical and Emergency Procedures
Chapter 4 Employee First Aid, Medical and Emergency Procedures Chapter 4 - Employee First Aid, Medical and Emergency Procedures Non-Occupational Illness or Injury Diagnosis and treatment of non-occupational
More informationEmployee First Aid, Medical and Emergency Procedures
Chapter 4 - Employee First Aid, Medical and Emergency Procedures Chapter 4 Employee First Aid, Medical and Emergency Procedures Non-Occupational Illness or Injury Diagnosis and treatment of non-occupational
More informationRURAL HEALTH CLINIC PRE-CERTIFICATION PRACTICE TOOL Updated: March 2016
OREGON OFFICE OF RURAL HEALTH WIPFLI ASSOCIATES RURAL HEALTH CLINIC PRE-CERTIFICATION PRACTICE TOOL Updated: March 2016 JTAG REGULATION THINGS TO LOOK FOR MEETS SPECIFICATIONS (Y/N) ACTION NEEDED/COMMENTS
More informationBLOODBORNE PATHOGENS EXPOSURE PREVENTION POLICY AND PROCEDURE BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
BLOODBORNE PATHOGENS EXPOSURE PREVENTION POLICY AND PROCEDURE This sample plan is provided only as a guide to assist in complying with the OSHA Bloodborne Pathogens standard 29 CFR 1910.1030, as adopted
More informationUrinalysis and Body Fluids
Urinalysis and Body Fluids Unit 1 A Safety in the Clinical Laboratory Types of Safety Hazards Physical risks Sharps hazard Electrical hazard Radioactive hazard Chemical exposure risk Fire / explosive hazards
More informationHouston Controls, Inc Safety Management System
Preparation: Safety Mgr Authority: Dennis Johnston Issuing Dept: Safety Page: Page 1 of 8 Purpose This Bloodborne Pathogen Exposure Control Plan has been established to ensure a safe and healthful working
More informationComply with infection control policies and procedures in health work
Student Information Course Name Course code Contact details Partial completion of one of these qualification Description of this unit against the qualification Descriptor Comply with infection control
More informationPolicy #2 INJURY & ILLNESS PREVENTION PROGRAM Version 2.2
INTRODUCTION Searles Valley Minerals is committed to safely operating all facilities/operations to keep accidents, injuries and illnesses to a minimum. It is our policy to provide all employees with a
More informationAccident Prevention Process
page 8 of 44 Accident Prevention Process Accidents and injuries can be prevented, but it takes planning, organizing, leadership and coordination to do so. Safety and health professionals have identified
More informationRegulations that Govern the Disposal of Medical Waste
Regulations that Govern the Disposal of Medical Waste In Louisiana, there are three (3) sources of regulations for medical wastes: OSHA, the Louisiana Department of Health and Hospitals, and the Louisiana
More informationOSHA Inspections: Real Life Story
OSHA Inspections: Real Life Story Stephanie Martin, BSN, RN, CNOR, CASC Administrator St. Augustine Surgery Center August 14, 2012, 6:00 AM August 14, 2012, 6:00 AM The day started like any other... Arriving
More information2016 Plan of Correction Data 1
2016 Plan of Correction Data 1 Retail Data Calendar Year 2015 2016 Number of Inspections 1263 1694 number of Plan of Correction s (POC s) issued 502 523 Regulatory Citations 2 & 2015 2016 number of POC
More informationNORTH CAROLINA A&T STATE UNIVERSITY Chemical Hygiene Plan
North Carolina Agricultural and Technical State University OFFICE OF ENVIRONMENTAL HEALTH & SAFETY Safety Manual Subject: Chemical Hygiene Plan Number: 5-1 Date February 1, 2009 Amends: None Supersedes:
More informationUniversity of North Dakota Facilities Department Respiratory Protection Program. Table of Contents. 1.0 Introduction Purpose...
University of North Dakota Facilities Department Respiratory Protection Program Table of Contents Section Page 1.0 Introduction...1 2.0 Purpose...1 3.0 Scope...1 4.0 Responsibilities...1 5.0 Respirator
More informationOPERATING ROOM ORIENTATION
OPERATING ROOM ORIENTATION Goals & Objectives Discuss the principles of aseptic technique Demonstrate surgical scrub, gowning, and gloving Identify hazards in the surgical setting Identify the role of
More informationBLOODBORNE PATHOGENS
BLOODBORNE PATHOGENS Supplement to Standard Training Module TRAINING REQUIREMENTS OVERVIEW This standard Vivid training module provides a general overview of Bloodborne Pathogens (BBP). It is important
More informationHealth and Safety in the lab. Seyed Hosseini SA Pathology Chemical Pathology
Health and Safety in the lab Seyed Hosseini SA Pathology Chemical Pathology ISO 15190 This International Standard specifies requirements to establish and maintain a safe working environment in a medical
More information