UPMC POLICY AND PROCEDURE MANUAL. This policy applies to all United States based UPMC facilities.

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1 UPMC POLICY AND PROCEDURE MANUAL POLICY: INDEX TITLE: HS-FM0209 Facilities and Safety SUBJECT: Safety Management Program DATE: April 19, 2013 I. POLICY Each UPMC entity establishes a Safety Management Program which is approved by the leadership of that organization. The UPMC Safety Management Program is mandated by the Board of Trustees, who delegate responsibility for implementation of the program to the respective Business Unit Presidents and other administrative staff as indicated in the plan. There are multidisciplinary committees (hereafter referred to as Safety Committees ) serving many functions to address safety issues. Safety Officers also review issues, incidents and compliance programs. Organizational specific elements of this program are maintained in procedures at the individual entity. II. SCOPE This policy applies to all United States based UPMC facilities. III. RESPONSIBILITY/AUTHORITY A. Entity Governing Body 1. Strives to ensure a physical environment of care free of recognized hazards for patients, staff and visitors by requiring and supporting the establishment and maintenance of a safety management program including a Safety Officer and a multidisciplinary Safety Committee. 2. Maintains familiarity with entity safety activities through requiring periodic reporting of safety-related issues through established reporting structures. 3. Evaluates and acts on recommendations or action plans submitted by the entity Administrative Leadership, Safety Committee and/or Safety Officer.

2 PAGE 2 B. Entity Administrative Leadership 1. Strives to ensure a physical environment of care free of recognized hazards for patients, staff and visitors by requiring and supporting the establishment and maintenance of a safety management program including a Safety Officer and a Safety Committee. 2. Maintains ultimate responsibility for establishment and maintenance of the Safety Management Program. 3. Delegates operational responsibility for this program to the Safety Committee and Safety Officer. 4. Ensures that required records of employee occupational illness and accident as well as other regulatory records are maintained. 5. Evaluates and acts on recommendations or action plans submitted by the Safety Committee and/or Safety Officer. 6. Maintains authority to take any actions necessary or alter any policy as necessary to provide for the protection of patients, visitors and staff. C. Safety Officer 1. Operationally responsible for ensuring the completion of all safety-related activities in the designated entity and affiliated facilities. 2. Maintains authority, as delegated by administrative leadership, to take appropriate action to correct conditions which may pose an immediate threat to life or health, or which pose a threat of damage to equipment and/or buildings. 3. Establishes and maintains an information collection and evaluation system concerning hazards and safety practices. 4. Participates in development of safety-related educational programs. 5. Ensures that the review of safety incidents occurs and that appropriate follow up actions are developed implemented and followed up. 6. Works with appropriate staff to implement the Safety Management Program as well as actions recommended by the Safety Committee. 7. Conducts follow-up and monitoring of all such recommendations.

3 PAGE 3 8. Coordinates responses to natural and man-made emergencies with involved staff and municipal agencies. 9. Ensures that reviews of individual departmental safety plans occur on a regular basis. D. Safety Committee 1. Develops, reviews and monitors compliance with all policies and procedures which are designed to enhance safety management features of the environment of care. 2. Reports safety activities and requirements to departments and assist them in implementation of relevant policies, practices and procedures. 3. Each Safety Committee shall establish a meeting frequency and schedule appropriate to the needs of that organization. 4. Reviews data as submitted. Develops, approves and monitors recommended plans of action. 5. Reviews safety and emergency policies and procedures. 6. Promotes the Hazard Surveillance Program (defined in Section III of this policy) where appropriate. 7. Requires and conducts an annual evaluation of the scope and effectiveness of the Safety Management Program and develops goals & objectives based on these findings. E. Department Managers 1. Ensure mandatory orientation and annual Safety Management training for all staff. 2. Investigate all hazards and/or potential hazards and implement appropriate plans of correction to eliminate or contacts the Safety Officer for assistance in amelioration of hazards. 3. Develop, support and maintain departmental safety plans. 4. Enforce general and departmental safety programs and safe work practices. Staff failing to follow safe work practices shall be subject to progressive disciplinary action as detailed in the individual entity s Human Resource policies.

4 PAGE 4 5. Participate in the development and implementation of policies and procedures as required in response to potential hazards or as recommended by the entity Safety Committee and/or Safety Officer. 6. Ensure that all work related exposures, illnesses, injuries and/or incidents are reported as per established reporting procedures. 7. Ensure that a complete investigation of all employee accidents and injuries is completed and documented. 8. Develop, implement and communicate to affected staff corrective actions taken to prevent further injuries and accidents. F. Staff/Supervisors 1. Comply with all applicable established Safety policies and procedures. 2. Employ established safe work practices at all times. 3. Eliminate and/or report to the appropriate persons any unsafe conditions, physical hazards or operational problems. 4. Report promptly all work-related exposures, illnesses, injuries and/or incidents. 5. Complete all required Safety training as assigned. 6. Supervisors are to complete and document initial investigations into employee accidents and injuries. 7. Develop, implement and communicate to affected staff corrective actions taken to prevent further injuries and accidents. IV. PROVIDING ACTIVITIES TO REDUCE RISK OF INJURIES A. MAINTAINING GROUNDS AND EQUIPMENT Efforts to ensure the safe use of grounds and equipment by patients, visitors and staff shall include items noted as part of the Hazard Surveillance program, reported by staff or noted in Incident Reports. These items are reported to the appropriate department (for grounds and non-patient care equipment) for response. Patient care equipment (if applicable) is maintained in accord with each entity s Medical Equipment Management Plan.

5 PAGE 5 B. SAFETY POLICIES AND PROCEDURES Each operational and administrative business unit shall have written safety polices and procedures. Safety plans and procedures should be reviewed on an annual basis. Staff and supervisors are responsible for observing and implementing all safety rules and regulations applicable to their job. C. HAZARD SURVEILLANCE PROGRAM A system of regular inspections of all facilities for potential life safety, physical, infection control, security and other hazards may be utilized. Results of inspections shall be forwarded to the appropriate staff responsible for the areas inspected and/or the deficiencies noted. D. RECALL PROGRAM Each entity has assigned a person responsible for forwarding notices of recalls to appropriate staff, ensuring that an assessment for products on site is completed and coordinating necessary follow up via the appropriate Supply Chain Management Department. E. INCIDENT REPORTING SYSTEM Incident Reports involving patients, visitors, staff and/or property damage or loss shall be integrated as part of the established Risk Management reporting system and in compliance with the entity incident reporting policy. F. OCCUPATIONAL ACCIDENT REPORTING Reports of Employee Incidents shall be reported in compliance with each entity s employee occupational accident and injury policy. Summaries of occupational accident occurrences should be presented to the Safety Committee on a scheduled basis. Trending of injury patterns shall be developed for incident investigation and injury prevention activities. V. ORIENTATION/EDUCATION Each new employee will receive an orientation to the Safety Management Program as part of the New Employee Orientation program. All other staff will complete regular mandatory inservicing.

6 PAGE 6 Each employee will receive training and information on safety rules, procedures and practices specific to their work area prior to initial assignment and annually or as changes in the environment occur thereafter. VI. EVALUATION OF PROGRAM The Safety Management Program, including established goals, objectives and performance measures, will be evaluated on an annual basis. The results of this evaluation are used in the development of subsequent years' goals and objectives. VII. PERFORMANCE MEASUREMENT As applicable to accredited Business Units an Information Collection and Evaluation Systems (ICES) designed to measure performance in the various functions shall be maintained. SIGNED: Elizabeth Concordia Executive Vice President, UPMC, President, Hospital and Community Services Division ORIGINAL: August 15, 2002 APPROVALS: Policy Review Subcommittee: March 14, 2013 Executive Staff: April1 19, 2013 PRECEDE: June 1, 2012 SPONSOR: Environmental Health & Safety Integration Team

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