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 of Date Reviewed: Care Committee; EC 2000 Date: Revised: Accident Reporting ; EC 2008 Environmental Tours Attachment: None Page 1 of 5 Purpose: To establish an Environment of Care at Premier Medical Group which provides protection to the organization s patients, visitors, and staff and complies with the New York State Department of Health, Joint Commission of Accreditation of Healthcare Organizations (JC) Standards, OSHA Standards and all other regulatory organizations dealing with safety, and JC Standards. A. There are 3 basic components of Environment of Care Buildings, Equipment and People. B. Effective Management of the Environment of Care includes using processes and activities to accomplish the following: Reduce and control environmental hazards and risks. Prevent accidents and injuries. Security maintaining safe conditions for patients, staff and others visiting the facilities. Maintaining an environment that is sensitive to patient s needs. Maintaining an environment that minimizes the unnecessary environmental stresses for patients, staff and others visiting the facilities. C. JC Standards related to Environmental Tours include: The organization collects information to monitor conditions in the environment according to EC.04.01.01. The organization analyzes identified environment of care issues according to EC.04.01.03. The organization improves environment of care according to EC.04.01.05. Policy: The Premier Medical Group will assure a safe environment for patients, employees, and visitors through the establishment and maintenance of an effective environment of care program which includes: Safety Security Life (Fire) Safety Hazardous Materials Emergency Management Medical Equipment Utilities This program will be based on monitoring and evaluation of organizational experience, applicable laws and regulations and acceptable practice. The program will promote occupational safety and health and minimize hazards, injuries and illnesses for all employees, patients, visitors and enhance worker safety.
Title: Environment of Care Management Program Policy No.: EC2007 Page 2 of 5 Responsibilities: D. The Environment of Care Committee administers the overall environment of care program. The EOC Committee s objective is to initiate corrective actions needed to make the environment compliant with the requirements of the Life Safety Code; NFPA 101. The EOC Committee requires Premier Medical Group to have written management plans for the following: Safety Management Security Management Emergency Management Fire Safety Hazardous Materials and Waste Management Medical Equipment Management Utilities Management These EOC Management Plans are evaluated annually. The objectives, scope, performance and effectiveness are evaluated with an Annual Review. Premier Medical Group establishes and implements processes for ongoing monitoring of performance regarding actual or potential risk in each of the Environment of Care Management Plans. The EOC recommends one or more PI (Performance Improvement) measure be implemented for the ongoing performance monitoring of each of the Environment of Care Management Plans. E. The Practice Administrator(s) chairs the EOC Committee F. The Safety Compliance Coordinator appointed by the CEO s, is responsible for: 1. Implementation and maintenance of an ongoing system to collect and evaluate information for use by the Premier Medical Group Environment of Care Committee about hazards, safety practices and safety management issues. 2. Perform an annual Security Risk Assessment and act upon areas of opportunity found in the assessment. The assessment will be forwarded to the EOC Committee for their review/action. 3. Safety Management Plan 4. Security Management Plan 5. Life (Fire) Safety Management Plan 6. The annual review of all safety plans, all safety policies and procedures and the submission of a summary report to the Premier Medical Group Environment of Care Committee. 7. Interventions whenever conditions exist that pose any immediate threat to life or health, or pose a threat of damage to equipment or buildings. When conditions permit, corrective actions will be initiated through the Environment of Care Committee. 8. Manages the EOC Inspection Team. 9. Responsible for monitoring all aspects of fire safety including fire drills, compliance with the National Fire Safety Code, portable equipment checks, hazardous surveillance rounds, Interim Life Safety Measures during construction and renovations. 10. Is a standing member of the EOC Committee.
Title: Environment of Care Management Program Policy No.: EC 2007 Page 3 of 5 Site Location Managers are responsible for: 1. Development and implementation of an ongoing and effective safety strategy for their site location, participating in and supporting the Environment of Care Program, including the review of all employee incidents. 2. Responsible that all issues highlighted by EOC Rounds are brought to standards as mandated by EC Policy Environmental Tours. 3. Ensure that employees participate in annual mandated training in general safety, fire, or fire prevention, hazardous material safety, emergency preparedness, infection control, bio-med, and security. 4. Enforcing the organizations safety and procedure policies, ensuring those procedures are practiced and enforced. 5. Using safety related information in the departmental orientation of new employees and continuing education. 6. Reporting all security incidents that involve patients, visitors, employees, medical staff, contractors, or property. See EC Policy on Accident Reporting. 7. Where applicable educate and ensure monitoring of employees that regularly comes into contact with hazardous materials and waste. 8. Identifying, evaluating and preparing an inventory of hazardous materials and wastes used or generated in their specific site location. 9. Reporting all hazardous materials and waste spills, and exposures or other incidents that involve patients, visitors, employees, contractors, or property. 10. Assessing and minimizing the clinical and physical risks employed with medical equipment through inspection, testing and maintenance of medical equipment, education of users. 11. Reporting and investigating equipment problems, failures or user errors that may have an adverse effect on patient safety and/or the quality of care. 12. Developing site specific procedures that detail employee actions to be taken when equipment fails. 13. Reporting all utility systems management problems, or failures or user errors that are or may be a threat to the patient care environment. 14. Reporting all fire protection deficiencies, failures and user errors. 15. Orienting and educating employees on the policies that deal with safety, fire prevention, security, hazardous materials and waste, medical equipment and utilities with specific training on reporting deficiencies in any area (safety, security, medical equipment, hazards etc.) G. The Respective Practice Administrator is responsible for: Managing and coordinating the various Management companies for the organizations buildings and grounds and will author and take possession of the organizations Utilities Management plan. Communicates with the Safety Compliance Coordinator regarding construction, renovations, repairs, utility disruptions or anything that might have an adverse effect upon anyone entering the locations of Premier Medical Group that may necessitate the need for an ILSM (Interim Life Safety Measure). Monitors and assures the operational reliability of, and or responds to a failure of any of the sites utility systems that could affect patient care. H. Manager of Human Resources: or designee is responsible for coordinating the overall orientation program and ensuring that the Environment of Care program (safety, security, hazardous materials, emergency preparedness, fire prevention are presented at new employee orientations. I. Biomedical: Contracted Vendor is responsible for: The design and implementation of a medical equipment management program which assesses and controls the clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment and care of patients; and other fixed and portable electrically powered equipment.
Title: Environment of Care Management Program Policy No.: EC 2007 Page 4 of 5 J. Nursing Supervisor: Is responsible for product safety recalls and is required to forward the information to the Environment of Care Committee. K. Nursing Supervisor: Is responsible for Hazardous Materials and will author and execute the organizations Hazardous Materials Management Plan. L. Manager of Human Resources: Member of the EOC Committee. In partnership with the Safety Compliance Coordinator conducts and/or oversees investigations into staff injuries, near misses, and suspected unsafe/unhealthy work environments. M. Infection Control Coordinator: Responsible for ensuring infection control standards are maintained. Member of the EOC Committee. Member of the EOC Inspection Team. Procedures: A. The Environment of Care Committee oversees the organizations compliance with: EOC regulatory standards. Convenes quarterly to review /discuss matters related to EOC. Maintain minutes of the EOC state of affairs and actions taken. Review the management plans and create an annual EOC report to be distributed and reviewed by management. Regulations/operations /conditions that do not meet regulatory and or the organizations standards may be directed to create a CAP (Corrective Action Plan) under the oversight of the EOC Committee until such time the deficiency is deemed corrected. B. Environment of Care Inspection Team: Chaired by the Safety Compliance Coordinator, with representation from management when available, safety, infection control, and site location managers will conduct a comprehensive EOC inspection of all sites quarterly. (See EC Policy Environmental Tours). C. The Safety Compliance Coordinator or Designee: With the full authority of the organizations CEO s will immediately intervene or stop work, operation, or acts which, in his/her opinion may result in injury, impairment, sickness or immediately endanger the lives of patients, employee, visitors or threaten damage to equipment or buildings. D. The Safety Compliance Coordinator or Designee: Will conduct an annual comprehensive Security/Safety Risk Assessment for the organizations site locations that proactively evaluates the impact on patient and public safety of buildings, grounds, equipment, occupants and internal physical systems. The findings of the assessments will be shared with site location managers, senior management, and followed up to ensure that all safety issues are addressed. E. The Safety Compliance Coordinator or Designee: Insures that ongoing fire drills are conducted per policy and that those fire drills are documented and a report of these activities are forwarded to the EOC Committee.
Title: Environment of Care Management Program Policy No.: EC 2007 Page 5 of 5 F. The Safety Compliance Coordinator or Designee: Insures that an effective hazardous surveillance program is conducted throughout the locations of Premier Medical Group and continuously improves as appropriate. References: OSHA Standards 29 CFR 1910 NFPA Life Safety 101 2000 Edition Date Policy to be reviewed: 04/15 Title: Policy No.: Page of
Date Policy to be reviewed: