San Francisco General Hospital and Trauma Center ENVIRONMENT OF CARE/SAFETY MANAGEMENT 2010-2011 Annual Report The goal of SFGH s Environment of Care/Safety Program is to provide for a safe and effective environment of care for patients, visitors, volunteers and staff in accordance with organizational needs and regulatory requirements. The Environment of Care (EOC) Safety Program encompasses the following seven elements: Safety Security Hazardous Materials/Waste Medical Equipment Utility Fire Safety Emergency Management The Environment of Care Committee Set and prioritizes the environmental safety goals/performance standards of San Francisco General Hospital and assesses whether those goals are being met. Meet at least every other month. Membership is comprised of: Program managers for each of the 7 EOC Management programs Representatives from nursing, infection control, clinical laboratory, pharmacy and quality management. EOC projects and initiatives include opportunities for improvement identified during ongoing hazard surveillance, risk assessment, and other EOC activities. These projects and initiatives further enable the EOC Committee to proactively promote a culture of safety awareness. Constant Readiness is the focus of the EOC Safety Program. The EOC Committee maintains compliance with Joint Commission Accreditation and other regulatory standards. Page 1 of10
REPORTS ON THE EOC SAFETY ELEMENTS 1. Safety Management Objective: To provide for a safe environment through ongoing assessments that identify conditions or practices related to the buildings, grounds, equipment, occupants, and internal physical systems that are potential safety risks. Accomplishments 100% of EOC Safety Inspection Rounds were conducted for buildings and grounds, patient care and non-patient care areas. EOC inspection teams work with department/unit supervisors and manage to resolve discrepancies noted in a timely manner. Staff Education o Collaborated with Infection Control to develop and implement a staff awareness of proper use of Personal Protective Equipment (PPE) in public areas (gloves mask, etc.). o Collaborated with San Francisco Sherriff s Department (SFSD) to enhance staff awareness and prevention in the area of Violence in the Workplace/Personal Safety. o Collaborated with Environmental Services (EVS) and Infection Control to develop and implement an infection control and safety training program within EVS. o Coordinated distribution of the SFGH Safety Gram - an opportunity to disseminate Safety and Environment of Care education to staff. o San Francisco General Hospital & Trauma Center (SFGH) recognizes the significance of workplace safety & violence and has taken several measures in response to issues of violence in the workplace. One measure has been the establishment of a Violence Prevention Team (VPT) to review summary data on violence and dissemination of information on preventing violence in the workplace. The VPT has recommended extending Safety Management and Response Technique (SMART) training to all hospital employees. The content of the training addresses general concepts and principles of workplace safety prevention and management, and is tailored to the population SFGH serves. This will be an ongoing project for SFGH. Establish an Electronic EOC Rounds Tracking and Reporting System for use by all members of the EOC Team EOC Safety Inspection Rounds - Based on 2010-2011 Work Orders trends, the focus for the upcoming year will be minimizing, eliminating and/or improving staff awareness of the following: Infection Control Prevention Expired supplies Door wedges Page 2 of10
Contraband Use of small appliances Wire management Storage To increase volunteers, residents, nursing students, and medical students ability to articulate their Emergency response by distributing EOC/EHS Emergency response reference cards to 90% of above staff by June 1, 2012 Annual Program Review: As required by Joint Commission, the Safety Management Plan/Program has been reviewed and revised accordingly. No major changes in the overall objectives, scope, or performance. The Safety Management program objectives, scope, performance, and effectiveness were reviewed and evaluated by the EOC Committee and were found to be effective. Page 3 of10
2. Security Management Objective: To provide a safe, secure, and accessible facility; promote security awareness and education; prevent crime; to protect patients, visitors, staff, and physicians from harm and reasonable fear of harm; to protect personal and hospital property from theft, misuse, and vandalism; and to help enforce medical center rules and policies. Accomplishments Staffing has been dedicated to increase security and to attend departmental staff meetings to address unit based and global security concerns. The SF Sheriff s Department (SFSD) conducted active shooter presentation at Management Forum and the Institutional Patrol Unit (IPU) prepared an active shooter presentation and training curriculum for campus-wide education. Security patrols were adjusted to meet the hospital s construction phases as they were implemented. Regular meetings and discussions with the Rebuild Team were maintained so as to stay current on changes. Enhance education of staff on the AB 1083 requirement of mandatory reporting of all Battery or Assaults on hospital staff within 72 hours of the incident. Continue to engage hospital personnel in discussions of security related matters and the shared responsibilities of all affected by attending committee and staff meetings to address unit based or global security concerns affecting them. Continue to conduct Active Shooter Awareness Training in all areas under the Sheriff s security umbrella. Quarterly updates of the Hospital Campus Physical Security Assessment, which includes working closely with Facilities to achieve improvements and corrections for safety in the physical plant. Continue to adjust security patrols to meet the hospital s construction phases as they are implemented. Annual Program Review: As required by The Joint Commission, the Security Management Plan/Program has been reviewed and revised accordingly. No major changes in the over all objectives, scope, or performance. The Security Management program objectives, scope, performance, and effectiveness were reviewed and evaluated by the EOC Committee and were found to be effective. Page 4 of10
3. Hazardous Materials/Waste Management Objective: Properly manage identified and potential hazards, handle and store hazardous materials, monitor and dispose of hazardous gases and vapors, manage waste streams, respond to spills of hazardous materials. Provide staff with the appropriate skills and knowledge to safely use and handle hazardous materials/waste. Maintain documentation required by local, regional, state, and federal environmental health and safety rules and regulations. Accomplishments Continued to work with the Hospital Rebuild Team, Facilities, and Infection Control to ensure that patients, visitors, and staff were appropriately protected from real and perceived hazards created by construction activities performed in extremely close proximity to hospital clinics, activities, and routes of access/egress. Efforts focused on (a) incorporating hazardous materials planning into the early phases of project planning, (b) using hazardous materials controls as a template for infection control activities, and (c) planning mitigation measures for rebuild-associated noise. Worked interactively with SFGH Departments to improve management of hazardous materials and hazardous waste. Activities included: o Working interactively with Nursing and Pharmacy management on medication handling in response to a Joint Commission notice on hazardous drugs. o Working with Materials Management on standardized methodology for evaluating new products under consideration by the SFGH Product Evaluation Committee. Maintained SFGH Environmental Permits, and acted as liaison between regulatory agencies including the SF PUC, DPH Hazardous Materials Unified Program Agency, and Cal/OSHA and SFGH. Informed and trained SFGH management and staff regarding Cal/OSHA regulations, policies, and practices and assisted in responding to inquiries from Cal/OSHA regarding concerns about working conditions. Work with SFGH Pharmacy on improving and streamlining the management of pharmaceutical waste. Deploy standardized procedures for testing of negative pressure rooms used to isolate potentially infectious patients. Develop improved tools for evaluating the industrial hygiene impacts (noise, dust, hazardous materials) of construction projects and documenting that such impacts are appropriately mitigated (goal continued from previous year). Annual Program Review: As required by Joint Commission, the Hazardous Materials/Waste Management program objectives, scope, performance, and effectiveness were reviewed and evaluated by the EOC Committee and were found to be effective. Page 5 of10
4. Equipment Management Objective: The assessment and control of the clinical and physical inventory of fixed and portable medical equipment used for the diagnosis, treatment, monitoring, and care of patients. This program is in place to ensure that all medical equipment, products, devices and non-medical equipment used throughout the Medical Center comply with appropriate safety and operational standards prior to initial use and on an ongoing basis. To ensure that all medical equipment, products, devices and non-medical equipment used to support the SFGH Medical Center mission, complies with appropriate safety and operational standards prior to initial use and on an ongoing basis. Accomplishments Replaced obsolete Hospira model 4100 PCA pumps with new Hospira wireless LifeCare PCA pumps. Installed new Philips Intellivue patient monitoring equipment in two Interventional Radiology rooms. Assigned all purchasing responsibilities to the department s Biomedical Engineering Services (BES) contract analyst to build a better working relationship with SFGH Materials Management and to allow more time for technicians to work on medical equipment instead of spending time researching part numbers and placing orders. Developed EOC Policy 11.07, Personally Supplied Medical Equipment, in order to regulate customers bringing in their own medical equipment while visiting SFGH. Installed new Philips cardiac monitors in ED to improve patient care and expand patient monitoring capabilities. Replace obsolete Baxter model AS50 syringe pumps with new Smith Medical wireless Medfusion model 4000 syringe pumps. Continue providing training opportunities to BES technicians to further expand Biomed service capabilities. Install and activate Aeroscout asset tags on mobile medical devices for better equipment tracking using Aeroscout Mobile View software. Annual Program Review: As required by Joint Commission, the Medical Equipment Management program objectives, scope, performance, and effectiveness were reviewed and evaluated by the EOC Committee and were found to be effective. Page 6 of10
5. Utility Management Objective: To provide for a safe, controlled, comfortable environment; assesses and minimizes the risk of failures and outlines appropriate responses to failures; and ensures operational reliability and effectiveness of all utility systems Accomplishments: The West Main Cooling Tower underwent an emergency renovation of the interior structure to insure adequate operational capability of Plant Chiller Units. A PUC funded project to replace both Main Cooling Towers is still necessary and is currently in planning stages. The main chiller unit for the Campus Data Trailer has suffered numerous failures and was replaced in September 2011. Main Hospital Modernization: Schematic plans for 13 elevators have been completed by the architectural design group. Work on the design drawings and specifications are currently underway with submission to OSHPD review set for October 2011. The temperature monitoring system for medication refrigeration units has been purchased and implementation is underway. The system will be used to remotely monitor all Campus refrigeration units used for storing medications. Wireless Infrastructure: A project to install a wireless infrastructure is approximately 75% complete in the Main Hospital. It is expected that many systems will be able to utilize this infrastructure including asset tracking of Hospital equipment. Major Maintenance was completed on the12kva transformers during the Summer of 2011. These units serve the Main Hospital electrical distribution center and were deemed to be in adequate operational condition. Systematic maintenance was performed on the Main Hospital electrical switchgear equipment. Due to the age of the equipment, a continuous inspection program has been established to repair any equipment malfunctions and to increase overall system reliability. The Department of Public Health completed the conversion to a 5 digit dialing plan for the SFGH Campus and other sites within the Department. The project was successfully completed per schedule with a minimum amount of system problems. This project has allowed the telephone system expansion that will be needed for the new Hospital. New television monitors continue to be installed as part of a Hospital wide system modernization. Currently, 6 of 10 units have been completed. The cable distribution system in the Hospital was also assessed and tuned to better support and deliver service. 5 Main Fan units were mechanically renovated in 2010/11. Critical components of the fan system were replaced and upgraded. This renovation avoids a costly replacement project allowing available funding to be used in other needed areas. Page 7 of10
Planning is underway to modernize elevators 26, 27, and 28 in buildings 80/90 to increase access for disabled patients and staff and also to increase overall reliability of these older units Modernize 2 major fan units in the Main Hospital. Mechanical repairs and improvements is expected to decrease overall labor hours and decrease the possibility of catastrophic failure. Refurbishment of the Main Hospital hot water heaters unit that will offer better temperature control and meet the demand loads of the building. Emergency Generators are scheduled for start-up in Spring 2012. Facility staff in conjunction with the project team to accept the project and begin utilizing them as the primary source of emergency power. Unit 4A Nurse Call System is scheduled to undergo renovation in October 2011 as part of an on-going project to modernize all inpatient units. Annual Program Review: As required by Joint Commission, the Utility Management program objectives, scope, performance, and effectiveness were reviewed and evaluated by the EOC Committee and were found to be effective. Page 8 of10
6. Fire Life Safety Objective: To provide for a safe facility, protection of patients, visitors, employees and property from fire and the products of combustion, fire safety prevention, training and drills, fire response plans, well maintained protection systems, and a medical center design which inherently protects against fire. Accomplishments: 4 Patient areas had all the emergency exit signs upgraded from fluorescent lamps to LED type lamps. The new exit signs provide for an increased maintenance period and improve illumination. Per EOC Policy 7.02.02, the project to install hospital grade power strips is considered complete. Approximately 1200 hospital grade power strips were systematically installed throughout the Main Hospital. Kitchen fire suppression system: Spray nozzles in the exhaust ducts were replaced and tested. This system has the dual function of keeping the duct free of grease and also to distribute suppression fluid in the event of a duct fire. Fire Exit Signage: As part of an ADA signage project, new building fire exiting signage has been installed on every floor. Continue systematic replacement and upgrade of exit signs at patient units in the Main Hospital. The plan is to upgrade 4 units per year. Installation of magnetic door holders in areas of the hospital where installed door closers are required and use of the space requires doors to be held open for operational reasons. Begin planning and investigation of code requirements regarding sprinklers in all Long Term Care units within the Main Hospital. Phased modernization of the existing fire alarm system for the SFGH Campus. Some existing system components are in excess of 40 years old. The Campus system is currently being assessed to determine how best to conduct a phased renovation. Install an overhead paging in Bldg 100 to better communicate Campus alerts to staff. Annual Program Review: As required by Joint Commission, the Fire Life Safety Management program objectives, scope, performance, and effectiveness were reviewed and evaluated by the EOC Committee and were found to be effective. Page 9 of10
7. Emergency Management Program Objective: To provide for a comprehensive emergency management program at San Francisco General Hospital & Trauma Center (SFGH) that ensures effective mitigation, preparation, response and recovery to disasters or emergencies affecting the environment of care. Accomplishments: Developed more detailed contingencies and procedures for hospital emergency response to Power Failure, Ventilation System Failure, Water & Sewer Failure, and Supply Chain Disruption. Conducted Emergency Management training for SFGH Management Academy and numerous departments including Respiratory Care, Radiology, Social Services, Clinical Lab, Pediatrics, Obstetrics & Gynecology, Neonatal Intensive Care Nursery, and Nursing Administration / Administrators on Duty. Met with World Health Organization researchers to discuss best practices for hospital earthquake preparedness and exercises. Successfully managed one major multi-casualty incident involving mutual aid response to a large gas pipeline explosion and fire, one partial power failure incident, one water main break affecting numerous clinics, one gas leak adjacent to the hospital, one minor fire and flood in a hospital campus building, and numerous pre-planned events including the World Series and celebration parade. Coordinated with DPH and DEM to provide ongoing alert messaging and public information following the Japanese earthquake, tsunami and nuclear plant radiation release. Also conducted 3 multi-functional exercises, and coordinated contingency plans and alert activations for 5 pre-planned electrical system maintenance repairs and power alert drills, including two high-voltage cutovers as part of the hospital rebuild. Goals for 2011-2012 and Opportunities for Improvement: Continue implementation of training program for HICS Incident Management Team members including section-specific advanced incident action planning training. Update hospital plans for continuity of operations, pediatric surge, shelter-inplace vs. evacuation, and active shooter security emergencies. Program Evaluation: The SFGH Disaster Committee reviewed the Emergency Response Plan, policies and procedures and made appropriate revisions and additions to those documents. Both the SFGH Disaster Committee and the Environment of Care Safety Committee have evaluated the objectives, scope and performance of the Emergency Management Program and found it to be effective. Page 10 of10