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Environment of Care Management Program

By Elsie Pierce,2014-04-11 21:54
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Environment of Care Management Program

    Mariners Hospital

    91500 Overseas Highway

    Tavernier, Florida 33070

    Environment of Care Management Program

    Calendar Year (CY) 2009

    Annual Evaluation

    CONTENTS

I. Safety Management..................................................................…. Page

    1

    II. Security Management..............................................................….. Page

    3

    III. Hazardous Materials and Waste Management.............................. Page

    5

    IV. Emergency Management............................................................... Page

    7

    V. Life Safety Management...........................................................… Page

    8

    VI. Medical Equipment Management.................................................. Page

    10

    VII. Utility Systems Management......................................................... Page

    12

    ENVIRONMENT OF CARE MANAGEMENT PROGRAM

    ANNUAL EVALUATION

    The Environment of Care (EC) management program is implemented under the guidance of the Environment of Care (Safety) Committee. Each of the seven EC plans has been evaluated with the objective, scope, performance, and effectiveness in mind. The seven plans of the EC Program are Safety, Security, Hazardous Materials and Waste Management, Emergency Management, Life Safety, Medical Equipment, and Utilities Systems Management. Patient safety is an integral part of the EC program, the Patient Safety Officer is an active participant in all the EC programs.

    SAFETY MANAGEMENT

    The Safety Management Program is designed to address potential safety risks the environment of Mariners Hospital presents to patients, staff, and visitors. It has been determined that this objective forms a solid foundation for providing an environment free from hazards. The program also assures compliance with all applicable local, State, and Federal codes and regulations.

SCOPE:

    The review of the scope is based on a comparison of actual operating experience to the program intent. The scope defines the areas the program includes for management and the kinds of services provided.

    The program is applied to Mariners Hospital of Baptist Health South Florida (BHSF) and its affiliate site; the Tassell Medical Arts Building. No significant changes to the facilities served or to the health care programs provided were made during the past year. The scope still accurately reflects the intent of the program.

PROGRAM OBJECTIVES:

    Each management objective is listed in the following table. Each objective is marked as met or not met. If an objective is not met, the appropriate Environment of Care (EC) program manager(s) review the objective to determine what needs to be done to meet it during the next year. The action required to address each change is indicated in the last column of the table.

    Objectives Met Not Met Adjusted Objective / Action Plan

    The hospital identifies safety & security risks associated with the environment of care. Initial risk assessments are conducted of the buildings, grounds, equipment, staff activity, and the care and work environment for patients and employees. Additional risk ? assessments are conducted when substantive changes involving these issues occur.

    The analysis system for accidents, incidents, and occurrences is used to identify key causal elements of those incidents, and organizes the information for the EC Committee use at least ? quarterly.

    1

     Objectives Met Not Met Adjusted Objective / Action Plan

    The environmental tours program includes all areas of the hospital, Medical Arts Building, and affiliated medical practices. The ? program includes the facilities, equipment; and all support areas annually, and all patient care areas at least semi-annually.

    The Environment of Care (Safety) Committee receives information from the EC program, and other sources, identifies key issues, ? recommendations. The Safety Officer manages the monitoring, documentation and presentation of this information.

    The performance measures for the Safety Management program ? are evaluated and reported quarterly.

    All departments have access to the current organization wide safety policies and procedures. Departmental safety procedures have ? been evaluated within the past three years or as new procedures or needs arise.

    The current CEO or designee signs the designation of the Safety Officer and the Safety Officer’s job description is current and ? reflects the expectations for the responsibility of that position.

    The individual(s) assigned to respond to immediate threats to life and health has received appropriate training of their role, and ? resources.

    Annual evaluations are conducted of the scope, and objectives of this plan, the effectiveness of the programs defined, and the ? performance monitors.

    The Safety Training program includes new employee orientation, With the assistance of Clinical Learning and the dept. specific orientation, and ongoing safety education, and the Center for Performance Excellence develop a results of such training are monitored and the aggregate results are tool to evaluate staff ability to demonstrate ? periodically reported to the EOC Committee. actions to take in the event of an environment of care incident as well as how to report environment of care risks.

    The Environment of Care (Safety) Committee has evaluated the objectives and determined that the majority have been met. The program continues to direct safety awareness in a positive proactive manner.

PERFORMANCE:

    An analysis of the program objectives and performance measurements is used to identify opportunities to resolve environmental safety issues and evaluate the effectiveness of the program.

     Additionally, it provides the Environment of Care (Safety) Committee with information that can be used to adjust the program activities to maintain performance or to identify opportunities for improvement. The following are current performance measurements:

    2009 2008 2009 2009 2009 Safety Management Performance Measurements Final Target 2nd Qtr. 4th Qtr. Stats 1st Qtr. 3rd Qtr.

    Injury Frequency Index: 14 15 4 4 4 3 Average The total number of recordable Injuries Injuries injuries injuries injuries injuries 7.6 injuries/illnesses per 100 FTE. = 5 =5.4 (2008) onal Lost Workday Index: 26 days 126 151 days Average The total number of lost days per 8 days 7 days 10 days = 9.3 days = 53.9 3.0 100 FTE. (2008)

    The incidence rates represent the number of injuries and illnesses per 100 full-time workers. N = number of injuries and illnesses Formula EH = total hours worked by all employees during the calendar year N/EH x 200,000 200,000 = base for 100 equivalent full-time workers (working 40 hours per week, 50 weeks per year) *Annual average number of employees = 280. This includes entity 500 and onsite 100 entity employees.

    2

    2009 2008 2009 2009 2009 Safety Management Performance Measurements Target 2nd Qtr. 4th Qtr. Stats 1st Qtr. 3rd Qtr.

    Needle sticks 2 0 0 0 1 Monitor for Trends

    Body Mechanics Related Injuries 3 0 0 2 1 Monitor for Trends (Lifting/Transporting)

    Product Safety Recalls not returned in 72 hours. 13% 21% 17% 10% 12% Reduce by 2%

EFFECTIVENESS:

    Effectiveness is based on how well the scope fits current organizational needs and the degree to which current performance measurement statistics weigh against stated performance goals. The Safety Management program is considered to be effective.

PLANNING OBJECTIVES FOR 2010:

    1. Re-evaluate all existing performance measures for each of the seven EC plans. 2. Review orientation materials and develop training methods/tools to evaluate staff ability to

    demonstrate actions to take in the event of an environment of care incident as well as how to

    report environment of care risks.

    SECURITY MANAGEMENT

    The Security Management Program is designed to manage the physical and personal security of patients, staff and individuals coming to Mariners Hospital facilities. It includes processes which minimize the risks of security threats, incidents, or violations, including injuries, property damage, or theft to the hospital facilities.

SCOPE:

    The review of the scope is based on a comparison of actual operating experience to the program intent. The scope defines the areas the program includes for management and the kinds of services provided.

    The program is applied to Mariners Hospital of Baptist Health South Florida (BHSF) and its affiliate site; the Tassell Medical Arts Building. No significant changes to the facilities served or to the health care programs provided were made during the past year. The scope still accurately reflects the intent of the program.

PROGRAM OBJECTIVES:

    Each management objective is listed in the following table. Each objective is marked as met or not met. If an objective is not met, the appropriate Environment of Care (EC) program manager(s) review the objective to determine what needs to be done to meet it during the next year. The action required to address each change is indicated in the last column of the table.

    3

    Objectives Met Not Met Adjusted Objective / Action Plan

    Patrol the hospital buildings and property on a consistent basis, to identify and document ? potential or actual problems. Establish and maintain security policies and procedures to direct staff performance when ? responding to security incidents.

    Provide timely response to emergencies and requests for assistance. Report crime, fire, injury, or other incidents. Communicate ? externally with local, state, or federal law enforcement and other civil authorities. Provide internal communications, as needed.

    Provide timely response to reports of violent activity or requests for assistance in restraining ? violent or aggressive patients or visitors (Code Green.)

    Limit access to the grounds, building, and sensitive areas by enforcement of staff ? identification policies and by assisting in the removal of persons from unauthorized areas.

    Provide timely response to requests for escort, keys and door openings, or other routine ? requests for assistance.

    Provide training of all new employees about the Security Management Program, including what types of incidents Security Department staff can ? respond to, how to report incidents and obtain assistance in an emergency.

    Annual evaluations are conducted of the scope, and objectives of this plan, the effectiveness of ? the programs defined, and the performance monitors.

    The Environment of Care (Safety) Committee has evaluated the objectives and determined that they have been met. The program continues to direct security awareness in a positive proactive manner.

PERFORMANCE:

    An analysis of the program objectives and performance measurements is used to identify opportunities to resolve security issues and evaluate the effectiveness of the program. Additionally, it provides the Environment of Care (Safety) Committee with information that can be used to adjust the program activities to maintain performance or to identify opportunities for improvement. The following are current performance measurements:

    2009 2009 2009 2008 2009 Security Management Performance Measurements 2nd 3rd 4th Goal Data Source Stats 1st Qtr. Qtr. Qtr. Qtr.

    Risk 2 Larceny; Other $0 $0 $0 $0 >$500 Management/Safety events >$20,000 Officer

    Risk <7 Visitor; Slip, Trip & Falls 18 3 1 3 0 Management/Safety Incidents Officer

    4

    2008 2009 2009 2009 2009 Security Management Performance Measurements Goal Data Source 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. Stats

    Unruly visitor or patient requiring police Risk <5 intervention 5 0 3 0 0 Management/Safety Incidents (Level 2 & 3) Officer

    COMMENTS/Classifications:

     Level 1 = Reportable occurrence not part of daily procedures

     Level 2 = Reportable occurrence that required additional assistance/measures to return to normal operations

     Level 3 = Significant occurrence with harm to persons

EFFECTIVENESS:

    Effectiveness is based on how well the scope fits current organizational needs and the degree to which current performance measurement statistics weigh against stated performance goals. The Security Management program is considered to be effective.

PLANNING OBJECTIVE FOR 2010:

    1. Seek Administrative approval to allocate resources for additional security technology and

    utilize current technology to its fullest potential.

    HAZARDOUS MATERIALS & WASTE MANAGEMENT

    The Hazardous Materials and Waste Management Program is designed to minimize the risk of injury and exposure to hazardous materials or wastes due to improper handling, storage, or disposal of materials. The program also assures compliance with all applicable local, State, and Federal codes and regulations.

SCOPE:

    The review of the scope is based on a comparison of actual operating experience to the program intent. The scope defines the areas the program includes for management and the kinds of services provided.

    The program is applied to Mariners Hospital of Baptist Health South Florida (BHSF) and its affiliate site; the Tassell Medical Arts Building. No significant changes to the facilities served or to the health care programs provided were made during the past year. The scope still accurately reflects the intent of the program.

PROGRAM OBJECTIVES:

    Each management objective is listed in the following table. Each objective is marked as met or not met. If an objective is not met, the appropriate Environment of Care (EC) program manager(s) review the objective to determine what needs to be done to meet it during the next year. The action required to address each change is indicated in the last column of the table.

    5

    Objectives Met Not Met Adjusted Objective / Action Plan

    The processes used to select, transport, store, use and dispose of hazardous materials, and to separate, segregate, transport, store, package and dispose ? of hazardous wastes are defined in written procedures.

    Monitoring of gases and vapors, including: formaldehyde, gluteraldehyde, waste anesthetic gases, and ethylene oxide are performed at least annually ? where used, and the results reported to affected departments and the EOC Committee at least annually.

    Inspections are conducted at least annually to assure that areas used to store and handle hazardous wastes have adequate space, are separated from ? clean and sterile goods and foodstuffs; and hazardous chemicals are stored appropriately to their hazards.

    Incidents involving spills, releases, and exposures to hazardous chemicals and wastes are reported, in aggregate, to the EOC Committee at least ? quarterly.

    Staff who handles hazardous chemical materials and/or hazardous wastes is trained about the hazardous of the materials they handle, protective ? methods, and responses to spills, and exposures.

    Partial compliance. This was a new Program Objective for the Hazardous Materials & ‘Waste Management Program. We began monitoring staff Monitoring staff knowledge and ability to retrieve Material Safety Data proficiency in order to validate ? Sheets (MSDS.) purchasing a new computerized MSDS program. This has matured to a system level expenditure. We will continue to monitor staff knowledge in 2010.

    Annual evaluations are conducted of the scope, and objectives of this plan, ? the effectiveness of the programs defined, and the performance monitors.

    The Environment of Care (Safety) Committee has evaluated the objectives and determined that the majority have been met. The program continues to direct hazardous materials and waste awareness in a positive proactive manner.

PERFORMANCE:

    An analysis of the program objectives and performance measurements is used to identify opportunities to resolve performance issues and evaluate the effectiveness of the program. Additionally, it provides the Environment of Care (Safety) Committee with information that can be used to adjust the program activities to maintain performance or to identify opportunities for improvement. The following are current performance measurements:

    2009 Hazardous Materials and Waste 2008 2009 2009 2009 2nd Target Data Source Performance Measurements Stats 1st Qtr. 3rd Qtr. 4th Qtr. Qtr.

    Safety Officer/Facilities Spills/Releases of Hazardous Materials 0 0 0 0 0 0 Management

    Did not New 9 out 9 out of 6 out of Evaluate Safety Officer/Facilities Employee Education - Retrieving MSDS distribute Element of 10 10 10 Performance Management memo

EFFECTIVENESS:

    Effectiveness is based on how well the scope fits current organizational needs and the degree to which current performance measurement statistics weigh against stated performance goals. The Hazardous Materials and Waste Management program is considered to be effective.

    6

PLANNING OBJECTIVES FOR 2010:

    1. Continue monitoring staff knowledge of retrieving Material Safety Data Sheets. 2. Incorporate tracking/trending of the new Pharmaceutical Waste Management Program.

    EMERGENCY MANAGEMENT

    The Emergency Management Program is designed to include internal resources as well as external resources in a coordinated, organized response to any event that disrupts or may potentially disrupt patient care. The plan also identifies major roles and responsibilities in response to the disruption and it provides safe alternatives for patients, staff, and the public.

SCOPE:

    The review of the scope is based on a comparison of actual operating experience to the program intent. The scope defines the areas the program includes for management and the kinds of services provided.

    The program is applied to Mariners Hospital of Baptist Health South Florida (BHSF) and its affiliate site; the Tassell Medical Arts Building. No significant changes to the facilities served or to the health care programs provided were made during the past year. The scope still accurately reflects the intent of the program.

PROGRAM OBJECTIVES:

    Each management objective is listed in the following table. Each objective is marked as met or not met. If an objective is not met, the appropriate Environment of Care (EC) program manager(s) review the objective to determine what needs to be done to meet it during the next year. The action required to address each change is indicated in the last column of the table.

    Objectives Met Not Met Adjusted Objective / Action Plan

    The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s services ? or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events.

    The hospital’s incident command structure used by the hospital should provide for a scalable response to different types of emergency as well as ? being integrated into and consistent with its community’s command structure.

    The hospital maintains a written Emergency Operations Plan that describes the response procedures to follow when emergencies occur. As well as manage the following critical areas of the organization so that we can respond effectively regardless of the cause(s) of an emergency: ; Communications ? ; Resources and Assets ; Safety and Security ; Staff Responsibilities ; Utilities ; Patient Clinical and Support Activities

    7

    Objectives Met Not Met Adjusted Objective / Action Plan

    The Emergency Operations Plan identifies the hospital’s capabilities and establishes response procedures for when the hospital cannot be supported by local community in the hospital’s efforts to provide communications, ? resources and assets, security and safety, staff, utilities, or patient care for at least 96 hours.

    The organization conducts exercises to assess the Emergency Operations Plan’s appropriateness; adequacy; and the effectiveness of logistics, human ? resources, training, policies, procedures, and protocols.

    Annual evaluations are conducted of the scope, and objectives of this plan, ? the effectiveness of the programs defined, and the performance monitors

    The Environment of Care (Safety) Committee has evaluated the objectives and determined that they have been met. The program continues to direct emergency management awareness in a positive proactive manner.

PERFORMANCE:

    An analysis of the program objectives and performance measurements is used to identify opportunities to resolve performance issues and evaluate the effectiveness of the program. Additionally, it provides the Environment of Care (Safety) Committee with information that can be used to adjust the program activities to maintain performance or to identify opportunities for improvement. The following are current performance measurements:

    2009 Emergency Management 2008 2009 2009 2009 Final Target Data Source 2nd Qtr. Performance Measurements Stats 1st Qtr. 3rd Qtr. 4th Qtr.

    Emergency Management 36 0 10 0 28 38 Increase by Safety Officer Staff Education Attendance Attendees Attendees 2%

    Emergency Management Drills 100% 0 1 1 2 4 100% EM Committee 2 per year with completed critique of the six critical areas: Communication; Resources; Safety/Security; Staff Roles; Utility Systems; Clinical Care Activities

EFFECTIVENESS:

    Effectiveness is based on how well the scope fits current organizational needs and the degree to which current performance measurement statistics weigh against stated performance goals. The Emergency Management program is considered to be effective.

PLANNING OBJECTIVE FOR 2010:

    1. Continue monitoring staff participation in Emergency Management education programs.

    LIFE SAFETY MANAGEMENT

    The Life Safety Management Plan is comprehensive in understanding, applying, and adhering to the latest life safety codes of the National Fire Protection Association, State and local standards. It is designed to assure appropriate, effective response to fire emergencies that could affect the safety of patients, staff and visitors, or the environment of Mariners Hospital.

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SCOPE:

    The review of the scope is based on a comparison of actual operating experience to the program intent. The scope defines the areas the program includes for management and the kinds of services provided.

    The program is applied to Mariners Hospital of Baptist Health South Florida (BHSF) and its affiliate site; the Tassell Medical Arts Building. No significant changes to the facilities served or to the health care programs provided were made during the past year. The scope still accurately reflects the intent of the program.

PROGRAM OBJECTIVES:

    Each management objective is listed in the following table. Each objective is marked as met or not met. If an objective is not met, the appropriate Environment of Care (EC) program manager(s) review the objective to determine what needs to be done to meet it during the next year. The action required to address each change is indicated in the last column of the table.

    Objectives Met Not Met Adjusted Objective / Action Plan

    The Fire Plan defines the hospital methods for protecting patients, visitors, and staff from the hazards of fire, smoke and other products of combustion ? and is reviewed and evaluated annually.

    The fire detection and response systems are tested as scheduled, and the New reporting format will be results forwarded to the EOC Committee quarterly. ? created and implemented.

    Summaries of identified problems with fire detection and response systems, NFPA code compliance, and fire response plans, drills and operations, in ? aggregate, are reported to the EOC Committee quarterly.

    Fire Prevention and Response training includes the response to fires, at the scene of the fire, and in other locations of the facility, and the use of the fire alarm system, processes for relocation and evacuation of patients if necessary, ? and the functions of the building in protection of staff and patients.

    Fire extinguishers are inspected monthly, and maintained annually, are positioned to be in visible locations, and are selected based on the hazards of ? the area in which they are installed.

    Annual evaluations are conducted of the scope, and objectives of this plan, the effectiveness of the programs defined, and the performance monitors ?

    The Environment of Care (Safety) Committee has evaluated the objectives and determined that the majority have been met. The program continues to direct life safety awareness in a positive proactive manner.

PERFORMANCE:

    An analysis of the program objectives and performance measurements is used to identify opportunities to resolve performance issues and evaluate the effectiveness of the program. Additionally, it provides the Environment of Care (Safety) Committee with information that can be used to adjust the program activities to maintain performance or to identify opportunities for improvement. The following are current performance measurements:

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