36C24419R0074-032.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 00Q-001 January 13, 2017

ENVIRONMENT OF CARE MANAGEMENT PROGRAM

I. PURPOSE: To provide a safe, functional, supportive, and effective environment for patients, residents, staff, volunteers, and other individuals in the facility in a manner consistent with the mission and vision of this Medical Center.

II. POLICY: The Medical Center will provide for a safe environment through the establishment, implementation, and maintenance of effective Environment of Care (EOC)

Management Plans. Safety, security, hazardous materials and wastes, emergency management, fire protection, equipment management, utilities management, worker safety and patient safety will be included in these EOC Plans.

The EOC Management Plan shall apply to all buildings on Medical Center property, VA staffed Community Based Outpatient Clinics (CBOCs), and any other owned or leased space staffed by employees assigned to the VA Medical Center, Erie, PA.

In addition, the Medical Center will establish and maintain an environment for patients and residents that meets their needs, encourages a positive self-image, respects their dignity, provides appropriate privacy, supports their interests, skills and opportunities for personal growth, has appropriate space and equipment and is based on established design criteria.

III. RESPONSIBILITY:

A. The Medical Center Director has overall responsibility for the planning and design of the EOC Management Program:

1. Maintaining an environment that is sensitive to patient and resident needs for comfort, social interaction, positive distraction, and respects the human dignity.

2. Designating the Chairperson(s) for the EOC Committee and reviewing the

EOC Committee activities.

3. Ensuring the EOC Committee analyzes identified environmental issues and develops recommendations for resolving them.

MCM 00Q-001, Environment of Care Management Program

4. Approving all policies and procedures relative to the EOC Management

Program.

5. Approving the methodology for the annual review of the EOC

Management Program.

6. As necessary, the Medical Center Director will act as final authority for modifications and conflicts directly associated with the EOC Management

B. The Safety & Occupational Health Manager (Safety Manager) or designee is responsible for effective management of the Environment of Care:

1. Reducing and controlling hazards and risks to patients, residents, visitors and staff.

2. Identifying activities that may contribute to worker injuries and illnesses, as well as developing processes for reporting and investigating all such incidents.

3. Developing orientation and education programs that address worker safety and health.

4. Ensuring that all Medical Center policies and procedures related to the

Environment of Care are reviewed as necessary (at least every three years).

5. Confirming compliance with the life safety standards as set forth by the

Joint Commission and the National Fire Protection Association (NFPA).

C. The Green Environmental Management Systems/Emergency Preparedness

Coordinator (GEMS/EPC) is responsible for:

1. Reducing and controlling environmental hazards and risks.

2. Identifying activities that may damage the environment as well as developing processes for reporting and investigating all such incidents.

3. Maintaining an environment that minimizes unnecessary environmental stresses for patients, residents, visitors and staff.

4. Developing, implementing and monitoring the Emergency Operations

Plan.

5. Developing orientation and education programs that address emergencies that may occur at this Medical Center.

6. Developing, implementing and monitoring facility waste stream programs including general waste, hazardous waste, regulated medical waste, and recyclable waste. He/she will ensure the proper collection, transportation and disposal of these waste streams.

7. Along with the Safety Manager, confirms compliance with the life safety standards as set forth by the Joint Commission and the National Fire

Protection Association (NFPA).

D. The Chief Engineer is responsible for:

1. The development, implementation and monitoring of the Medical

Equipment Management Program, which assesses and controls the clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment, monitoring and care of patients and residents. This responsibility includes ensuring that the equipment meets applicable safety standards and operates within the VA and manufacturers’ specifications.

2. The development, implementation and monitoring of a Utility Systems

Management Program which confirms the operational reliability, assessment of special risks involved, and response to failure of any utility system which supports the patient care environment.

3. The investigation of hazards and incidents that are equipment/utility-related and take remedial action as appropriate.

E. All Supervisors/Managers are responsible for:

1. Participating in and supporting the EOC Management Program of the

Medical Center.

2. Providing their staff with orientation and education regarding their individual and collective roles as they relate to the EOC Management

3. Orienting and educating their personnel on the EOC policies, with specific training on area processes for reporting deficiencies in any area (safety, security, environmental issues), specific area hazards (toxic materials, flammable storage, medical equipment usage, etc.), specific equipment assembly and operation, location of and proper use of emergency equipment, operation of emergency shut-off controls, (oxygen control valves), and appropriate use of personal protective equipment.

(Supervisors will review the applicable Hazard Assessment and Personal

Protective Equipment Selection Form with each affected employee upon initial assignment and annually. Refer to MCM 00Q – 303, Personal

Protective Equipment.)

4. Reporting all security incidents.

5. Ensuring that their personnel who regularly come in contact with hazardous materials and wastes are included in the facility medical surveillance program.

6. Identifying, evaluating and preparing an inventory of hazardous materials and wastes used or generated in their respective area.

7. Prompt reporting of all hazardous materials and waste incidents (spills, leaks, exposures).

8. Providing training, education and assessment of competence for personnel who are required to use medical equipment in the performance of their duties.

9. Reporting equipment problems, failures, or user errors that may have an adverse effect on patient safety and/or the quality of care.

10. Developing specific procedures that detail staff actions to be taken when equipment fails. (Example: To indicate actions taken when a defibrillator fails, how to get backup and where it is located, etc.)

11. Reporting all utility systems management problems, failures or user errors that are or may be a threat to the patient care environment. (Example: An

110V plug forcible inserted in a 208V outlet.)

12. Reporting all fire protection deficiencies, failures, and user errors.

(Examples: Bells or strobe lights not working, fire doors not closing and latching, exit paths blocked, etc.)

13. Investigate and report all occupational illnesses/injuries and/or property damage in their area.

14. Correcting EOC deficiencies in their respective areas identified during

Administrative Rounds inspections.

F. All Medical Center Personnel are responsible for:

1. The prevention of accidents and injuries;

2. Reporting all incidents that involve property damage, occupational illness/injury;

3. Reporting all unsafe conditions to their supervisor; and

4. Completing annual safety training provided by the Medical Center.

G. Chief of Police is responsible for monitoring and assisting in the development and implementation of policies and procedures for the security and appropriate identification of patients, residents, visitors, volunteers, contractors and staff.

H. Logistics has overall responsibility for the return of any recalled item to the manufacturer.

I. Human Resource Officer is responsible for ensuring that personnel receive safety-related information during orientation and continuing education.

J. Occupational Health is responsible for implementation of a medical surveillance program, medical evaluations and follow-up, on-going surveillance of job related illnesses and injuries, and providing emergency treatment.

K. Infection Control Coordinator is responsible for overseeing the Medical Center’s

Infection Control Program. This includes the education and training requirement of the most current OSHA regulations and CDC guidelines.

L. Patient Safety Specialist is responsible for the development, implementation and monitoring of the Patient Safety Improvement Program.

IV. PROCEDURES:

A. The GEMS/EPC or designee is granted the authority to immediately intervene and stop any work, operation, project or act which, in his/her opinion, may endanger life, result in injury/impairment/sickness, or threaten damage to the environment.

B. The Safety Manager or designee is granted the authority to immediately intervene and stop any work, operation, project, or act which, in his/her opinion, may endanger life, result in injury/impairment/sickness; or threaten damage to equipment or property.

C. The GEMS/EPC and the Safety Manager will establish a risk assessment program that pro-actively evaluates the impact of buildings, grounds, equipment, occupants and internal physical systems on patient, personnel and public safety.

D. The Safety Manager will establish and implement a program for conducting and documenting fire drills.

E. The Safety Manager will provide for the inspection of Community Residential

Care Homes, Contract Nursing Homes, and other VA-funded program facilities in accordance with VA standards.

F. The GEMS/EPC and Safety Manager will provide for an effective hazard surveillance inspection program that is conducted throughout the Medical Center, outer building, CBOCs, and other VA occupied spaces (owned or leased), and is continuously measured and improved upon, as appropriate.

G. The Safety Manager will prepare an annual evaluation of the objectives, scope, performance and effectiveness of the documented EOC Management Program.

H. An EOC Committee is established as required. The Associate Director and Safety

Manager will act is Co-Chairpersons as appointed by the Medical Center Director.

The EOC Committee will review the annual evaluation of the objectives, scope, performance and effectiveness of the documented EOC Management Program.

V. REFERENCES:

A. The Joint Commission Comprehensive Accreditation Manuals for Hospitals, Home Care, Behavioral Health, and Laboratory & Point-of-Care Testing, current editions

B. VA Directive 7700, Occupational Safety and Health, dated February 11, 2009

C. VHA Handbook 7701.01, Occupational Safety and Health (OSH) Program

Procedures, dated August 24, 2010

VI. FOLLOW UP RESPONSIBILITY: As identified in Section III above

VII. REPORTING REQUIREMENTS: None

VIII. RESCISSION: MCM 00Q-001, Environment of Care Management Program, dated

January 21, 2014 (Note: See Attachment for revisions made to this MCM).

(Original Signed 1/13/17)

John A. Gennaro

Medical Center Director

Attachment: EOC MCM Revision History

ATTACHMENT

EOC MCM REVISION HISTORY

1/12/17 EOC Triennial Review: Updated titles; Verified and revised references;

Added Attachment, MCM Revision History. No other changes required.