36C26119Q0918-004.docx

VA PALO ALTO HEALTH CARE SYSTEM

3801 Miranda Avenue Palo Alto, CA 94304 -1290

Effective Date: September 14, 1998 Issue Date: December 10, 2018

HEALTH CARE SYSTEM MEMORANDUM No. SAFE-18-02

SUBJECT: PERSONAL PROTECTIVE EQUIPMENT (PPE)

1. SUMMARY: Health Care System Memorandum (HCSM) No. SAFE-15-02, dated November 9, 2015 has been rescinded. Minor changes have been made.

2. PURPOSE: To establish safety guidelines that govern the issuance of personal protective equipment (PPE). In many VA Palo Alto Health Care System (VAPAHCS) workplaces, chemical, physical, biological, radiation and laser hazards can create a potential for injury. We can protect against these hazards by using appropriate personal protective equipment for the job and by following established safety guidelines.

3. POLICY: PPE will be used when engineering controls and management practices are not feasible or not yet installed. VAPAHCS will provide each employee with all (PPE) that will protect the employee from identified hazards associated with specific assigned tasks.

4. PROCEDURES:

a. PPE for eyes, face, head and extremities, protective clothing and respiratory devices shall be provided, used and maintained in a sanitary and reliable condition. PPE will be used when hazards of process or environment, chemical hazards, radiological hazards or mechanical irritants are encountered in a manner capable of causing injury or impairment of any part of the body through absorption, inhalation or physical contact. The specific details of respiratory protection are covered by HCSM No. SAFE-16-14, Respiratory Protection Program, dated August 12, 2016.

b. Service chiefs will ensure that a hazard assessment, PPE selection, and training are accomplished in each work area under his/her area of responsibility. The Hazard Assessment and PPE Selection Survey Form (available through the Facility Industrial Hygienist (FIH) in the PPE Guide) shall be utilized for the purpose of documentation and certification of this process. This process shall be performed through a written certification that identifies:

(1) The person certifying that the assessment has been performed;

(2) The date(s) of the hazard assessment;

(3) The area performed in; and

(4) The document as a certification of hazard assessment.

c. Hazard assessments shall be completed on each assigned task within a service.

d. The procedures set forth in HCSM No. QSV-15-86, “Standard Precautions, Isolation Procedures, and Hand Hygiene,” shall be followed in determining additional requirements, and PPE that may be needed under the Infection Control Program.

e. Procurement and Replacement of PPE:

(1) Employees will replace protective safety equipment that becomes worn out or outdated at the expense of the Health Care System (HCS) upon proper notification to the Supervisor.

(2) In the event that a HCS-furnished piece of PPE is willfully or negligently damaged, lost, or not properly cared for, the employee to whom the equipment was issued may be held responsible for its replacement.

f. Disposition of PPE upon Termination:

(1) Articles such as hard hats, goggles, hearing protectors, respirators, gloves, etc., will remain the property of the HCS.

(2) Personal items such as safety shoes, prescription eye glasses, items that are not easily interchangeable, and expendable items will become the property of the individual.

g. Supervisors of employees utilizing safety PPE shall maintain control records of all expendable and non-expendable equipment.

h. Hazard Assessment. These guidelines outline general compliance for identifying, organizing and analyzing sources of hazards and selection criteria for PPE. They may not be inclusive, and are not intended to diminish the responsibility of the service chief to comply with the requirements of this program.

(1) The objective of the Certified Hazard Assessment is to specify PPE needs of each employee. It will ensure that supervisors make themselves aware of both present and likely hazards in their areas of responsibility. After analyzing these hazards and determining that guards, engineering controls and management practices are not feasible to protect employees, supervisors must select and have each affected employee use the types of PPE appropriate for identified workplace exposure.

(2) A walk-through survey by the service chief, foreman, or supervisor should include observations on the likelihood of injury or illness which may occur from the following:

(a) Sources of motion such as machinery or processes where an injury could result from movement of tools, machine elements or particles, or movement of personnel that could result in collisions, blows, or tripping around stationary objects.

(b) Sources of extreme temperatures (high or low) that could result in burns, eye injury, or ignition of protective equipment.

(c) Types of chemical exposures such as splash, vapor, spray, or immersion that could cause chronic illness or physical injury.

(d) Sources of harmful dust that can accumulate or become airborne and cause a physical hazard to the eyes or a respiratory hazard.

(e) Sources of light radiation, such as welding, brazing, cutting, furnaces, heat treating, lasers, or high intensity lights.

(f) Sources of falling objects or potential for dropping objects that could pose a compression or projectile hazard to head, face, hands or feet.

(g) Sources of sharp objects, which might pierce the body, feet or cut the hands.

(h) Sources of rolling or pinching objects, which could crush the feet or hands.

(i) Layouts of workplace and location of co-workers.

(j) Any electrical hazards.

(k) Sources of radiation exposure that may be encountered in Radiology Service, Nuclear Medicine Service, or from portable sources.

(l) Sources of exposure from chemotherapy drugs or other therapeutic chemicals that may expose employees to harmful exposure.

(m) Sources of exposure from blood borne pathogens.

(n) Sources of exposure from hazardous waste.

(o) Sources of inclement weather, or areas such as walk-in refrigerators.

(p) Sources of exposure from noise.

(q) Animal exposures that may include traumatic injury, biologic exposure (e.g., rabies), or toxic exposure (e.g., snakes).

i. PPE

(1) Eye and Face Protection:

(a) Appropriate eye wear or face shields are required when an employee is exposed to eye or face hazards from flying particles, molten metal, liquid chemicals, acids or caustic liquids, chemical gases or vapors, potentially injurious radiation, and blood or body fluids.

(b) Side shields are required, but detachable side shields are permitted. Those wearing prescription glasses must be provided either eye protection worn over the prescription lenses without disturbing their positioning, or they must wear prescription safety glasses with side shields.

(c) The filter lens shade must be specified when prescribing eye protection for welding, cutting or brazing.

(d) Equipment purchased after July 5, 1994, must comply with the American National Standards Institute (ANSI) standard Z87.1-edition in effect at time of purchase.

(2) Head Protection:

(a) Helmets are required in areas where there is a potential for injury from falling objects, and when near exposed electrical conductors which could contact the head.

(b) A Class A hard hat may be selected when there may be contact with conductors up to 2,200 volts. Class B hard hats must be selected when there may be contact with high voltage conductors (up to 20,000 volts). Class C hard hats provide impact and penetration resistance, but they are often made of aluminum and are prohibited where there may be electrical hazards.

(c) Equipment purchased after July 5, 1994, must comply with ANSI standard Z89.1-edition in effect at time of purchase.

(3) Foot Protection:

(a) Safety shoes or boots are required for employees working where there is a danger of foot injuries due to falling and rolling objects or objects piercing the sole and where the feet are exposed to electrical hazards. Some situations may require metatarsal protection (stiff shields for the top part of the foot).

(b) Safety shoes or boots with impact protection should be required when employees carry or handle materials such as packages, objects, parts or heavy tools that could be dropped; and for other activities where objects may fall onto the feet. Safety shoes or boots with compression protection would be required for work activities involving wheeled carts that carry heavy materials or when handling heavy bulk rolls (paper, fabric, carpet, etc.), around heavy pipes, or similar situations where a heavy object may roll over a person's foot.

(c) Safety shoes or boots with puncture protection would be required where an employee could step on sharp objects such as nails, wire, tacks, screws, large staples, or scrap metal.

(d) Special insulating or conductive shoes may be necessary for certain types of electrical work.

(e) Equipment purchased after July 5, 1994, must comply with the ANSI Standard Z41-edition in effect at time of purchase.

(4) Hand Protection:

(a) Appropriate gloves must be selected when employees are exposed to skin absorption of harmful substances, chemical burns, thermal burns, harmful temperature extremes, severe cuts or lacerations, severe abrasions, punctures, and blood or body fluids.

(b) No gloves provide protection against all potential hand hazards, and commonly available glove materials provide only limited protection against many chemicals. Therefore, it is important to select the most appropriate glove for a particular application and to determine how long it can be worn and whether it can be reused. The work activities of the employee should be studied to determine the degree of dexterity required, the duration, frequency, and degree of exposure of the hazard, and the physical stresses that will be applied.

(c) Review the Material Safety Data Sheet or glove permeation rate data found in a vendor’s catalog to specify the type of protective glove for chemical exposure. If a specific chemical or chemicals cannot be found in a vendor’s catalog, contact the glove vendor or chemical manufacturer for recommendation. Complete a report of contact for documentation and forward copy to the Safety and Emergency Management Service (SAFE).

(5) Hearing Protection: Please see the HCSM No. SAFE-18-17, “Hearing Conservation Program,” for requirements.

(6) Respiratory Protection: Please see the HCSM No. SAFE-16-14, “Respiratory Protection Program,” for requirements.

(7) Bloodborne Pathogens: Please see the Infection Control Manual for program PPE requirements.

(8) Protective Clothing: Protective clothing intended for the protection of employees from inclement weather or working in areas such as walk-in refrigerators, shall meet the requirements essential for the protection of the employee while engaged in the assigned task.

(a) Chemotherapy Drugs: Please see the HCSM No. 11-18-108, Ordering, Preparing and Administering Parental Chemotherapy and Biotherapy.

(b) Radiation Exposure: Please see the Stanford/VA Palo Alto Health Care System Radiation Safety Manual, for program requirements.

(9) Chemical Protective Clothing (CPC): The need and use of CPC will be evaluated by the FIH or the Safety Program Manager before purchasing, in accordance with National Institute for Occupational Safety and Health (NIOSH).

j. Cleaning and Maintenance:

(1) It is important that all PPE be kept clean and properly maintained. Cleaning is particularly important for eye and face protection where dirty or fogged lenses could impair vision.

(2) All PPE should be inspected, cleaned, and maintained at regular intervals so that the PPE provides the required protection.

(3) It is important to ensure that contaminated PPE, which cannot be decontaminated, is disposed of in a manner that protects employees from exposure to hazards.

k. Training.

(1) Each employee that is required to wear PPE will be trained by the supervisor so that each employee knows and can demonstrate an understanding of the following:

(a) When PPE is necessary and what PPE must be worn.

(b) The limitations of the issued PPE.

(c) How to put on, adjust, wear, and remove PPE properly.

(d) How to inspect PPE so that defective or damaged PPE is removed from service.

(e) Proper storage of the PPE.

(2) The supervisor conducting the training shall verify that each employee has received and understood the required training through a written certification that contains the name of each employee trained, the date(s) of training, and that identifies the subject of the certification.

(3) Circumstances where re-training is required include, but are not limited to situations where:

(a) Changes in the workplace render previous training obsolete.

(b) Changes in the types of PPE.

(c) Inadequacies in an employee's knowledge or use of assigned PPE indicate that the employee must be retrained.

(4) All HCS safety training on PPE requirements will be documented on the Education Training Tracking System (ETTS), available through Veterans Health Information Systems and Technology Architecture (VISTA). This documentation will be utilized to comply with regulatory requirements and as an agenda item for the Safety Advisory Committee.

5. RESPONSIBILITIES:

a. Service Chiefs are responsible for:

(1) Ensuring that personnel in their area of responsibility are not exposed to potential occupational safety and health hazards, by procuring only PPE, which is recommended for the intended use and meets the regulatory requirements for that protection;

(2) Conducting a Hazard Assessment and PPE Selection Survey (available through the FIH in the PPE Guide) for every position under his/her supervision to determine that each employee is receiving the proper PPE and in-service training in the use and care of that equipment. All requests for PPE will be submitted for approval to the Facility Safety Officer (FSO), FIH or the subject matter expert in Safety or Engineering Service before ordering;

b. The Chief, Logistics, is responsible for ensuring no PPE items are ordered without the "Safety Office Approval" appearing in the Special Remarks section of the Integrated Funds Distribution Control Point Activity Accounting and Procurement (IFCAP) request.

c. Supervisors are responsible for:

(1) Determining the PPE needs, requirements and training for each employee under his/her supervision and for working with the service chief in obtaining the proper items through the normal purchasing procedures;

(2) Enforcing all safety and health procedures;

(3) Ensuring that employees under his/her supervision wear all the protective items that have been provided when accomplishing assigned tasks; and

(4) Ensuring all PPE is properly maintained and kept in proper working condition.

d. Employees:

(1) The employee is required to properly wear or use the PPE issued by the Supervisor. Non-compliance in the proper use and care of this equipment will subject the employee to disciplinary action.

(2) All PPE issued to employees shall be worn or used as a condition of employment. Employees not in possession of this provided equipment upon reporting to work will take annual leave until they are properly utilizing the required item(s).

(3) Each employee will properly clean, maintain and store all safety PPE issued.

(4) Each employee is responsible for attending all required formal and in-service training classes for which they are scheduled.

e. The FSO is responsible for reviewing and approving/disapproving each Hazard Assessment and PPE Selection Survey form submitted to the Safety Office by individual services.

f. The FSO and FIH are responsible for reviewing all submitted purchase requests for PPE ordered by the HCS to ensure that:

(1) The hazards of concern cannot be eliminated; and

(2) That such equipment meets the regulatory requirements for the exposure and for the equipment requested. This action will be accomplished within six (6) working days.

g. The FSO or FIH, upon request, will provide consultation services on eliminating hazard exposures, on PPE needs and on regulatory requirements for the supervisor. The FSO or FIH will also provide review services on request for concurrence of need before the service implements the purchase request.

h. At the written request of the service chief involved, the FSO or FIH will supply the needed expertise in specific areas to enable supervisors to set up an effective presentation for in-service safety training on PPE.

6. REFERENCES:

a. 29 CFR1910.132-138 General Industry Standards.

b. Personal Protective Equipment (PPE) Guidebook, 1995, Department of Veterans Affairs.

c. The American National Standards Institute (ANSI) standards:

(1) Eye and Face Protection: ANSI Z87.1-1989;

(2) Head protection: ANSI Z89.1-1986; and

(3) Foot Protection: ANSI Z41.1-1991.

7. RESCISSION DATE: December 31, 2021.

8. RESPONSIBLE OFFICIAL: Chief, Safety and Emergency Management Service.

Thomas J. Fitzgerald III Director

Attachment (1)

Health Care System Memorandum No. QM-98-32 September 14, 1998 Health Care System Memorandum No. SAFE-18-02 December 10, 2018

Attachment A

Certification of PPE Training

Employee Name: ___________________________ Job Title:____________________

SSN:____________________________________ Service:______________________

By signing below, I certify that I have received training specific for PPE required to complete my assigned tasks/procedures, demonstrated proficiency in the use and maintenance of such PPE, and training received included each item listed below.

Employee Signature_________________________________Date_______________

Supervisor Signature_________________________________Date_______________