SOW ATT - SAFETY MANAGEMENT PLAN.pdf

DEPARTMENT OF HEALTH AND HUMAN SERVICES

INDIAN HEALTH SERVICE

WESTERN OREGON SERVICE UNIT

CHEMAWA INDIAN HEALTH CENTER

DEPARTMENT

Admin

TOPIC:

Safety Management Plan

POLICY #

Admin.2

POLICY:

WOSU will have a plan Safety Management Plan that describes the processes utilized by the Chemawa Indian Health Center to Establish and manage a highly functioning environment that ensures patient, staff, and visitor safety.

PURPOSE: The purpose of the Safety Management Plan is to provide a safe, functional, supportive and effective environment for patients, staff and visitors.

DEFINITIONS:

See below

STAFF GOVERNED BY THIS POLICY:

All

AAAHC:

Ch 7.II.A.1

Effective Date:

4/9/14

New/Revised Date:

3/7/18

Approved By:

I. ORGANIZATION AND RESPONSIBILITY

A. Governing Board/Administration: The Health Center CEO and Executive Committee receive regular reports on the activities of the Safety Program from the Risk Management Officer. The Executive Committee reviews, reports and, as appropriate, communicates concerns about identified issues and regulatory compliance. They provide support to facilitate the ongoing activities of the Safety Program. The CEO receives regular reports on the activities of the Safety Program. The CEO reports and, as appropriate, communicates concerns about key issues and regulatory compliance to the Governing Board.

B. Safety Officer: The Facility Manager holds the duties and responsibilities as the clinic The Safety Officer activities works under the general direction of the CEO and in coordination with the Risk Management Officer. The Safety Officer in collaboration with the facility manager and other department heads, and the Risk Management Committee, manages all aspects of the Safety Program. The Safety Officer advises the Risk Management Committee regarding safety issues that may necessitate changes to policies, orientation or education, or purchase of equipment.

Delegated Authority: The CEO has delegated authority to the Safety Officer to take immediate and appropriate action in the event of an emergency situation where there is a clear and present danger that poses a threat to life, a threat of personal injury, or a threat of damage to property.

C. Chairperson of the Risk Management Committee: The Chairperson has responsibility for identification, collection, and analysis of information regarding safety deficiencies, development of plans for improvement, accident and injury prevention and investigation, and emergency response in collaboration with the Safety Officer and other appropriate staff members.

D. Risk Management Committee: The goal of the Risk Management Committee is to minimize the risk of harm to patients, ensure the health and safety of staff, and mitigate the liability exposure of the health care providers and financial loss to the organization. The Risk Management Committee meets as often as is necessary, but at least every month to monitor data, receive reports and analyze performance related to safety issues. Additional meetings may be scheduled at the call of the Risk Management Officer to address any pertinent risk management issues and/or make recommendations of quality improvement activities that impact risk management issues, are guided by benchmarking best practices, and other advancing innovative risk management practices.

Membership of the Committee: The Risk Management Committee is composed of:

Risk Management Officer Public Health Nurse

Safety Officer Chief of Pharmacy

Infection Control Officer Director of Nursing

Employee Health Officer Medical Director

E. Department Directors/Managers: Department Directors/Managers are responsible for safe practices of employees in their department. The managers shall:

Provide Orientation to new employees to their department to include position/task-specific safety procedures (see Orientation, Training, and Education below).

Maintain clinic-wide safety plans and ensure coordination with department heads and departmental staff to ensure situational awareness and opportunities to contribute to improvement in the policies and procedures around risk management practices.

Ensure that safety equipment and personal protective equipment are available.

Ensure that staff receives mandatory orientation and ongoing safety training.

Monitor compliance with safety regulations in the department.

Participate in the activities of the Safety Program and stimulate and promote employee interest.

Communicate safety issues/concerns to the Safety Officer.

F. Employees: Individual employees are responsible for performing safe practices including:

Learning and following the job/task-specific safety procedures.

Meeting the annual safety education requirements (see Orientation, Training, and Education below).

Knowing their department/position roles in the event of an incident or emergency and the reporting procedure.

Utilizing personal protective clothing, supplies, and equipment as appropriate for the job/task.

Reporting unsafe acts and conditions to their supervisor and/or the Safety Officer.

Orientation, Training, and Education

All staff must attend new employee orientation within 30 days of hire. New employee orientation addresses key issues and objectives of all areas of safety (plus life safety and emergency management) including the role each area and staff play in the overall patient safety program.

Employees also receive safety orientation during their initial employee orientation and new safety practices will be debriefed within departments and/or at all staff meetings. In addition, all staff participates in periodic refresher training relative to department safety.

II. OBJECTIVES – PERFORMANCE INDICATOR(S)

It is the objective of the Chemawa Indian Health Center to provide a safety environment in which to provide high quality health care services to clients and customers and staff. The following fundamental issues are critical in meeting safety objectives:

Proactive risk assessments are the foundation for the safety management program.

Safety is information driven. Without appropriate information, incidents affecting the health and safety of patients, visitors, and staff may not be predicted or prevented.

All health center staff and managers need appropriate information to understand the importance of safe working conditions and safe work practices within their area of responsibility.

Analysis of safety incidents provides information to predict and prevent future incidents and injuries and is useful in mitigating the impact of incidents.

Training and Orientation of staff is critical to their performance and to maintain a safe and healthy environment for patients and visitors and themselves

Safe working conditions and practices are established by using knowledge of safety principles to educate staff, evaluate existing conditions, design appropriate work environments, and provide for appropriate equipment and supplies.

The safety program establishes processes for identifying, evaluating, and remediating practices or situations that have a potential to harm patients, staff, or visitors or damage property.

The following specify activities to meet the objectives:

A. Periodic risk assessments are conducted of the facility processes, buildings, grounds, equipment, staff activity, patient care and staff work environments risks and hazards. Additional risk assessments are conducted when substantive changes involving these issues occur. Action plans to address those threats or risks are developed and introduced to the Risk Management Committee for action.

B. Environmental Tours include all areas of the health center and out buildings, including the facilities, equipment and all support areas at least annually, and all patient care areas at least semi-annually.

C. Current organization wide safety policies and procedures will be available to all staff on the Z:

Drive. Departmental Safety Procedures are evaluated at least every three years or as new procedures or needs arise.

D. The current CEO or designee officially designates the Safety Officer to provide program direction and oversight.

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

F. There are processes for follow-up to product and equipment safety recalls. Summary reports of recalls and hazard alerts are forwarded to the Risk Management Committee at least quarterly.

G. Meaningful, measurable performance measures are developed and monitored on a periodic basis. Sub-standard performance is corrected in a timely fashion.

III. ELEMENTS OF SAFETY MANAGEMENT

A. Plans to Minimize Risk

Designated Individual: The Safety Officer is identified to coordinate the development, implementation, and monitoring of the safety management activities. The Safety Officer is designated officially by the Chief Executive Officer in writing (see letter of designation).

Immediate Threat to Life Policy: The Chief Executive Officer is responsible for identifying individuals who may intervene whenever conditions pose an immediate threat to life or health, or threaten damage to equipment or buildings. The objective is to intervene before a loss occurs. Through this policy, the authority to intervene has been given to the Safety Officer.

Written Safety Management Plan: The Chemawa Indian Health Center has developed and maintains a written management plan describing the processes it implements to effectively manage the safety of everyone (patients, staff, visitors, contractors) within the facility and on its grounds.

Annual Evaluation of the Plan: This plan is evaluated annually to include the scope, objectives, performance, and effectiveness of the safety management program operating at the facility.

The evaluation is the foundation for any changes that are made and the findings and recommendations are presented to, and evaluated by, the Risk Management committee.

B. Managing Safety Risks

Identification of Safety Risks The Chemawa Indian Health Center identifies risks through a variety of means, including the continuous on-going monitoring of the environment through daily inspections, annual proactive risk assessments, staff referrals, environmental rounds, WebCident reports, and through critical findings from root cause analysis and through sentinel events.

Proactive Risk Assessments The Chemawa Indian Health Center, thru the Safety Officer conducts proactive risk assessments to evaluate the potential for adverse impact on the safety of patients, staff, and other people coming to the organization’s facilities. The Risk Assessment is used to evaluate current programs, and help identify new programs and activities to better protect the patients, staff, and the organization. The annual risk assessment is provided to the Risk Management Committee. The findings from the risk assessment are prioritized and those issues that rise to a level of criticality are addressed independently to determine cause, factors that contribute to the risks and means to reduce them are identified and a Risk Assessment Plan is developed and reported to the Executive Committee.

Actions Taken to Minimize or Eliminate Identified Safety Risks: The Chemawa Indian Health Center uses the information from the risk assessment and other sources to select, develop and implement procedures, activities, and access controls to reduce the probability of critical safety risks or maintain risks and threats to acceptable levels. Findings during assessments, inspections, evaluations, or referrals are evaluated by the Safety Officer, Facility Engineer, and Administration and action is taken based on the findings. Information is summarized and reported to the Risk Management committee as a standing committee item.

Possible outcomes from the risk assessment process may be as follows:

Create new or revised safety policies and procedures, Identify new environmental rounds items for the areas affected, Improve safety orientation and education programs, and

Help defined safety performance indicators and monitoring.

Grounds and Equipment Maintenance The Facilities Management Supervisor is responsible for scheduling and performing maintenance to the facility grounds and external equipment. They will provide periodic surveillance to observe and correct conditions and ensure the safety of the facility grounds and external equipment.

Grounds include lawns, shrubs and trees, sidewalks, roadways, parking lots, lighting, signage, fences, etc. Some external equipment, such as the oxygen storage facility, has established protocols for inspection, testing, or preventive maintenance.

Preventive maintenance is scheduled, as required and corrective maintenance is completed on an as needed basis. Emergency maintenance procedures have been developed for snow removal.

Product Safety Recalls and Hazard Alerts: The Chemawa Indian Health Center ensures responses to product and equipment safety recalls by appropriate organization representatives.

Facilities Manager manages the process, receiving reports from manufacturers and vendors, and distributing the information to those departments using or managing the products. He will document the follow-up, and report the results to the Risk Management Committee on a periodic basis. Critical recalls or alerts are brought to the attention of the Safety Officer upon receipt, and the Safety Officer assists in assuring effective response.