VHA Directive 1611.pdf

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Department of Veterans Affairs VHA DIRECTIVE 1611 Veterans Health Administration Transmittal Sheet Washington, DC 20420 July 11, 2023

SAFE PATIENT HANDLING AND MOBILITY PROGRAM

1. SUMMARY OF MAJOR CHANGES: Major changes include:Updates the position title for the program office Director to Director, Office of Occupational Safety and Health (see paragraph 2.f.).

b. Updates the position title and responsibilities for the Safe Patient Handling and Mobility (SPHM) Facility Coordinator to SPHM Program Manager (see paragraph 2.j.).

c. Updates responsibilities for the National Program Manager, Veterans Health Administration (VHA) SPHM Program; Veterans Integrated Service Network Directors;

and Department of Veterans Affairs (VA) medical facility Directors (see paragraph 2).

d. Adds the SPHM Staffing Methodology/Equivalency Request (Appendix A) and related responsibilities for submission and approval (paragraph 2).

e. Removes the requirement that VA medical facilities develop local policies regarding VA medical facility SPHM programs and instead requires standard operating procedures that specify local responsibilities as needed.

2. RELATED ISSUES: None.

3. POLICY OWNER: The VHA Office of Occupational Safety and Health (19HEF) is responsible for the contents of this directive. Questions may be addressed to VHAOccSafetyandHealthAction@va.gov.

4. RESCISSIONS: VHA Directive 1611(1), Safe Patient Handling and Mobility Program, dated March 23, 2018, is rescinded.

5. RECERTIFICATION: This VHA directive is due to be recertified on or before the last working day of July 2028. This VHA directive will continue to serve as a national VHA policy until it is recertified or rescinded.

6. IMPLEMENTATION SCHEDULE: This directive is effective upon publication, with the exception that VA medical facilities have 24 months from the date of publication to convert local SPHM policies to other appropriate guidance documents.

mailto:VHAOccSafetyandHealthAction@va.gov

July 11, 2023 VHA DIRECTIVE 1611

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BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Alfred A. Montoya Jr., MHA, FACHE

Acting Assistant Under Secretary for Health for Support

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publication Distributions List on July 12, 2023.

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CONTENTS

SAFE PATIENT HANDLING AND MOBILITY PROGRAM

1. POLICY

2. RESPONSIBILITIES

3. TRAINING

4. RECORDS MANAGEMENT

5. BACKGROUND

6. REFERENCES

APPENDIX A

PEFORMANCE CRITERIA FOR SAFE PATIENT HANDLING AND MOBILITY

PROGRAMS ..................................................................................................................... A-1

APPENDIX B

EXAMPLES OF SAFE PATIENT HANDLING AND MOBILITY TECHNOLOGY.......... B-1

SAFE PATIENT HANDLING AND MOBILITY PROGRAM

1. POLICY

It is Veterans Health Administration (VHA) policy that a Safe Patient Handling and

Mobility (SPHM) program be implemented in every Department of Veterans Affairs (VA) medical facility and that SPHM technology be incorporated as appropriate in the planning, design and construction of new construction and renovation projects, to protect VHA health care workers and Veterans from injuries due to patient handling and mobility, ensure that all Veterans have equitable opportunity to access SPHM technology, as needed, and to meet and improve Veteran care needs. Employees must utilize SPHM technology for routine and urgent patient handling tasks that require lifting over 35 pounds of patient weight or when performing tasks that require the generation of excessive force, such as repositioning a Veteran in a bed by pushing, pulling or supporting a Veteran during mobility. In addition, all design projects in spaces used by Veterans must include VA medical facility SPHM Program Manager (PM) input.

AUTHORITY: 29 U.S.C. § 668; 38 U.S.C. § 7301(b); 29 C.F.R. Part 1960; Executive

Order 12196 (February 26, 1980).

2. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Support. The Assistant Under Secretary for Health for Support is responsible for establishing policy and providing guidance and oversight as necessary to ensure the timely and successful implementation of this directive.

c. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

d. Assistant Under Secretary for Patient Care Services/Chief Nursing Officer.

The Assistant Under Secretary for Patient Care Services is responsible for ensuring collaborative partnerships between nursing and SPHM throughout VHA, VISNs and VA medical facilities for the standardization of SPHM programs.

e. Executive Director, VHA Healthcare Environment and Facilities Program.

The Executive Director, Healthcare Environment and Facilities Program (HEFP) is responsible for:

(1) Overseeing the VHA Occupational Safety and Health (OSH) program.

(2) Coordinating with the Assistant Under Secretary for Health for Operations, VISN Directors and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address SPHM program performance in a manner that meets the requirements of Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

f. Director, Office of Occupational Safety and Health. The Director, OSH is responsible for:

(1) Providing oversight for VISN and VA medical facility compliance with this directive and ensuring corrective action is taken when non-compliance is identified.

(2) Overseeing the VHA SPHM program.

(3) Periodically assessing the VHA SPHM program for continued need, currency and effectiveness.

(4) Hiring and managing a National SPHM Program Manager.

g. National Program Manager, VHA Safe Patient Handling and Mobility Program. The National SPHM Program Manager is responsible for:

(1) Administrating the national SPHM program to include recognition and dissemination of best practices and innovation to SPHM stakeholders.

(2) Partnering with stakeholders including but not limited to the Office of Nursing Services; Office of Healthcare Engineering; Healthcare Technology Management

(HTM); Office of Capital Asset Management; HEFP Enterprise Support Service; Patient Care Services; National Center for Health Promotion and Disease Prevention;

Rehabilitation and Prosthetic Services; Workplace Violence Prevention Program;

Inpatient Mental Health Services; Spinal Cord Injury and Diseases (SCI/D) National

Program Office; other clinical program offices; Institute for Learning, Education and Development; VHA Procurement & Logistics Office; VA Office of Construction and Facilities Management (CFM); VHA National Center for Patient Safety (NCPS); and VA medical facility leadership to provide direction for the management and oversight of

SPHM programs, and for training, outreach and innovation projects at the national, VISN and VA medical facility levels.

(3) Developing national guidelines for training on safe patient handling technology and program management for VA medical facility and nursing leadership, patient and employee safety personnel, health care technology managers, SPHM PMs, SPHM Unit/Service Peer Leaders (PLs) and other clinical services as appropriate. NOTE:

Guidelines for training and education can be found in Chapter 9 of the SPHM Guidebook at: http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook. This is an internal VA website that is not available to the public .

(4) Disseminating and delivering national SPHM training programs, as needed, and a repository of curriculum resources to support local SPHM programs.

(5) Developing and reviewing national performance standards and metrics for SPHM programs and monitoring and evaluating the effectiveness of this directive, including administering a national SPHM survey and reviewing the annual VISN evaluation of the performance criteria in Appendix A.

(6) Monitoring and supporting SPHM PMs and VISN SPHM Points of Contact (POCs) to enable them to meet national performance standards and metrics.

(7) Reviewing and approving or disapproving equivalency requests submitted by VISN Directors for VA medical facilities who have less than 1.0 full-time equivalent (FTE) allocated for the SPHM PM. NOTE: For details regarding equivalency requests, see Appendix A.

(8) Establishing standards for SPHM technology and design across the continuum of care, including the needs of individuals who are plus-sized.

(9) Creating and overseeing technical advisory groups who work on specialty topics related to SPHM (e.g., special environments such as mental health or perioperative, bariatric care, Veteran education, early mobility, SPHM Unit/Service PL engagement or construction and design).

(10) Leading monthly discussion and guidance for SPHM PMs and VISN SPHM POCs.

(11) Determining whether there are national employee or patient safety trends that require intervention using incident reports and workers compensation claim data from patient handling injuries and by collaborating with NCPS and HTM to identify patient safety trends.

(12) Collaborating with other Federal health care systems, especially the Defense Health Agency, on SPHM programs and principles and supporting integrated electronic health record systems.

h. Veterans Integrated Service Network Directors. VISN Directors are responsible for:

(1) Ensuring that all VA medical facilities within the VISN comply with this directive and informing leadership when barriers to compliance are identified.

(2) Designating a VISN SPHM POC as a collateral duty to coordinate VISN SPHM training or practice improvement efforts and mentoring with SPHM PMs within the VISN.

http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook

The VISN SPHM POC may collaborate with experienced SPHM PMs within the VISN.

See the SPHM Guidebook (Enclosure 6-5) for example activities of a VISN SPHM POC at http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook.

NOTE: This is an internal VA website that is not available to the public .

(3) Ensuring that the VISN SPHM POC meets at least quarterly with SPHM PMs in the VISN, establishes mentoring relationships with new and experienced SPHM PMs, participates in national VISN SPHM POC calls and discussions and disseminates best practices and innovations at the VISN and VA medical facility level.

(4) Ensuring that resources are available to carry out VA medical facility SPHM programs, including management support, program coordination, mentoring/education and technology (to include new installations, maintenance, supplies and replacement at the end of manufacturer-recommended life cycles).

(5) Ensuring VA medical facility compliance with this directive is evaluated annually according to program criteria in Appendix A and reported to the National SPHM Program Manager. The VISN SPHM POC leads this evaluation and may use national

SPHM survey results, other tools and collaboration with SPHM PM mentors in this evaluation.

(6) Ensuring that equivalency requests from VA medical facilities are collected when required according to Appendix A and sending them with recommendations to the

National SPHM Program Manager for review and approval.

(7) Collaborating with VISN stakeholders on topics related to SPHM and reporting on SPHM in appropriate VISN committee(s).

i. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring overall VA medical facility compliance with this directive and appropriate corrective action is taken if non-compliance is identified.

(2) Establishing procedures delineating local responsibilities and authority related to local SPHM program alignment, implementation and sustainment. NOTE: Sample VA medical facility SPHM procedures are included in the VHA SPHM Guidebook at http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook. This is an internal VA website that is not available to the public.

(3) Designating at least one full-time SPHM PM, based on clinical needs of Veterans served and safety needs of staff, unless the National SPHM Program Manager approves an equivalency request.

(4) Evaluating staffing needs and submitting equivalency requests through the VISN SPHM POC to the National SPHM Program Manager annually whenever there is less than one full-time SPHM PM for a VA medical facility. An approved equivalency must illustrate the rationale for the collateral duty. NOTE: Staffing needs must be calculated using the SPHM Staffing Methodology/Equivalency Request at:

http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests. This is an internal VA website that is not available to the public.

See Appendix A, paragraph 2 for details regarding the SPHM Staffing

Methodology/Equivalency Request.

(5) Ensuring oversight of SPHM program operations and activities by VA medical facility leadership via a standing VA medical facility committee that reports through a VA medical facility governing board (appropriate committees include Safety, Environment of

Care, Patient Safety or others, and the committee chair is responsible for oversight).

The committee should include but is not limited to the SPHM PM, nursing leadership, the Occupational Safety Manager, the Patient Safety Manager, Employee Occupational Health, Engineering/Facilities Management and Biomedical Engineering/HTM. NOTE:

The committee that oversees the SPHM program varies by VA medical facility and is determined by the VA medical facility Director based on local needs and reporting structures.

(6) Ensuring that at least twice a year the VA medical facility committee chosen to oversee the SPHM program reviews the aggregate patient and employee safety incidents associated with patient handling; evaluates equipment maintenance, logistics and availability of supplies; and addresses barriers to the SPHM program.

(7) Ensuring that employee safety incidents related to patient handling are reported to the SPHM PM by VA medical facility Occupational Safety personnel as soon as they are received, in order for the SPHM PM to investigate such injuries, provide recommendations and track these injuries by unit, area and hospital-wide.

(8) Ensuring that SPHM technology and supplies are maintained, inspected appropriately and replaced at end-of-life as recommended by manufacturers.

(9) Ensure that ceiling lift installation and maintenance follows all relevant VHA requirements, including NCPS Patient Safety Alerts such as AL14-07 and its VHA Installation and Relocation Checklist for Ceiling Mounted Patient Lifts and VHA

Corrective and Preventive Maintenance Checklist for Ceiling Mounted Patient Lifts which are listed at: https://www.publichealth.va.gov/employeehealth/patient-handling/index.asp.

(10) Providing necessary resources for implementation of the VA medical facility

SPHM program, including meeting SPHM needs of Veterans with specific medical conditions and patients who are plus-sized, in order to provide a workplace that is free from recognized hazards that are causing or are likely to cause serious physical harm to VHA employees and ensuring that appropriate technology is implemented to prevent hazards identified in patient care ergonomic assessments completed by the SPHM PM.

(11) Ensuring that all individuals and work groups that handle and mobilize patients or provide or approve equipment for patients are included in the SPHM program, including but not limited to nursing units; SCI/D Centers; Community Living Centers;

treatment areas; diagnostic and imaging areas; procedure areas; perioperative areas;

http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests https://www.publichealth.va.gov/employeehealth/patient-handling/index.asp rehabilitation units; physical, occupational, recreation and kinesiotherapy clinics; mental health areas; outpatient clinics including community-based outpatient clinics (CBOCs);

morgues; Prosthetic and Sensory Aids Service; home care; volunteers; and patient transportation.

(12) Ensuring that patients are screened before mobilization to ensure that methods chosen for their mobility are safe and effective for their needs. NOTE: Methods for this screening include VA Mobility and Screening Solutions Tool (VA MSST). Information on

VA MSST may be found at https://dvagov.sharepoint.com/:f:/r/sites/vhasafe-patient-handling-and-mobility/Shared%20Documents/VA%20MSST?csf=1&web=1&e=eTrCUi.

This is an internal VA website that is not available to the public .

(13) Ensuring that staff who are directly involved with handling and mobilizing

Veterans maintain competence in SPHM technology and methods.

(14) Ensuring that SPHM Unit/Service PLs are assigned on all shifts and in all areas.

NOTE: For guidance on the SPHM Unit/Service PL role and resource requirements, see the SPHM Guidebook and Enclosure 7-1 at: http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook. This is an internal VA website that is not available to the public.

(15) Ensuring that the planning, design, construction and activation phases of new construction and renovation projects of spaces used by Veterans, including major, minor, non-recurring maintenance and station-level equipment projects, incorporate SPHM PM collaboration and appropriate and necessary SPHM equipment as defined by VA CFM Safe Patient Handling and Mobility Design Criteria (PG-18-13) at https://www.cfm.va.gov/til/catalog.asp.

j. VA Medical Facility Safe Patient Handling and Mobility Program Manager.

The VA medical facility SPHM PM is responsible for:

(1) Collaborating with managers and staff with patient care responsibilities, Patient Safety staff, Occupational Safety staff, health care technology staff, Logistics staff, Environment of Care stakeholders and others as appropriate, to lead, coordinate and monitor a comprehensive SPHM program which meets the performance criteria provided in Appendix A, including making systems changes as necessary.

(2) Reporting annually on performance metrics requested by the national SPHM program through a national SPHM survey.

(3) Leading and updating ergonomic assessments for patient care activities in order to recognize hazards and recommend and implement solutions to prevent harm to staff or patients caused by patient handling or mobilization. NOTE: For information to support ergonomic assessments, see paragraph 6 in Appendix A, the VA CFM Safe Patient Handling and Mobility Design Criteria (PG-18-13), at https://www.cfm.va.gov/til/catalog.asp, the HEFP Safe Patient Handling and Mobility Guidebook at http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook and the Bariatric Safe Patient Handling and Mobility Guidebook at https://dvagov.sharepoint.com/:f:/r/sites/vhasafe-patient-handling-and-mobility/Shared%20Documents/VA%20MSST?csf=1&web=1&e=eTrCUi https://dvagov.sharepoint.com/:f:/r/sites/vhasafe-patient-handling-and-mobility/Shared%20Documents/VA%20MSST?csf=1&web=1&e=eTrCUi http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook https://www.cfm.va.gov/til/catalog.asp https://www.cfm.va.gov/til/etc/dcSPHM.pdf https://www.cfm.va.gov/til/etc/dcSPHM.pdf https://www.cfm.va.gov/til/catalog.asp http://vaww.hefp.va.gov/guidebooks/bariatric-safe-patient-handling-and-mobility-guidebook. These are internal VA websites that are not available to the public.

(4) Providing opportunities and resources for managers and supervisors to schedule and provide staff SPHM education and training and maintain competence for all personnel who are directly involved with handling and mobilizing Veterans. NOTE: For details, see paragraph 10 in Appendix A. Content and sample templates for staff education curriculum and competency assessment can be accessed in the SPHM

Guidebook at: http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook. This is an internal VA website that is not available to the public . Detailed sample training products are also available from the OSH Office.

(5) Leading, training and mentoring SPHM Unit/Service PLs to train staff and recognize hazards at the unit level, including providing Unit/Service PL training at least once per year, providing training resources and references, and periodic opportunities for interaction.

(6) Investigating and tracking employee and patient safety incidents involving patient handling and mobilization activities, and encouraging reporting of such incidents, in order to identify causes and prevent future incidents.

(7) Participating and providing expertise on SPHM requirements in every phase of design, construction, remodeling, activation and equipment projects that affect patient handling activities.

(8) Reporting incident trends and program activity to the VA medical facility committee chosen to oversee SPHM and stakeholders including VISN SPHM leadership.

(9) Selecting and coordinating SPHM-related equipment and supplies in coordination with Unit/Service PLs, affected patient care services and stakeholders from Engineering, HTM and Logistics.

3. TRAINING

Training and education requirements are tailored to the needs of the VA medical facility; for details, see paragraph 10 in Appendix A.

4. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive must be managed as required by the National Archives and Records Administration (NARA) approved records schedules found in VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Officer.

http://vaww.hefp.va.gov/guidebooks/bariatric-safe-patient-handling-and-mobility-guidebook http://vaww.hefp.va.gov/guidebooks/bariatric-safe-patient-handling-and-mobility-guidebook

5. BACKGROUND

a. VA started safe patient handling program studies in 2000 and rolled out the national safe patient handling program in 2008, which has reduced manual patient handling injuries by at least 54%. In 2021, VA CFM published the Safe Patient Handling and Mobility Design Criteria, and new design guides incorporate SPHM as they are being developed. In 2021, the Department of Labor added source code 0980 to identify patient handling and repositioning injuries.

b. The VHA SPHM program supports VHA’s High Reliability Organization vision of being the safest health care system for all by weaving high reliability principles within VHA’s operations and culture. The VHA SPHM program is a necessary component of safe early and continuous mobility programs in order to preserve the safety of patients and VHA employees while increasing patient mobility and improving related outcomes.

Examples of SPHM technologies are included in Appendix B.

6. REFERENCES

a. 29 U.S.C. § 668.

b. 38 U.S.C. § 7301(b).

c. 29 C.F.R. Part 1960.

d. Executive Order 12196 (February 26, 1980).

e. HEFP Bariatric Safe Patient Handling and Mobility Guidebook.

http://vaww.hefp.va.gov/guidebooks/bariatric-safe-patient-handling-and-mobility-guidebook. NOTE: This is an internal VA website that is not available to the public.

f. HEFP Safe Patient Handling and Mobility Guidebook.

http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook.

NOTE: This is an internal VA website that is not available to the public.

g. HEFP SPHM Staffing Methodology/Equivalency Request.

http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests. NOTE: This is an internal VA website that is not available to the public.

h. VA CFM Safe Patient Handling and Mobility Design Criteria (PG-18-13).

https://www.cfm.va.gov/til/catalog.asp.

i. VA Mobility and Screening Solutions Tool (VA MSST).

https://dvagov.sharepoint.com/:f:/r/sites/vhasafe-patient-handling-and-mobility/Shared%20Documents/VA%20MSST?csf=1&web=1&e=eTrCU. NOTE: This is http://vaww.hefp.va.gov/guidebooks/bariatric-safe-patient-handling-and-mobility-guidebook http://vaww.hefp.va.gov/guidebooks/bariatric-safe-patient-handling-and-mobility-guidebook http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests https://www.cfm.va.gov/til/etc/dcSPHM.pdf https://www.cfm.va.gov/til/catalog.asp https://dvagov.sharepoint.com/:f:/r/sites/vhasafe-patient-handling-and-mobility/Shared%20Documents/VA%20MSST?csf=1&web=1&e=eTrCU https://dvagov.sharepoint.com/:f:/r/sites/vhasafe-patient-handling-and-mobility/Shared%20Documents/VA%20MSST?csf=1&web=1&e=eTrCU an internal VA website that is not available to the public .

j. VHA Corrective and Preventive Maintenance Checklist for Ceiling Mounted Patient Lifts. https://www.publichealth.va.gov/employeehealth/patient-handling/index.asp.

k. VHA Installation and Relocation Checklist for Ceiling Mounted Patient Lifts.

https://www.publichealth.va.gov/employeehealth/patient-handling/index.asp.

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APPENDIX A

PEFORMANCE CRITERIA FOR SAFE PATIENT HANDLING AND MOBILITY

PROGRAMS

1. The Department of Veterans Affairs (VA) medical facility has written Safe Patient Handling and Mobility (SPHM) procedures that specify local responsibilities and apply to all areas where Veterans Health Administration (VHA) employees handle, mobilize or assist patients and residents.

2. The VA medical facility Director has appointed a full-time SPHM Program Manager (PM) or greater based on clinical needs of Veterans served and safety needs of staff.

The SPHM Staffing Methodology/Equivalency Request at http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests must be used to identify additional SPHM coordinator needs.

NOTE: This is an internal VA website that is not available to the public.

a. VA medical facilities with less than 1.0 full-time equivalent (FTE) allocated for the

SPHM PM must have an annual equivalency request approved by the National SPHM Program Manager. An approved equivalency must illustrate the rationale for the collateral duty and be evaluated annually by the VA medical facility of origin and resubmitted by the VA medical facility Director through the VISN SPHM point of contact

(POC) to the National SPHM Program Manager to ensure the continued growth of the VA medical facility and the SPHM program are in tandem.

b. Factors that are considered include, but are not limited to, the number of Veterans served, VA medical facility complexity, bed days of care, number of direct care providers, number and distance of offsite facilities, employee injuries, construction projects, existing challenges and implementation failures.

c. No collateral duties, responsibilities or ownership will be assigned to the SPHM PM without an equivalency submission and approval by the National SPHM Program

Manager. Occupational health, falls coordinator roles, supervisory roles for teams, Safe Early and Continuous Mobility program leadership, coordination of vehicle assistance or transport, management of non-SPHM equipment, emergency evacuation management or front-line clinical assignments are collateral duties and cannot count toward the

SPHM PM FTE. For SPHM PM education and competency assessment, see paragraph 10 in this appendix.

3. A VA medical facility committee, as described in paragraph 2.i.(5) in the body of this directive, which includes the SPHM PM, an executive sponsor and major stakeholders, oversees SPHM program activities; tracks staff and patient injuries related to patient handling; and evaluates equipment maintenance, logistics and availability of supplies.

4. VA medical facility Safety personnel ensure that the SPHM PM receives information about employee injuries sustained while handling patients as soon as they are received by Safety personnel and that the SPHM PM participates in the safety investigations.

http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests http://vaww.hefp.va.gov/resources/sphm-facility-coordinator-staffing-methodology-and-equivalency-requests

APPENDIX A

A-2

5. Patient Safety and Quality staff collaborate with the SPHM PM to report clinical patient outcomes related to SPHM, such as trends in falls or adverse effects of immobility, and investigate patient safety incidents related to patient handling and mobility.

6. SPHM PM or designees have completed unit-based ergonomic assessments in all areas where patient handling and mobilization is expected, in order to identify hazards related to patient handling and mobilization and strategies to address hazards.

a. Unit-based ergonomic assessments are updated when conditions change, through methods that include Comprehensive Environment of Care rounds and meeting and discussion with supervisors and SPHM Unit/Service Peer Leaders (PLs) or other staff. NOTE: High-risk tasks addressed by unit-based ergonomic assessments include lifting and repositioning more than 35 pounds of patient weight in optimal position, working in awkward positions, pushing and pulling patients, pushing and pulling patient handling equipment and handling falling patients. Guidance is available in the SPHM Guidebook at http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook and in SPHM algorithms from VHA, National Association of Orthopedic Nurses and Association of Perioperative Registered Nurses. This is an internal VA website that is not available to the public.

b. SPHM technology is available in sufficient quantity and in locations convenient to staff as indicated by unit-based ergonomic assessments.

c. Overhead lifts are recommended over floor-based lifts particularly where frequent patient handling tasks are required.

d. SPHM PMs, SPHM Unit/Service PLs and clinical end users are the primary decision makers on SPHM technology purchasing choices.

7. New construction and remodeling projects in patient care areas include the SPHM PM on the team for the duration of the project, including planning, design, construction, activation and installation.

8. Patients are screened to determine the need for SPHM technology in all settings across the continuum of care.

9. The VA medical facility SPHM program includes SPHM Unit/Service PLs on all shifts and in all areas where patient handling occurs who provide training, coaching and assistance to front-line VHA health care workers. SPHM Unit/Service PLs are provided with time to check equipment and train staff.

10. EDUCATION AND COMPETENCY

a. The SPHM PM completes initial and ongoing education, hands-on practice and competency assessments sufficient to manage the VA medical facility SPHM program effectively. This education and competency assessment may include VA medical facility-funded site visits or in-person conferences to acquire hands-on SPHM handling

APPENDIX A

A-3 and mobility skills. Sources for SPHM PM training and education may be from the national SPHM program, VISN-coordinated events or private conferences. For details, refer to Chapter 9 of the SPHM Guidebook at http://vaww.hefp.va.gov/guidebooks/safe-patient-handling-and-mobility-guidebook. NOTE: This is an internal VA website that is not available to the public.

b. SPHM Unit/Service PL education is offered at least once a year and is intended to prepare SPHM Unit/Service PLs for educating others and assessing competency in

SPHM.

c. New employee orientation for staff expected to perform any form of direct patient handling includes the importance of using technology for manual patient handling tasks, mobility assessment methods, hands-on practice with the SPHM technology that will be used and the process for reporting patient and staff injuries.

d. VHA employees receive ongoing education or competency/proficiency evaluation to maintain competence in accordance with their roles and responsibilities.

B-1

APPENDIX B

EXAMPLES OF SAFE PATIENT HANDLING AND MOBILITY TECHNOLOGY

Safe Patient Handling and Mobility technology includes, but is not limited to:

1. Overhead full-body lifts (ceiling-mounted, wall mounted or freestanding gantry, on a room-covering traverse system in the vast majority of cases).

2. Floor-based full-body lifts (rolling).

3. Powered stand assist lifts (sit-to-stand lifts).

4. Non-powered stand aids.

5. Air-assisted lateral transfer devices.

6. Air-assisted lifting devices.

7. Slings and other reusable or disposable supplies, in styles necessary to complete high-risk tasks.

8. Transport devices with power drive or power rise/repositioning features, including stretchers, chairs, beds or movers that attach to beds or chairs.

9. Hygiene devices with power rise/repositioning features.

10. Powered lift devices for toilets.

11. Beds or chairs with specialized features to support mobility or prevent manual repositioning.

12. Friction reducing devices (including slide sheets, slide boards and roll boards).

13. High/low powered exam tables and procedure chairs.

14. Repositioning products that control direction or prevent slipping (including one-way slides).

15. Self-repositioning aids such as handles, ladders and poles.

16. Ambulation and mobility devices and aids.