VHA Directive 7703.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 7703

Transmittal Sheet February 1, 2016

SAFETY MANAGEMENT SYSTEM (SMS) AND GOVERNING SAFETY POLICY

STATEMENT

1. REASON FOR ISSUE: This Directive establishes policy for the development, implementation and sustainment of Safety Management Systems within the Veterans Health Administration.

2. SUMMARY OF CONTENTS: This Directive outlines the key elements necessary to implement a SMS as a management framework for VHA Safety Programs.

3. RELATED ISSUES: VA Directive 7700, VHA Directive 7701, VHA Handbook 7701.01.

4. RESPONSIBLE OFFICE: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the content of this Directive. Direct questions to the Director, Occupational Safety, Health and GEMS Programs (10NA8) at 202-632- 7889.

5. RESCISSIONS: None.

6. RECERTIFICATION: This VHA Directive is scheduled for recertification on or before the last working day of February 2021.

David J. Shulkin, M.D.

Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publications Distribution List on 2/3/2016.

February 1, 2016 VHA DIRECTIVE 7703

SAFETY MANAGEMENT SYSTEM (SMS) AND GOVERNING SAFETY POLICY

STATEMENT

1. PURPOSE

This Directive establishes policy requiring VHA facilities to develop and implement a SMS and governing safety policy to pursue continual improvement of workplace safety programs. AUTHORITY: 38 U.S.C. 501, 512, 901, 1709, and 7301(b); 29 U.S.C. 668 and 673; 29 CFR Part 1960.

2. BACKGROUND

VHA’s mission is to deliver quality health care to our Nation’s Veterans. To achieve this, VHA must demonstrate a commitment to protecting and improving the safety of patients, employees, and visitors. SMS will require VHA facilities to integrate accountability for safety into daily decision-making and long-term planning processes across all VHA organizations, activities, functions, and services.

a. The SMS process provides a systematic approach to managing safety hazards at VHA facilities; in turn, this improves facility operations and the delivery of health care to the Veteran. When implemented as one element of an overarching business management system, a SMS provides a set of processes and practices enabling VHA facilities to:

(1) Identify and address hazards inherent to a VHA facility’s work processes.

(2) Evaluate how safety programs are managed.

(3) Ensure compliance with applicable safety requirements.

(4) Determine opportunities for additional and continual improvement.

(5) Manage safety responsibilities in a proactive manner and pay greater attention to safety regulatory requirements.

(6) Integrate safety programs with the existing organizational structure, responsibilities, facility planning activities, work practices and processes, organizational goals, operations, and resource allocation.

(7) Prevent injuries and mitigate hazards.

(8) Enhance their image with regulators, patients, stakeholder groups, and the general public.

b. All management systems share common structural elements, processes and management actions. The SMS process is similar to VHA’s established and mature Green Environmental Management System (GEMS) Program, which will provide facility staff and management with a level of familiarity, simplicity, and ease of implementation.

VHA DIRECTIVE 7703 February 1, 2016

The General Safety Guidebook, developed by the VHA Center for Engineering and Occupational Safety and Health (CEOSH), describes the SMS structure in more detail and provides a “stepped” implementation approach. In the same manner that GEMS programs strive for continuous improvement, the SMS will incorporate best practices identified during management review phases.

c. The systematic approach of a SMS allows standardized implementation across VHA facilities, while retaining flexibility for regional and facility-specific requirements.

This improved consistency will strengthen relationships with Federal, State and local regulators, Veterans Service Organizations, and other stakeholders.

d. The SMS approach to managing facility safety follows the familiar “Plan-Do- Check-Act” cycle used in many of our existing processes, including those facilitating The Joint Commission accreditation. As such, VHA can seamlessly integrate many of the SMS requirements with our current practices to avoid duplication. By documenting established program elements that overlap with SMS requirements, facilities can avoid duplicative effort and reduce the time to full implementation.

3. POLICY

It is VHA policy to develop and implement Safety Management Systems for the management and operation of safety practices at all VHA facilities, organizations, activities, functions, and services within 6 months of the effective date of this Directive.

4. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health (10) is responsible for ensuring that all VHA facilities develop and implement a SMS

b. VA Office of General Counsel including VA District Chief Counsels. VA Office of General Counsel including VA District Chief Counsels is available to provide legal counsel and guidance, as necessary, to VHA organizations including, but not limited to, VHA Central Office, VISNs, and VHA facilities, regarding the development and implementation of SMS, safety compliance, and other matters related to safety program management.

c. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management is responsible for:

(1) Implementing policies and issuing guidance related to the development and implementation of VHA facility SMS.

(2) Overseeing VHA safety programs at the national level.

d. VHA Central Office Program Directors. VHA Central Office Program Directors (including, but not limited to Consolidated Mail Outpatient Pharmacies and Consolidated Payment Accounting Centers) are responsible for developing, implementing and sustaining the SMS process within their organizations.

http://vaww.ceosh.med.va.gov/01HP/02HP_Guidebooks/03_Collections/04HP_safety/gensafety/GS2017.pdf

e. Director, Occupational Safety, Health and GEMS Programs. The Director, Occupational Safety, Health and GEMS Programs is responsible for overall program management of VHA efforts related to SMS at the national level, to include:

(1) Developing policy and safety program guidance for use at VHA facilities in the development and implementation of SMS.

(2) Developing a facility audit process to verify the, implementation status of the facility SMS.

(3) Acting as VHA liaison to Occupational Safety and Health Administration (OSHA) and other government entities regarding SMS and related safety matters.

(4) In conjunction with appropriate VA and VHA officials, developing performance standards and/or measures along with position description statements related to SMS for appropriate upper level VHA managers.

f. Director, Center for Engineering and Occupational Safety and Health. The Director, Center for Engineering and Occupational Safety and Health (CEOSH), is responsible for promoting best practices related to SMS and safety compliance by:

(1) Publishing and updating SMS guidance along with best practices relevant to VHA as part of the General Safety Guidebook; and

(2) Supporting SMS implementation through development of information technology and web-based information services.

g. Director, VHA Employee Education System. The Director, VHA Employee Education System is responsible for developing and delivering training related to SMS implementation.

h. VISN Directors. VISN Directors are responsible for:

(1) Ensuring a SMS is developed and implemented at VA medical facilities for which they are responsible within 6 months of the effective date of this Directive.

(2) Performing a gap analysis of VA medical facility SMS on an annual basis to determine the status and effectiveness of implementation. Gap analysis is performed by VISN health and safety staff members or qualified consultants using recognized and established OSH protocols.

(3) Providing VA medical facilities the resources needed to develop and implement VA medical facility SMS and safety compliance programs.

(4) Developing and implementing performance standards and/or measures along with position description statements related to safety program management for VISN managers and VA medical facility Directors.

(5) Providing SMS and other safety training to VISN health and safety staff members and other staff members responsible for SMS to:

(a) Oversee the implementation of SMS at VA medical facilities.

(b) Perform gap analysis to determine the status and effectiveness of VA medical facility SMS implementation.

(c) Assess the effectiveness of VA medical facility safety programs.

i. VA Medical Facility Directors. VA medical facility Directors are responsible for:

(1) Developing and implementing a facility SMS, based on the principles and elements outlined on the SMS resources Web site (NOTE: This is an internal VA Web site that is not available to the public) within 6 months of the effective date of this Directive.

NOTE: Tools, templates, and additional guidance for development and implementation can be found at the same location (SMS resources Web site). Copies of documents and documentation related to the SMS must be available at all affected facilities.

(2) Preparing an Annual Report. The facility Safety Committee will submit an annual report to the VA medical facility director for approval or modification and signature. The annual report must meet The Joint Commission Environment of Care requirements for an annual program effectiveness evaluation and must include:

(a) Accomplishments for the year (e.g., the status and results of objectives and targets).

(b) Resources expended on the SMS.

(c) Results of SMS Gap Analysis, internal audits and the Annual Workplace Evaluation (AWE).

(d) Status of action items for correction of deficiencies identified in the SMS Gap Analysis, internal audits and the AWE.

(e) Significant safety hazards identified at the facility.

(f) Proposed objectives and targets for the upcoming year (either new or modified).

(3) Operating facilities in a manner that complies with their facility’s SMS and governing safety policy.

(4) Developing a facility-specific governing safety policy.

(5) Taking necessary steps to meet objectives and targets established by the facility

SMS.

http://vaww.ceosh.med.va.gov/01SA/Pages/Safety.management.system.shtml http://vaww.ceosh.med.va.gov/01SA/Pages/Safety.management.system.shtml

(6) Implementing actions to correct safety deficiencies in a timely manner.

(7) Taking steps to obtain funding to achieve SMS objectives/targets and correct identified SMS deficiencies.

(8) Communicating SMS requirements to all staff members.

(9) Including SMS and other safety requirements, as appropriate, in Standard Operating Procedures (SOP), work practices and other processes of all VHA facility operational units.

(10) Taking appropriate action to make certain work performed by contractors and consultants conforms to the requirements of the facility SMS.

(11) Developing and implementing performance standards and/or measures and position description statements related to safety program management for managers and staff members of VHA facilities.

5. REFERENCES

a. 38 U.S.C. 501, 512, 901, 1709, & 7301(b).

b. 29 U.S.C. 668 & 673.

c. Executive Order 12196, Occupational Safety and Health Programs for Federal Employees. 29 CFR pt 1960.

d. Occupational Safety and Health Administration http://www.osha.gov

e. Public Law 91-596, Occupational Safety and Health Act, 1970.

f. VA Directive 7700, Occupational Safety and Health.

g. VHA Directive 7701, Occupational Safety and Health.

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

i. VHA General Safety Guidebook.

6. DEFINITIONS

a. SMS Facility. For the purposes of developing and implementing SMS, a multi-campus Health Care System (HCS) under common management is considered a single SMS facility. Community-Based Outpatient Clinics (CBOC) and other affiliated satellite VHA medical facilities shall be included under the parent VA medical facility’s SMS.

b. Occupational Safety and Health Management Information System. An Occupational Safety and Health Management Information System is a process used to http://www.osha.gov/ provide safety and health training for a variety of employee groups (see Executive Order 12196, Occupational Safety and Health Programs for Federal Employees).

c. SMS Management Infrastructure. SMS management infrastructure includes all elements, including policy and guidance, used to implement and sustain Occupational Safety and Health programs (see VA Directive 7700, Occupational Safety and Health).