Transcript EOC Annual Evaluation of the Management Plan

Annual Evaluation of the
Environment of Care (EOC)
Program
Randy Benson
Executive Director
Rural Healthcare Quality Network
November 13, 2012
Environment of Care Program
Annual Evaluation
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Why?
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When?
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How?
EOC Program Evaluation
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What Should be Covered/Included:
◦ All Seven/Eight Parts of the EOC
 Safety Management
 Emergency Preparedness
 Life Safety Management
 Hazardous Materials Management
 Security Management
 Equipment Management
 Utilities Management
EOC Program Evaluation
◦ This Year’s Goals for Each Part of the
Program
 Were Goals Met or Not
◦ This Year’s Accomplishments for Each Part
of the Program
 Performance Indicators or PI Activities
 Acceptable Performance Thresholds
 Actual Performance
◦ Next Year’s Goals for Each Part of the
Program
EOC Program Evaluation
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Safety Management Goals (Examples):
◦ Support Mandatory Safety Education
◦ Implement All New OSHA/DOSH, DOH, L&I,
DOE Standards, as Appropriate
◦ Quarterly Safety Rounds
◦ Evaluate All On-the-Job Injuries (RCA)
◦ Trend and Manage Medication Errors
◦ Support and Encourage Ergonomics Education
◦ Discuss All Construction Safety Issues
◦ Track and Participate in New Employee
Orientation
EOC Program Evaluation
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Safety Management Accomplishments
◦ Percentage of Staff Attending Orientation and
Mandatory Safety Education
◦ Hand Hygiene
◦ Alerts/Recalls Compliance
◦ Safety Surveys Completed and Deficiencies
Addressed
◦ On-The-Job Injury Reporting
◦ Needle Stick Evaluation and Reporting
EOC Program Evaluation
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Emergency Preparedness Goals: (Examples)
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Participate in Regional Disaster Planning Efforts
Conduct and Evaluate Disaster Drills
Provide Terrorism Training
Conduct Infant Abduction Training/Drills (if
appropriate)
◦ Review/Revise the Internal and External Disaster
Plans
◦ Support Staff Training on Disaster/Earthquake
Response
EOC Program Evaluation
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Emergency Preparedness Accomplishments
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Staff Disaster Preparedness Education Percentage
Staff Disaster Response Skills
Number of Drills/Actual Occurrences
Staff Completing Earthquake Response Training
EOC Program Evaluation
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Life Safety Management Goals (Examples)
◦ Conduct and Evaluate All Fire Drills
◦ Conduct Quarterly Fire Suppression System
Inspections
◦ Conduct Quarterly Fire Marshal Safety Rounds
◦ Monitor Staff knowledge of Medical Gas Valve
Locations and Shut Off Procedure
◦ Post Up-To-Date Fire Evacuation Route Maps
◦ Fire Alarms Are Heard In All Parts of Facility
EOC Program Evaluation
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Life Safety Management Accomplishments
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Corridors Free of Obstructions
Fire Doors Close and Latch Appropriately
Enforce 18” and 24” Rules
Storage Areas Safe and Uncluttered
Two Exit Signs Visible at All Times
All Fire Extinguisher Inspections Completed
Engineers Respond to All Fire Alarms
EOC Program Evaluation
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Hazardous Material Management Goals:
(Examples)
◦ Staff Complete Worker Right to Know Training
◦ Staff Trained To Use Spill Kits (as appropriate)
◦ Staff Know How to Properly Dispose of Hazardous
Chemicals
◦ Follow-up On All Deficiencies Related to Chemical
Spill Clean up
◦ Maintain a Current Inventory and Location of All
Hazardous Chemicals in the Facility
◦ Maintain All Necessary Paperwork For Disposal of
Identified Hazardous Chemicals
EOC Program Evaluation
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Hazardous Materials Management
Accomplishments
◦ Staff Can Identify and Locate All Hazardous
Chemicals in Their Work Area
◦ Chemicals In Secondary Containers Are Properly
Labeled
◦ Sharps Containers Contain Only Sharps (No
Garbage)
◦ Log of Bio-hazardous Waste Volumes Disposed of
Is Up-To-Date
EOC Program Evaluation
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Security Management Goals: (Examples)
◦ Staff Wear Proper Name Tag At All Times
◦ Report All Workplace Violence Incidents and
Conduct an RCA on Each
◦ Workplace Violence Training Completed by All
Employees Annually
◦ Closed Circuit TV System Maintained and
Monitored At All Times
◦ Construction Related Security Management
Issues Discussed at Safety Committee Meetings
EOC Program Evaluation
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Security Management Accomplishments
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Thefts on Hospital Property
Security Incident Reports
Staff Completion of Workplace Violence Training
Staff Wearing Name Tag
EOC Program Evaluation
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Equipment Management Goals: (Examples)
◦ All Equipment PMs Completed in Appropriate
Timeframes
◦ All Bio-Med Equipment PMs Completed In
Appropriate Timeframes
◦ All Elevator PMs Completed In Appropriate
Timeframes
◦ All HVAC Air Flows Are Correct
◦ QI Monitoring of All Rental Equipment in Facility
◦ Biomed Vendors Are Competent to Perform PMs
◦ All Alarm Systems/Call Lights Work Properly
EOC Program Evaluation
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Equipment Management Accomplishments
◦ PMs Completed On Time
◦ Biomed PMs Completed On Time (Contracted)
◦ Demonstrated Staff knowledge of What To Do
With Defective Equipment
◦ Blood Bank Refrigerator Alarm Working Properly
◦ All Call Lights Are Tested
◦ All Bed Brakes and Side Rails PMed Annually
◦ All Wheelchairs are PMed Routinely
EOC Program Evaluation
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Utilities Management Goals: (Examples)
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All Utilities Equipment is PMed Routinely
All Generator Tests are Completed as Required
Generator(s) Are Routinely Run Under Load
All Wiring and Circuit Breaker Panels Are
Within NFPA 2000 Code
◦ Pediatric Protected Outlets Placed Where
Appropriate
◦ Contracts in Place For Provision of Food, Water
and Fuel During Disasters
EOC Program Evaluation
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Utilities Management Accomplishments
◦ Number of Elevator Maintenance Calls
◦ Number of Successful Generator Runs Under
Load
◦ Percentage of Staff Trained to Respond to Power
Failure (Emergency Lighting, Computers)
◦ Backflow Valves Checked Routinely
◦ All Circuit Breaker Panels Properly Wired and
Labeled
EOC Program Evaluation
QUESTIONS?
Randy Benson
RHQN Executive Director
206 577-1821
randyb@wsha.org