1. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
TITLE: Safety Management Plan
REFERENCES: Joint Commission on Accreditation of Healthcare Organization’s
Comprehensive Accreditation Manual for Ambulatory Care
(CAMAC) 2000 Standards EC.1.3 & EC.2.2
OBJECTIVE: To effectively manage the components of the organization’s safety
management systems and to minimize risks to People and Property.
It is expected that there will be compliance to relevant Joint
Commission standards.
PROCEDURE(S):
1. A Safety Committee will be comprised of representatives from each department and
administrative personnel. The CEO appoints all members of the Safety Committee.
The chair of the Safety Committee is the Safety Officer. The Safety Committee will
meet at least quarterly and perform the following functions:
A. Keep minutes of meetings.
B. Conduct and review periodic hazard surveillance and risk assessments.
C. Evaluate the effectiveness of the organization in the performance of fire and other
emergency-preparedness drills.
D. Respond to safety-related incident reports.
2. Responsibility for implementation of the Safety Management plan rests with the
Director of Operations. The Safety Committee is responsible for the supervision and
day-to-day execution of the Safety Management Plan. Each Safety Committee
member will be assigned one of the areas of responsibility listed below:
A. Safety
B. Life Safety
C. Emergency Preparedness
D. Security
E. Utilities Systems
F. Medical Equipment
G. Hazardous Materials and Waste
H. Infection Control
3. Pre-appointed Safety Committee members will conduct monthly/quarterly/ periodic
hazard surveillance and risk-assessment inspections. The attached checklist will be
used for this periodic inspection, and will be filed with the Safety Officer.
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2. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
4. Significant findings, discrepancies, or observations will be reviewed by the Safety
Committee, which will develop a corrective action plan. This plan will be reported to
the QI committee.
5. Risk assessments will be performed on an ongoing basis by department coordinators/
managers. Serious problems will be reported by work order to the Safety Officer, for
immediate correction by the appropriate individual. Problems of a less immediate
nature will be forwarded to the Safety Committee, which will proactively evaluate the
impact of the situation on patient, staff and public safety.
6. All incidents of property damage, and patient or visitor injury will be reported
immediately to administration. Staff witnessing the event will encourage the injured
patient or visitor to be seen by a Provider, will complete the appropriate
documentation and forward it to the Director of Operations. Responsible
administrative staff will determine HCHN liability and subsequent billing.
All Incident Reports will be forwarded to the Safety Committee for review and
analysis. The Safety Committee will determine whether corrective action needs
to be taken and will look for patterns, which suggests a need for system
improvement.
7. Incidents of staff injury or occupational illness will be reported immediately to the
supervisor. Affected staff must complete an Incident Report form, which must be
sent to the Safety Officer and forwarded to the Human Resources Department so that
a Workman’s Compensation claim can be initiated as appropriate. For needlestick
injuries, see Policy for Exposure to Bloodborne Pathogens.
8. Ongoing surveillance of the building, grounds, and equipment will be carried out by
all department coordinators/managers, but will be the ultimate responsibility of the
Director of Operations.
9. All products recalls will be reported in writing to the Safety Officer who will present
the information at the next scheduled Safety Committee meeting.
10. Safety policies are distributed to new employees upon hire, discussed at Orientation,
and reviewed via supervisors at departmental meetings. The Board will review the
effectiveness, scope, objectives, and performance annually.
11. New employee orientation and ongoing in-service education will incorporate all
relevant elements of this Safety Plan.
12. The overall performance of the agency in meeting the objectives of the Safety
Management Plan will be assessed at least annually, and will include assessment of:
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3. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
A. The level of safety knowledge and skill of the staff, as determined by post-
instruction quizzes, and documented performance in safety and disaster
drills.
B. A review of staff participation on the Safety Committee.
C. Timely completion of all safety inspections, including the reporting of
deficiencies.
D. A review of incident reporting procedures, and analysis of the reported
incidents.
E. Inspection, testing and maintenance of all safety equipment and systems.
13. All supervisors, Safety officers and department heads are authorized to intervene
whenever conditions pose an immediate threat to life or health, or threaten damage to
equipment or buildings.
14. The following are safety codes that will be used by Hamilton Community Health
Network, Inc.:
a. CODE WHITE: Intruder With Weapon or Disruptive Behavior
Staff in the immediate vicinity of the security incident will act to protect
other staff, patients, and visitors. The intercom system will be used to call
for assistance. If necessary, the local police/emergency service will be
called using 911. Following the incident, an Incidence Report will be
executed and delivered to the Safety Officer.
b. CODE SEARCH: Bomb Threat
This is the only code that will not be announced over the intercom/paging
system. If you receive a bomb threat call, you should gather all the
information you can (time of call, attitude of the caller, background noises,
etc.).This information will be used to assist emergency response
authorities in their investigation. Try to keep the caller on the line as long
as possible and discreetly have another personnel member notify the
operator via another extension of the bomb threat call.
c. CODE RED: Fire – See Life Safety Management Plan.
d. CODE BLUE: Cardiac Arrest / Medical Emergency
The center has an established a Code Blue response team consisting of
personnel trained to respond to this type of emergency. If you are a part of
this team, you will be notified by your supervisor and should respond to
the area announced upon hearing this code. If you are not a part of this
team, you should continue your current job task. Note: It is the policy of
this organization to stabilize patients in Cardiac Arrest using basic life
saving techniques and to transport as soon as possible using available
ambulance and EMT services.
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4. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
e. CODE STORM: Severe Weather Warning
Upon hearing this code announced, staff should assist other personnel
members in your area by moving all patients and visitors into areas of
safety (away from glass windows and exterior walls) and wait for further
instructions.
f. CODE BLACK: Utility Failure:
This procedure is discussed in the Utilities Management section and
Section 208 of the Environment of Care Policy and Procedure Manual.
However, if electricity is the failure and the lighting system has been
compromised, you must immediately secure a flashlight from designated
sites and assist patients (particularly those in exam rooms), personnel, and
visitors to a well-lit area. Medication in the refrigerator should be placed
in the larger cooler located in the conference room kitchen and transported
to the Main location.
g. CODE SPILL: Chemical Spill
Upon hearing this code announced, you should report immediately to your
supervisor, who upon receiving instructions from the Safety Officer will
determine whether evacuation of patients will be necessary. Staff on the
scene of the spill will immediately clear the area and determine the risks
involved with this specific spill. Cleaning the spill area will follow the
procedures identified in the Hamilton Community Health Network health
center’s Hazardous Materials and Waste Management Plan.
h. CODE MANPOWER: Everyone help
Upon hearing this code announced, you should report immediately to the
given location, staff will act to protect other staff, patients, and visitors.
The intercom will be used to call for assistance. If necessary, the local
police/emergency service will be called using 911. Following the
incident, an Incidence Report will be executed and delivered to the Safety
Officer.
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5. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
HAMILTON COMMUNITY HEALTH NETWORK, INC.
HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM
TO BE COMPLETED EVERY SIX MONTHS
Date: Site:
Program Hazard Surveillance/ Yes No Comments &
Risk Assessment Item Resolution
Safety 1. Are grounds clean & free of hazards?
Management
2. Are floors clean, dry, in good repair, & free
of obstructions?
3. Are mechanisms for access (i.e. ramps,
handrails, door opening mechanisms, etc.)
operational?
4. Is the parking area free of potholes or other
hazards?
Security 1. Are doors functioning & locked as
Management appropriate?
2. Are medical records centrally located and
accessible ONLY to authorized personnel.
3. Are alarms functioning, tested, and
maintained in accordance with
manufacturer’s specifications.
4. Are systems/mechanisms in place to quickly
notify officials or other staff quickly in the
event of a security related problem.
Hazardous 1. Are OSHA Hazard Communication and
Materials & Exposure Control Documents available?
Waste 2. Have all biohazard and toxic substances
Management been identified?
3. Are MSDS sheets quickly available for all
identified toxic substances?
4. Are all waste contaminated with blood/body
fluid considered and handled as infectious?
5. Are sharps containers puncture resistant and
in accordance with require safety standards?
6. Are sharps and disposable syringes placed in
approved Sharps containers?
7. Are all engineering, personal protective
equipment & workplace controls in effect.
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6. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM
Continued (Page 2)
Program Hazard Surveillance/ Yes No Comments &
Risk Assessment Item Resolution
Emergency 1. Is there an updated disaster plan in the
Preparedness department?
Management 2. Has an non-fire related emergency drill
been performed in the past six months?
3. Are staff aware of at least three different
types of potential non-fire emergencies and
their role in eliminating or reducing the risk
to patients, staff and property?
4. Are staff aware of the primary and
secondary exits from the facility?
Life Safety 1. Is the evacuation plan posted and can staff
Management demonstrate knowledge of the plan.
2. Are fire extinguishers located in accordance
with NFPA standards?
3. Are fire extinguishers inspected monthly and
documented on/near the extinguisher?
4. Are smoke/fire alarm systems functioning,
tested, and maintained in accordance with
manufacturers specifications?
5. Are egress hallways well lit & obstacle free?
6. Is emergency exit lighting operational and
tested in accordance with NFPA standards?
7. Are fire/smoke doors operating effectively?
8. No smoking policies are in effect and signs
are posted appropriately?
Medical 1. Is there a unique inventory of all medical
Equipment equipment in the facility?
Management 2. Is all equipment evaluated & prioritized
0(Form EC 1.8) prior to use?
3. Has all equipment been tested/maintained
according to manufacturer’s specifications?
4. Are maintenance records complete, (i.e. do
they record the results of both electrical
safety as well as calibration, as appropriate?
5. Are systems/mechanisms in place to
respond appropriately to a medical
equipment failure?
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7. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM
Continued (Page 3)
Program Hazard Surveillance/ Yes No Comments &
Risk Assessment Item Resolution
Utility 1. Are the lights, emergency lights, and power
Management plugs operational and in working order?
2. Does the water/sewage system appear to be
working properly and has the water quality
been tested within the past year?
3. Is the telephone system operational?
Infection 1. Are all staff utilizing Universal Precautions
Control (i.e. utilizing appropriate PPE,
Monitoring handwashing, etc.) in the performance of
Issues their job duties?
2. Are cleaning solutions secured, mixed, and
utilized appropriately throughout the
facility?
3. Are potentially “infectious patients”
aggressively identified and processed in a
manner which would minimize the risk of
infection of staff and other patients?
4. Can staff intelligently describe their role in
infection control within the organization?
Other Key 1. Are Utility Rooms locked, clean and clear
Safety of debris?
Monitoring 2. Are Storage Rooms secure, clean, and free
Issues of flammables?
3. Is the breakroom clean and clear of debris
and flammables?
4. Are all medications, including samples,
secured and accounted for by lot number?
Additional Findings:
Inspection Conducted By: Date:
Reports Noted: Date:
Safety Officer
October 2004, Hamilton Community Health Network, Inc. Page 7

8. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
HAMILTON COMMUNITY HEALTH NETWORK, INC.
ANNUAL COMPREHENSIVE RISK ASSESSMENT REPORT FORM
Directions: Assess and comment on any aspects of the environment of care that could potentially place patients, staff
or the public at risk. Suggest corrective actions that might reduce such risk. Address at least the following areas:
Buildings:
Grounds:
Equipment:
Occupants:
Internal Physical Systems:
Other:
Inspection Conducted By: Date:
Reports Noted: Date:
Safety Officer
October 2004, Hamilton Community Health Network, Inc. Page 8

9. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
HAMILTON COMMUNITY HEALTH NETWORK, INC.
HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM
TO BE COMPLETED MONTHLY
Date: Site:
Program Hazard Surveillance/ Yes No Comments &
Risk Assessment Item Resolution
Safety 1. Are grounds clean & free of hazards?
Management
2. Are floors clean, dry, in good repair, & free
of obstructions?
3. Is the parking area free of potholes or other
hazards?
Security 1. Are doors functioning & locked as
Management appropriate?
2. Are alarms functioning, tested, and
maintained in accordance with
manufacturer’s specifications.
3. Are systems/mechanisms in place to quickly
notify officials or other staff quickly in the
event of a security related problem.
Hazardous 1. Have all biohazard and toxic substances
Materials & been identified?
Waste 2. Are all waste contaminated with blood/body
Management fluid considered and handled as infectious?
3. Are sharps and disposable syringes placed in
approved Sharps containers?
4. Are all engineering, personal protective
equipment & workplace controls in effect?
Emergency 1. Is there an updated disaster plan in the
Preparedness department?
Management 2. Are staff aware of at least three different
types of potential non-fire emergencies and
their role in eliminating or reducing the risk
to patients, staff and property?
3. Are staff aware of the primary and
secondary exits from the facility?
Life Safety 1. Is the evacuation plan posted and can staff
Management demonstrate knowledge of the plan.
2. Are fire extinguishers located in accordance
with NFPA standards?
HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM
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10. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
Continued (Page 2)
Program Hazard Surveillance/ Yes No Comments &
Risk Assessment Item Resolution
3. Are fire extinguishers inspected monthly and
documented on/near the extinguisher?
4. Are smoke/fire alarm systems functioning,
tested, and maintained in accordance with
manufacturers specifications?
5. Are egress hallways well lit & obstacle free?
6. Is emergency exit lighting operational and
tested in accordance with NFPA standards?
Utility 1. Are the lights, emergency lights, and power
Management plugs operational and in working order?
2. Does the water/sewage system appear to be
working properly and has the water quality
been tested within the past year?
3. Is the telephone system operational?
Infection Control 1. Are all staff utilizing Universal Precautions
Monitoring (i.e. utilizing appropriate PPE, hand
Issues washing, etc.) in the performance of their
job duties?
2. Are cleaning solutions secured, mixed, and
utilized appropriately throughout the
facility?
Other Key 1. Are Utility Rooms locked, clean and clear
Safety of debris and flammables?
Monitoring 2. Is the break room clean and clear of debris
Issues and flammables?
Additional Findings: _________
________________ _________
_________
Inspection Conducted By: Date: _ _____ ___
Reports Noted: Date: ___
Safety Officer
October 2004, Hamilton Community Health Network, Inc. Page 10

11. Hamilton Community Health Network, Inc.
Policy and Procedure
Environment of Care
HAMILTON COMMUNITY HEALTH NETWORK, INC.
MONTHLY COMPREHENSIVE RISK ASSESSMENT REPORT FORM
Directions: Assess and comment on any aspects of the environment of care that could potentially place patients, staff
or the public at risk. Suggest corrective actions that might reduce such risk. Address at least the following areas:
Buildings:
Grounds:
Equipment:
Occupants:
Internal Physical Systems:
Other:
Inspection Conducted By: Date:
Reports Noted: Date:
Safety Officer
October 2004, Hamilton Community Health Network, Inc. Page 11