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Annual Evaluation of the Environment of Care (EOC) Program Randy Benson Executive Director Rural Healthcare Quality Network November 13, 2012.

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Presentation on theme: "Annual Evaluation of the Environment of Care (EOC) Program Randy Benson Executive Director Rural Healthcare Quality Network November 13, 2012."— Presentation transcript:

1 Annual Evaluation of the Environment of Care (EOC) Program Randy Benson Executive Director Rural Healthcare Quality Network November 13, 2012

2 Environment of Care Program Annual Evaluation Why? When? How?

3 EOC Program Evaluation 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

4 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

5 EOC Program Evaluation 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

6 EOC Program Evaluation 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

7 EOC Program Evaluation Emergency Preparedness Goals : (Examples) ◦ 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

8 EOC Program Evaluation Emergency Preparedness Accomplishments ◦ Staff Disaster Preparedness Education Percentage ◦ Staff Disaster Response Skills ◦ Number of Drills/Actual Occurrences ◦ Staff Completing Earthquake Response Training

9 EOC Program Evaluation 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

10 EOC Program Evaluation Life Safety Management Accomplishments ◦ 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

11 EOC Program Evaluation 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

12 EOC Program Evaluation 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

13 EOC Program Evaluation 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

14 EOC Program Evaluation Security Management Accomplishments ◦ Thefts on Hospital Property ◦ Security Incident Reports ◦ Staff Completion of Workplace Violence Training ◦ Staff Wearing Name Tag

15 EOC Program Evaluation 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

16 EOC Program Evaluation 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 LightsAre Tested ◦ All Bed Brakes and Side Rails PMed Annually ◦ All Wheelchairs are PMed Routinely

17 EOC Program Evaluation Utilities Management Goals: (Examples) ◦ 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

18 EOC Program Evaluation 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

19 EOC Program Evaluation QUESTIONS? Randy Benson RHQN Executive Director


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