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 Why? When? How?

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

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 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 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 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

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

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

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

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

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

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

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

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

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 Lights Are Tested All Bed Brakes and Side Rails PMed Annually All Wheelchairs are PMed Routinely

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

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

EOC Program Evaluation QUESTIONS? Randy Benson RHQN Executive Director 206 577-1821 randyb@wsha.org