The Environment of Care (EOC) Tours were completed in 2013 for the patient-care areas (twice per year) that are Joint Commission Accredited. As one of our requirements by The Joint Commission (TJC), these accredited facilities are required to complete an internal self-audit (EOC Tour) by a multi-disciplinary team. After collecting all the data, I wanted to share with you the areas that we are collectively succeeding in, and the areas that need additional training and education.
Clinical Engineering
Staff had an overall performance score of 94%, well above our 90% required compliance. During the assessment, Clinical Engineering staff reviewed clinical equipment, record keeping by staff, and new equipment not currently being tested. During the second round of EOC Tours, it was determined that staff needed additional training in daily record keeping for code carts and that patient equipment was provided with a visible inspection tag.
Emergency Management
LLUH is well above the standard for conducting Emergency Management drills. We are currently performing quarterly disaster drills that test the knowledge of staff and the ability to put our resources in action. Staff knowledge of how to access these disaster plans, Emergency Operation Plan (EOP) & Hospital Emergency Protocols, was at 76%. In order to better assist staff in finding the disaster plans, you can easily find the “Emergency Preparedness & Response” page by going to the VIP Page and clicking General Emergency Preparedness & Response or by clicking here.
Facilities Management
Staff are great when identifying a facility problem and reporting it to Facilities Management. 96% of patient-care areas were found to be in good repair and without outstanding work orders. This is a great compliance score that reflects the work you are doing as a result of completing your EOC Self-Audit form and following through with work orders. Thank you for taking pride and ownership of your department.
Fire & Life Safety
Patient-care departments scored a compliance rate of 85% for 2013. The main contributing factor for this score was availability of documentation. Departments are required to show the last two quarters of EOC self-audits and fire drill forms when EOC Tours are conducted. Unfortunately, if these forms are unavailable at the time of request, it is assumed that the department did not complete the requirements for those quarters. Environmental Health & Safety (EH&S) has improved this process by introducing a digital fire drill form available for all departments. It would be in the department’s best interest to complete the fire drill form digitally to ensure records are accurately kept and easily accessible should TJC request these during a survey. Already, we are seeing higher compliance for 2014 and are well on our way to beating last year’s score. Great job!
Environmental Services
Environmental Services completed a 90% compliance score last year. They focused on overall cleanliness of the department, as well as a detailed assessment of alcohol-based hand rub dispensers. Departments did a great job in ensuring that their departments were well maintained and, of course, this could not have been done without our fantastic EVS department. A big congratulations goes to EVS Director, Kelvin Moore, and his team!
Hazardous Materials & Waste Management
The focus of this discipline was mainly on staff competency and the segregation of hazardous waste. The overall program score was 81% with majority of the low scoring in staff competency. The staff was asked if they knew how to access the Safety Data Sheets (SDS) and if they knew the procedures should a hazardous material spill occur. There is definitely opportunity for departments to become more familiar with these processes. The good news is that EH&S is here to assist you with filling in these educational gaps.
Radiation Safety
Departments had an overall compliance score of 94% when knowing Radiation Safety procedures. Although there was overall successful compliance for this program, there still may be opportunity to help coach staff on who is allowed to handle radioactive waste and where to find radioactive waste containers. The need to know this information may not apply to some departments as much as others. In conclusion, staff seems to be well prepared and understand the overall processes of Radiation Safety.
Security
The need to know Security procedures is always at the top of our list. Whether we are dealing with an angry family member or assisting in a Code Pink drill, this knowledge is extremely important to know and you have all proven well that you know it! Departments had a compliance score of 95% in 2013. This number surely instills confidence in our staff and our Security Department for educating and taking a lead role in our disaster drill. Thank you Security and staff!
I hope this information is useful to you and assists you in opportunities for improvement. Most of all, congratulations goes to YOU for an outstanding performance. As we are concluding the first half of 2014, we can already see the increased compliance in staff knowledge for most of these areas. Thank you for your continued passion in safety by ensuring your environment is cared for and your staff is educated.
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This article originally posted in Environmental Health & Safety's Speaking of Safety Blog. Environmental Health & Safety is a division of Risk Management. Visit the Speaking of Safety Blog here.