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Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

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JCAHO:  Employee Review and Easy Reference

Safety Management

  1. Have you received training about Vanderbilt's Safety Program and how you can perform your job safety?
    • Yes, initial safety training is provided at Hearts and Minds orientation when employees are hired at Vanderbilt. Annually, staff participate in the Safety Fair and departmental safety training as a review.
  2. What topics are included with your Safety Orientation and annual Safety Training?
    • General Safety and Vanderbilt policies, electrical and equipment safety, hazard communication (chemical safety), fire safety and emergency preparedness, bloodborne pathogens and isolation procedures, needles and sharps safety, personal safety and security, and fire safety
  3. What are some general safety risks in your work area?
    • Some general safety risks found in all areas of the Medical Center include: spilled fluids, damaged electrical cords, broken furniture, etc.
  4. What should you do if you notice a general safety risk such as those mentioned above?
    • Remove/confine the safety hazard and call the appropriate department
    • Plant Services should be called for immediate repairs.
    • Biomedical Electronics for medical equipment that is broken or damaged.
    • Environmental Services for non-hazardous spills if Service Associate is unavailable
    • Vanderbilt Environmental Health and Safety (VEHS) for hazardous spills.
  5. What is an incident?
    • Any occurrence that is not consistent with the routine operation of VUMC.
  6. What should you do if you are injured at work?
    • Report the injury to your supervisor; seek medical attention (if needed) through the Occupational Health Clinic or the ED; complete a first report of injury form.
  7. How should you report an incident involving a patient or visitor?
    • Complete an Occurrence Report (MC 1518) within 24 hours of the incident.
  8. What should you do if there is a serious incident or possible Sentinel Event?
    • Notify Risk and Insurance Management of incident as soon as possible.
  9. How should the Occurrence report or first report of injury be written?
    • In clear, concise terms with no assumptions or "blame". Only pertinent information and factual data should be documented. Document complete details of incident.
  10. What do you do if a visitor is involved in an incident?
    • Notify VUPD immediately of all visitor incidents involving theft. An incident or adverse occurrence report should be filled out for all incidents involving patients or visitors and sent to Risk Management when completed. 
    • If the staff member discovering the incident feels that the visitor should go to the Emergency Department, this fact and reason must be noted on the incident report.
  11. What should hospital personnel tell visitors that have had an incident?
    • Hospital staff should NOT inform visitors that Vanderbilt will the guarantor of any expenses incurred or make any statement indicating the hospital is responsible for the incident. Refer any questions to Risk and Insurance Management (6-0660).
  12. Where can you smoke at VUMC?
    • Smoking is NOT permitted inside any Medical Center buildings or clinics.  There are no exceptions.
    • Designated smoking areas are listed in the VUMC Smoking Policy, SA 40-10.02.
  13. Where can you find information about VUMC’s safety, infection control, operational and clinical requirements?

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Medical Equipment

  1. Who should you call about problems (failures/malfunctions) with medical equipment?
    • Call Clinical Engineering (formerly Biomedical Electronics) to report equipment problems.
  2. How can you tell if equipment has been inspected by the Clinical Engineering department?
    • A current inspection sticker must be displayed on the equipment. Check the date on the sticker and never use equipment that is "out of date" for its check by BioMed.
  3. How do you know if the medical equipment you are using is safe and working properly?
    • Whenever medical equipment is used, make sure the equipment is clean, and make sure the equipment is working properly.
  4. What should you do if medical equipment breaks of does not function correctly?
    • Remove the equipment from service.
    • Notify your supervisor/manager
    • Send the equipment for repair.
  5. What should you do if patient injury is caused by equipment failure?
    • Call Clinical Engineering and Risk Management as soon as possible. 
    • Secure the equipment so that it can be evaluated by Risk Management. It is vital that hospital personnel preserve and protect any equipment involved in a patient/employee/visitor incident for further examination and investigation.
  6. Does your job require you to use medical equipment?
    • If you use medical equipment for your work at Vanderbilt, you must be able to describe or demonstrate operating and safety procedures for equipment use. For example, if you are expected to use a defibrillator, you should know how to turn the equipment off/on, how to use the equipment safely, and describe how and why you know that the equipment is working properly.

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Emergency Preparedness (Disaster)

  1. How do you know what your duties are in a disaster?
  2. Does VUMC test the emergency preparedness/disaster plans?
    • Yes, all areas should participate in disaster drills at least twice every year. Off-site clinics must have one disaster drill annually.
  3. What back up communications systems can be used if the medical center phones fail?
    • The red phones can be used if the regular phone system fails. Also pagers and 2-way radios can be used.
  4. What is the overhead announcement used to alert Medical Center staff about a missing patient?
    • Code Pink – Missing Infant (younger than 12 months)
    • Code Purple – Missing Child (1-12 years)
    • Code Walker Adolescent - missing teen (13-17 years)
    • Code Walker Adult – missing adult (18 years or older)
  5. What overhead announcement is used to tell staff that they should PREPARE for a disaster plan activation?
    • "YELLOW Alert for 'situation'"
  6. What overhead announcement is used to tell staff to ACTIVATE the disaster plan for their area?
    • "ORANGE Alert for 'situation'"
  7. What actions should you take if an "Orange Alert for Tornado" is announced?
    • Move patients, visitors, staff into interior areas away from exterior walls and windows.
    • Close windows and drapes
    • For patients that cannot be moved, cover patients with blankets and move bed so that patients' heads are turned away from windows.
  8. What should you do if you receive a threatening phone call (or bomb threat)?
    • Do not hang up the phone.
    • Make detailed notes about the call and caller. Note the time.
    • Have someone call VUPD immediately from another phone.
    • Report the call to the AOC
    • Prepare to evacuate but wait until directed to do so.
    • Overhead announcement is Code Black.
  9. What should you do if you encounter a suspicious package or letter?
    • Do not disturb, shake, or open the package.
    • Do not give the package to someone else to look at or remove the package from the area.
    • Call VUPD immediately.
    • Isolate the package or letter.

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Utilities

  1. How do you know what to do if there is a utility failure (water, electricity, natural gas, suction)?
  2. Who should you contact if there is a utility failure in your work area?
    • Call Plant Services to report utility failures (2-2041)
    • Call Respiratory Therapy (Adult 835-5978, Pediatric 835-5955) for Med gas (oxygen) failure and then call Plant Services (2-2041).
    • Notify Telecommunications for phone failure
  3. If the lights go out in the Medical Center, what should you do?
    • Wait 8-10 seconds; the emergency generator will turn on the power.  Check that all essential equipment is plugged into red outlets and all life support equipment is properly functioning. Disconnect or turn off non-essential equipment that may be plugged into emergency power (red outlets). Examples of non-essential equipment include: fans, personal portable equipment.
  4. What should you do if you get stuck in the elevator?
    • Stay calm
    • Use the elevator phone or emergency alarm to call for assistance.
    • Do NOT try to climb out of the elevator.
Security

  1. How do you contact VUPD in the event of an emergency?
    • On Campus: 911 or "O" for operator.
    • Off-site practices - 911 for local emergency services
  2. How do you contact VUPD for non-emergency issues (escorts, security information, reports of criminal incidents not in progress)?
    • Call 322-2745
  3. How do you enter the hospital during non-business hours (9pm - 6am)?
    • As a VUMC employee, you are able to enter the Medical Center at any entrance with ID card access.
    • The only public entrances into VUH/VCH are through the respective Emergency Departments. (To further ensure the safety of staff and patients, the ED’s have metal detectors which are monitored by Security 24 hours/day.)
  4. If you work in a security sensitive area (pediatrics, handling money or pharmaceuticals), what measures are in place to control access and provide additional security?
    • Security-sensitive areas may be secured from public access
    • Special procedures may be in place to verify staff access (i.e. card swipe in doors, special ID access for Pyxis)

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Fire Safety
  1. What should you do in the event of a fire?
    • R.A.C.E.: 
      R      emove anyone from the immediate fire area; 
      A      lert others and pull the manual fire alarm pull station; 
      C      onfine the fire by closing doors; 
      E      xtinguish or Evacuate
  2. When should you begin evacuating in a fire situation?
    • The fire response plan for some buildings (Oxford House, Medical Arts, and most off-site clinics) is evacuation. If your office is in one of these buildings and the fire alarm is activated, you must evacuate the building.
    • The fire response plan for most patient care buildings is called “defend in place.” If there is danger from smoke or fire in your work area, evacuate that “smoke compartment.” When escaping from fire or smoke danger, evacuate beyond the fire/smoke rated doors.
      If your area is not in immediate danger, wait for further instructions.
  3. What does the term “smoke compartment” mean in terms of fire safety?
    • A smoke compartment is a building space enclosed by smoke barriers on all sides, top and bottom.
    • In terms of fire safety, an easily recognizable feature of a smoke compartment is the fire/smoke doors. These are the doors that either remain closed and are automated closing devices or drop to close when the fire alarm is activated.
  4. Your manager tells you to evacuate - where do you begin?
    • Evacuate horizontally first. Evacuate into the next “smoke compartment” (beyond the smoke/fire rated doors) or further away if there is still danger from smoke or fire.
    • Evacuate vertically to the ground floor if you don’t have a safe horizontal alternative. Use the stairs; NOT the elevator for vertical evacuation.
    • Evacuate those closest to danger first, then
      1. Ambulatory Patients and visitors
      2. Non-ambulatory patients
      3. Critical patients on life support
  5. If you hear the fire alarm and the overhead announcement indicates that the fire is NOT in your work area, what should you do?
    • Clear corridors
    • Close doors
    • Prepare for further actions (possibly receiving patients from evacuated areas or evacuating if your area is endangered)
  6. What is the overhead announcement in the Medical Center to make sure staff know about a potential fire?
    • Red Alert, "location"
  7. When would it be important to shut off the medical gas to a room or an area? Who is responsible to shut off the med gas?
    • The oxygen to a room or area should be shut off if there is a fire in the immediate area. The Charge nurse or area manager is responsible for shutting off the med gas.
  8. What is the best way to get help in a fire situation?
    • Activate the closest manual pull station!
    • If you do not hear the alarm or you feel that you need to call someone else, call VUPD.
    • If you are at an off-site clinic, call 911.
  9. Do you know where the pull stations and fire extinguishers are in your work area?
    • If you don't know, go look for them!
  10. Do you know the evacuation routes to take if you have to evacuate your work area?
    • You should know at least two routes to evacuate your work area. Your group should have a plan to meet at a remote site to make sure everyone is accounted for.
  11. How do you operate a fire extinguisher?
    • P.A.S.S.:
      P      ull the pin in the nozzle of the extinguisher; 
      A      im the nozzle of the extinguisher at the base of the fire; 
      S      queeze handles together; 
      S      weep from side to side - covering the fire.

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Hazardous Materials
  1. 1. What does "Right to Know" mean?
    • You have the "right to know" about the chemical hazards you work with or may be exposed to at work.
  2. What is an MSDS?
    • MSDS stands for material safety data sheet. An MSDS is a fact sheet about a chemical; providing information about the manufacturer, safe handling and storage procedures, first aid and spill procedures, etc.
  3. Where can you find material safety data sheets for chemicals used in your department?
    • For every hazardous chemical used in your department, there should be a paper copy of the material safety data sheet available for you to review. You should know where the paper copy is maintained. If you don't know, ask your supervisor.
  4. What hazardous materials could you possibly be exposed to in your work area?
    • Do you work with any of the following materials: cleaning agents, chemotherapeutic drugs, compressed gases, laboratory chemicals, radioactive materials or x-ray producing equipment, blood or body fluids, infectious wastes, etc?
  5. What should you do if there is a hazardous material spill in your area?
    • Evacuate anyone in the immediate area,
    • Isolate the spill area, closing doors as you leave
    • Notify VUPD, Environmental Health & Safety, Plant Services
    • Obtain an MSDS of the spilled chemical
  6. What should you do if you spill a chemical on your skin and clothing?
    • Remove the contaminated clothing. 
    • Immediately wash the affected skin area with copious amounts of water.
    • Go to Occupational Health or the Emergency Department for evaluation and treatment (if necessary).
    • Complete a first report of injury and report the incident to your supervisor.
  7. Do you know how to manage a
    • Blood or Body fluid spill?
    • Chemotherapeutic drug spill (if you work in pharmacy or an oncology area)
    • Mercury spill
    • Radioactive material spill
    • If you work with these agents, you MUST know how to manage a spill. Refer to the VUMC Emergency Operations Quick Reference Guide.

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Social Environment (For patient-care areas)

  1. What special accommodations are made in your work area to ensure patient privacy?
    • List special accommodations such as private rooms, privacy curtains/screens, individual telephones for each patient
  2. What special accommodations are made in your work area to provide a care site that is suitable for the patient's age, developmental level and clinical status?
    • List the special patient care features that make your unit unique. For example, the Peds area has a classroom, children's videos, the Child Life Center, special decorations and furnishings that cater to children. The Subacute Unit has a community room where entertainment activities are planned. 

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About the Joint Commission on Accreditation of Healthcare Organizations: 

Vanderbilt University Medical Center is accredited by the Joint Commission on Accreditation of Healthcare Organizations.

The Joint Commission is an independent, not-for-profit organization charged with establishing standards and accrediting health care organizations. JCAHO evaluates and accredits nearly 18,000 health care organizations and programs in the United States.

JCAHO accreditation is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. To earn and maintain accreditation, an organization must undergo an on-site survey by a JCAHO survey team at least every three years.

Vanderbilt University Medical Center's last accreditation survey was in June, 2003. The next JCAHO survey will be unannounced and take place between January 1 and December 31, 2006. Since the survey is unannounced, faculty and staff within the organization will be informed of a survey via an overhead announcement using the VUMC standard emergency preparedness terminology: Yellow and Orange Alert. The overhead announcement that will be used to alert staff that surveyors are on-site is “Orange Alert - Survey.”

JCAHO's standards address the organization's level of performance in key functional areas, such as patient rights, patient treatment, and infection control. The standards focus not simply on what the organization has, but what it does. Safety-related standards are established in many of the chapters. However the primary safety emphasis is under the Environment of Care chapter.

JCAHO Environment of Care standards are pivotal for the ongoing operation and improvement efforts in making Vanderbilt University Medical Center a safe and healthy environment for patients, visitors, staff and employees. All work must be conducted in such a manner as to ensure your safety and the safety of others around you, and to protect the environment.

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VUMC Environment of Care
Introduction

The Vanderbilt University Medical Center Safety Program is dedicated to continual improvement of health, safety and environmental compliance at this institution. To foster this improvement, there are Safety and Health policies, procedures, and guidelines that closely align the Environment of Care (EC) philosophy established by JCAHO and the needs of the Medical Center.

The JCAHO Environment of Care (EC) function has nine primary standards. The JCAHO standard and VUMC response are briefly summarized below. JCAHO’s requirement for ongoing training for EC issues was moved from the EC chapter to the HR chapter. That information is also included below. A complete copy of the JCAHO standards (Comprehensive Accreditation Manual for Hospitals) is available to Vanderbilt faculty and staff through the Eskind Library website.

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Safety Management Plan

EC.1.10
Each organization has inherent safety risks associated with providing services for patients, the performance of daily activities by staff, and the physical environment in which service occur. It is important that each organization identifies these risks and plans and implements processes to minimize the likelihood of those risks causing incidents.

In response to EC.1.10, the VUMC Safety Management Plan includes the following Elements of Performance:

  1. Developing and maintaining a written safety management plan describing the processes to effectively manage the environmental safety of patients, staff, and other people coming to the organization’s facilities.
  2. Identifying persons, as designated by leadership, to coordinate the development, implementation, and monitoring of the safety management activities.
  3. Identifying persons to intervene whenever conditions immediately threaten life or health or threaten damage to equipment or buildings.
  4. Conducting risk assessments that proactively evaluates the impact of buildings, grounds, equipment, occupants, and internal physical systems on patients and public safety
  5. Using the identified risks to select and implement improvement activities promoting safety for faculty, staff, patients and others within the organization
  6. Developing safety policies and procedures that are distributed, practiced, enforced, and reviewed as frequently as necessary, but at least every three years
  7. Responding to product safety recalls
  8. Maintaining all grounds and equipment

EC.1.20
It is essential that the organization conduct periodic environmental tours to determine if its current processes for managing patient, public, and staff safety risks are being practices correctly and are effective. These tours can also be used to assess staff knowledge and behaviors, identify now or altered risks in areas where construction or changes in services have occurred, and identify opportunities to improve the environment.

In response to EC.1.20, the VUMC Safety Management Plan includes the following Elements of Performance:

  1. Conducting environmental tours to identify environmental deficiencies, hazards, and unsafe practices.
  2. Conducting environmental tours at least every six months in all areas where individuals are served.
  3. Conducting environmental tours at least annually in areas where individuals are not served.

EC.1.30
The organization develops and implements a policy to prohibit smoking except in specified circumstance.

In response to EC.1.30, the VUMC Safety Management Plan includes the following Elements of Performance:

  1. VUMC has a policy regarding smoking in all areas of the buildings.
  2. The policy prohibits smoking in all areas of the buildings and no medical exceptions are permitted in outpatient or pediatric areas.
  3. JCAHO Standards do provide some exceptions for in-patients to smoke within the facility. However, there are no exceptions provided in the VUMC policy.
  4. Compliance is monitored by designated staff (assigned to Plant Services).

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Security Management

EC.2.10
The organization identifies and manages its security risks

In response to EC.1.20, the VUMC Security Management Plan includes the following Elements of Performance:

  1. Developing and maintaining a written security management plan describing the processes to effectively manage the security of patients, staff, and other people coming to the organization’s facilities.
  2. Designating personnel responsible for developing, implementing, and monitoring the security management activities.
  3. Providing proactive risk assessments to manages actual or potential security risks.
  4. Addressing security issues concerning patients (including patient elopement, when applicable), visitors, personnel, and property;
  5. Providing identification, as appropriate, for all patients, visitors, and staff.
  6. Controlling access to and egress from sensitive areas,
  7. Reporting and investigating all security incidents involving patients, visitors, personnel, or property.
  8. Developing and implementing security procedures that address:
    1. actions taken in the event of a security incident
    2. managing infant or pediatric abduction
    3. handling of situations involving VIPs or the media,
    4. managing vehicular access to emergency care areas

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Hazardous Materials & Waste Management

EC.3.10
The organization identifies and manages its hazardous materials and waste risks.

In response to EC.3.10, the VUMC Hazardous Materials and Waste Management Plan includes the following Elements of Performance:

  1. Developing and maintaining a written hazardous materials and waste management plan describing the processes to effectively manage the security of patients, staff, and other people coming to the organization’s facilities.
  2. Establishing written criteria consistent with applicable law and regulation (for example, Environmental Protection Agency, Occupational Safety and Health Administration) to identify, evaluate, and inventory hazardous materials and waste used or generated
  3. Selecting, handling, storing, transporting, using, labeling, and disposing of hazardous materials and waste from receipt or generation through use or final disposal. The Hazardous Materials Management Plan includes the following hazard categories:
    1. Chemicals
    2. Chemotherapeutic materials
    3. Radioactive Materials
    4. Infectious and regulated medical wastes, including sharps
  4. Providing adequate and appropriate space and equipment for safe handling and storage of hazardous materials and waste
  5. Monitoring and disposing of hazardous gases and vapors
  6. Developing and implementing emergency procedures that describe the specific precautions, procedures, and protective equipment used during hazardous materials and waste spills or exposures
  7. Maintaining hazardous materials documentation as required by law (manifests, permits, licenses)

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Emergency Management

EC.4.10
The organization addresses emergency management.

In response to EC.4.10, the VUMC Emergency Management Plan includes the following Elements of Performance:

  1. Developing and maintaining a written Emergency Management Plan describing the processes to effectively manage disaster readiness and emergency management.
  2. Conducting a hazard vulnerability analysis to identify potential emergencies that could affect the need for its services or its ability to provide those services
  3. Identifying processes for notifying staff when emergency response measures are initiated
  4. Identifying processes for notifying external authorities of emergencies
  5. Identifying and assigning staff to cover essential staff functions during emergency conditions
  6. Emergency plans that include the following provisions:
    1. Care, treatment and services for patients
    2. Staff support
    3. Staff family support
    4. Logistics for critical supplies
    5. Security/crowd control
    6. Communication (media, patients, staff)
    7. Alternate staff activities during emergencies
  7. Planning for building evacuation and establishing an alternate care site
  8. Identifying care providers and other personnel during emergencies
  9. Collaboratively planning emergency response activities with other healthcare organizations within this geographic area.
  10. Identifying means to provide backup communication systems and backup utility sources (water, power, ventilation, fuel, medical gas, etc)
  11. Identifying means for radioactive, biological and chemical isolation and decontamination

EC.4.20
The organization conducts drills regularly to emergency management.

In response to EC.4.20, the VUMC Emergency Management Plan includes the following Elements of Performance:

  1. Testing the organization’s emergency preparedness response plans at least twice annually either in response to an actual emergency or in planned drills.
  2. At least one of the annual drills/activations includes an influx of volunteers or simulated patients
  3. At least one of the annual drills/activations involves a communitywide response

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Fire Safety Management

EC.5.10
The organization manages fire risks

In response to EC.5.10, the VUMC Fire Safety Plan includes the following Elements of Performance:

  1. Developing and maintaining a written Fire Safety Management Plan describing the processes to effectively manage fire safety.
  2. Identifying proactive processes for protecting life and property from fire and smoke
  3. Identifying processes for regularly inspecting, testing and maintaining fire protection and safety systems, equipment and compartments. This includes the following components (listed in EC.5.40):
    1. Initiating devices, fire detection and alarm equipment
    2. Alarm notification devices (audible alarms, speakers, strobes)
    3. Off-premises emergency services notification
    4. Water-based automatic fire-extinguishing systems
    5. Kitchen automatic fire-extinguishing systems
    6. Gaseous automatic fire-extinguishing systems
    7. All portable fire extinguishers
    8. Fire and smoke dampers
    9. Automatic smoke-detection shutdown devices for air handling equipment
    10. Horizontal and vertical sliding and rolling fire doors

EC.5.20
Each building in which patients are housed or receive care, treatment, and services complies with the Life Safety Code, NFPA 101, 2000 edition.

EC.5.30
The organization conducts fire drills regularly.

In response to EC.5.30, the VUMC Fire Safety Plan describes how the organization accomplishes the following Elements of Performance:

  1. Conducting Fire drills quarterly on all shifts in ambulatory care and health care occupancies and annually in business occupancies
  2. Planning drills so that at least 50% are unannounced.
  3. Conducting drills to include staff participation and staff knowledge
  4. Critiquing drills to identify deficiencies and opportunities for improvement
  5. Evaluating the effectiveness of fire response training at least annually

EC.5.50
The organization develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code.

In response to EC.5.50, the VUMC Fire Safety Plan includes an organization-wide policy outlining the required measures for interim life safety measure and infection control.

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Medical Equipment Management

EC.6.10
The organization manages medical equipment risks.

In response to EC.6.10, the VUMC Medical Equipment Management Plan includes the following Elements of Performance:

  1. Developing and maintaining a written Medical Equipment Management Plan describing the processes to effectively manage the safe, effective, and reliable operation of medical equipment
  2. Identifying and implementing processes for selecting and acquiring medical equipment
  3. Establishing and using risk criteria for identifying, evaluating, and creating an inventory of equipment to be included in the medical equipment management plan
  4. Identifying appropriate inspection and maintenance strategies for all equipment on the inventory
  5. Defining intervals for inspecting, testing, and maintaining appropriate medical equipment
  6. Identifying and implementing processes for monitoring and acting on equipment hazard notices and recalls
  7. Identifying and implementing processes for emergency procedures for monitoring and reporting incidents in which a medical device is or maybe implicated in a serious injury, illness or death.
  8. Identifying and implementing processes to manage medical equipment emergencies
    1. Procedures for equipment disruption or failure
    2. Emergency clinical interventions in the event of equipment malfunction/failure
    3. Availability of back up equipment
    4. Obtaining repair services

EC.6.20
Medical equipment is maintained, tested, and inspected.

In response to EC.6.20, the VUMC Medical Equipment Management Plan includes the following Elements of Performance:

  1. Inspecting, testing, and maintaining appropriate equipment on the inventory (that is, those pieces of equipment on the inventory benefiting from scheduled activities to minimize the clinical and physical risks) based on criteria such as manufacturers' recommendations, risk levels, and current organization experience
  2. Testing all sterilizers for performance
  3. Documenting chemical and biological testing of water used in renal dialysis

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Utility Management

EC.7.10
The organization manages utility risks.

In response to EC.6.10, the VUMC Utility Management Plan includes the following components:

  1. Developing and maintaining a written Utility Management Plan describing the processes to effectively manage the safe, effective, and reliable operation of building utilities
  2. Designing and installing utility systems to meet patient care and operational needs of the organization
  3. Establishing and using risk criteria for identifying, evaluating, and creating an inventory of equipment to be included in the utility management plan
  4. Identifying appropriate inspection and maintenance strategies for all utilities on the inventory
  5. Identifying and implementing processes to minimize pathogenic biological agents in cooling towers, domestic hot/cold water systems and other aerosolizing water systems
  6. Designing, installing, and maintaining ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies to control airborne contaminants.

EC.7.20
The organization provides an emergency electrical power source.

In response to EC.7.20, the VUMC Utility Management Plan includes the following components:

  1. Providing reliable emergency power (as required by the Life Safety code) for the following:
    1. Alarm systems
    2. Exit route illumination
    3. Emergency communication systems
    4. Illumination of exit signs
  2. Providing reliable emergency power for the following:
    1. Blood, bone and tissue storage units
    2. Emergency/urgent care areas
    3. Elevators (at least one for non-ambulatory patients)
    4. Medical Air compressors
    5. Medical and surgical vacuum systems
    6. Areas where electrically powered life-support equipment is used.
    7. Operating rooms
    8. Postoperative recovery rooms
    9. Obstetrical delivery rooms
    10. Newborn nurseries

EC.7.30
The organization maintains, tests, and inspects its utility systems.

In response to EC.7.30, the VUMC Utility Management Plan includes provisions for maintaining, testing and inspecting utility systems. These systems include critical components identified in the Plan, life support utility systems, infection control utility systems, and critical components of non-life support utility systems.

EC.7.40
The organization maintains, tests, and inspects its emergency power systems.

In response to EC.7.40, the VUMC Utility Management Plan includes provisions for maintaining, testing and inspecting emergency power systems. These systems include generators, automatic transfer switches, battery-powered lights for exiting, and stored emergency power supply systems.

EC.7.50
The organization maintains, tests, and inspects its medical gas and vacuum systems.

In response to EC.7.50, the VUMC Utility Management Plan includes provisions for maintaining, testing and inspecting the medical gas and vacuum systems.

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Physical Requirements for the Environment of Care

EC.8.10
The organization establishes and maintains an appropriate environment.

In response to EC.8.10, VUMC proactively and retrospectively evaluates the physical environment for functionality and promotion of healing/caring. This evaluation process includes:

  1. Providing interior spaces which:
    1. Are Appropriate to the care, treatment, and services provided and the needs of the patients related to age and other characteristics
    2. Provide closet and drawer space according to patient needs
    3. Provide recreational interchange for patients in long term care settings
    4. Provide equipment for rehabilitation and activities for patients in long term care settings
  2. Providing furnishings and equipment that:
    1. Are safe and in good repair
    2. Reflect the patient’s level of ability/needs
    3. Normalize the patient’s living environment (long term care)
  3. Providing outside areas (as appropriate) for patients in long term care
  4. Patient care areas that are safe, clean, functional, and comfortable
  5. Lighting suitable for care, treatment, and services
  6. Ventilation appropriate for the level of care and needs of the area
  7. Door locks and other structural restraints which are consistent with needs of the patient, program policy, law and regulation
  8. Emergency access provision to all locked, occupied spaces

EC.8.30
The organization manages the design and building of the environment when it is renovated, altered, or newly created.

In response to EC.8.30, VUMC proactively and continually evaluates the physical environment during construction/renovation/repair process. This evaluation process includes:

  1. Using state rules and regulations, Guidelines for Design and Construction of Hospitals and Healthcare Facilities to provide design criteria
  2. Proactive risk assessments for all demolition, construction, or renovation projects to minimize impact to patient care

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Program Requirements for Managing the Environment of Care

EC.9.10
The organization monitors conditions in the environment.

In response to EC.9.10, the VUMC Safety Plan describes how the organization accomplishes the following Elements of Performance:

  1. Establishing and implementing processes for reporting and investigating
    1. Injuries to patients or others coming to the organization
    2. Occupational illnesses or injuries
    3. Security incidents
    4. Hazardous materials and waste spills, exposures, and other related incidents
    5. Fire safety management problems
    6. Equipment management problems
    7. Utility systems management problems
  2. Organizational leadership assigns individuals to monitor and respond to conditions in the environment of care
    1. Coordinating the collection and dissemination of hazard/recall notices
    2. Coordinating the preparation of summaries of deficiencies, problems, failures and user errors
    3. Coordinating information from performance improvement activities
    4. Participating in hazard surveillance and incident reporting
    5. Participating in safety policy and procedure development
  3. The objectives, scope, performance and effectiveness of each required Environment of Care management plan are evaluated annually.
  4. Communicating environment of care monitoring and response activities to the patient safety program and organizational leadership.

EC.9.20
The organization analyzes identified environment issues and develops recommendations for resolving them.

In response to EC.9.20, the VUMC Safety Plan describes how the organization accomplishes the following Elements of Performance:

  1. Establishing an ongoing process for resolving environment of care issues that involves representatives from clinical, administrative, and support services (VUMC Safety Committee)
  2. The VUMC Safety Committee/representatives:
    1. Meet at least bi-monthly
    2. Analyze environment of care issues in a timely manner
    3. Develop recommendations for improvement
    4. Establish measurement guidelines
    5. Report environment of care issues to organizational leaders and persons responsible for performance improvement

EC.9.30
The organization improves the environment.

In response to EC.9.30, the VUMC Safety Plan describes how the organization accomplishes the following Elements of Performance:

  1. Providing appropriate staff to implement improvement recommendations.
  2. Monitoring the effectiveness of PI recommendations
  3. Monitoring communication of PI recommendations and outcomes to organizational leadership and appropriate safety committees/teams
  4. Providing communication of PI recommendations and outcomes to organizational leadership.

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Safety Training and Knowledge Requirements

HR.2.20
Staff members, licensed independent practitioners, students and volunteers, as appropriate, can describe or demonstrate their roles and responsibilities, based on specific job duties or responsibilities, relative to safety.

The human element is the most critical factor in any process, determining whether the right things are done correctly. The best policies and procedures for minimizing risks in the environment where care, treatment, and services are provided are meaningless if staff, licensed independent practitioners, if applicable, students, and volunteers don not know and understand them well enough to perform them properly.

It is important that everyday precautions identified by the health car organization for minimizing various risks, including those related to patient safety and environmental safety are properly implemented. It is also important that the appropriate emergency procedures be instituted should an incident or failure occur in the environment.

Elements of Performance
Staff members, licensed independent practitioners, students, and volunteers, as appropriate, can describe or demonstrate the following:

  1. Risks within the hospital’s environment
  2. Actions to eliminate, minimize, or report risks
  3. Procedures to follow in the event of an incident
  4. Reporting processes for common problems, failures, and user errors.

HR.2.30
On-going education, including in-services, training, and other activities, maintains and improves competence.

Elements of Performance
The following occurs for staff, students, and volunteers who work in the same capacity as staff providing care, treatment and services

  1. Training occurs when job responsibilities or duties change
  2. Participation in ongoing in-services, training, or other activities occurs to increase staff, student or volunteer knowledge of work-related issues
  3. Ongoing in-services and other education and training are appropriate to the needs of the population(s) served and comply with law and regulation
  4. Ongoing in-services, training, or other activities emphasize specific job-related aspects of safety and infection prevention and control
  5. Ongoing in-services, training or other education incorporate methods of team training, when appropriate
  6. Ongoing in-services, training, or other education reinforce the need and ways to report unanticipated adverse events
  7. Ongoing in-services or other education are offered in response to learning needs identified through performance improvement findings and other data analysis
  8. Ongoing education is documented

 

EOC Contacts

Ken Browning
Director, VUMC Plant Services
Chair, VUMC Safety Committee
Co-Chair of the VUMC Disaster Committee
Phone: 343-4443
Email: ken.browning@vanderbilt.edu
www.mc.vanderbilt.edu/plantservices/PlantServicesHome.html

Susan Johnson, MS, MT(ASCP), OHST
Assistant Director / Medical Center Safety Officer
Vanderbilt Environmental Health and Safety
Phone: 343-2242
Email: s.johnson@vanderbilt.edu 
www.safety.vanderbilt.edu/about_staff.htm#medical_center 

Cathy Ryan, Lieutenant
Vanderbilt Police Department
Phone: 936-0683
Email: cathy.ryan@vanderbilt.edu 
police.vanderbilt.edu

Steve Grimes
Director, Clinical Engineering
Phone: 322-3440
Email: steve.grimes@vanderbilt.edu
www.mc.vanderbilt.edu/root/vumc.php?site=CEServices&doc=9705 

Andrea George, MS
Associate Director, Laboratory & Environmental Compliance
Vanderbilt Environmental Health and Safety
Phone: 322-4551
Email: andrea.george@vanderbilt.edu 
www.safety.vanderbilt.edu/about_staff.htm#waste 

Pam Hoffner, MSN
Emergency Preparedness Coordinator
Phone: 322-0242
Email: pam.hoffner@vanderbilt.edu
www.mc.vanderbilt.edu/ep

Susan Moseley, RN, MSN
Director, Accreditation and Standards
Center for Clinical Improvement
Phone: 343-1424
email: susan.moseley@vanderbilt.edu 
www.mc.vanderbilt.edu/cci/team/moseleys.html 

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