Annual Evaluation of the Environment of Care Safety Management Plans - 2017

TEMPLATES FOR ANNUAL EVALUATION OF THE ENVIRONMENT OF CARE MANAGEMENT PLANS

...... Sa fety...... 1

...... Se curity...... 13

...... Ha zardous Materials and Waste ...... 19

...... Fir e Safety...... 28

 Medical Equipment...... 37

...... Uti lity Systems...... 48

U.S. Army Public Health Center 5158 Blackhawk Road Aberdeen Proving Ground, MD 21010

December 2017

2 OFFICE SYMBOL 2 January 2018

MEMORANDUM THRU: Safety/Environment of Care (EC) Committee

FOR: Executive Committee

SUBJECT: Evaluation of the 2017 Safety Management Plan

1. Reference. The Joint Commission (TJC) SELECT REFERENCE, Oakbrook Terrace, Illinois, 2017.

2. Purpose. The purpose of this evaluation is to measure and document the extent that the HEALTHCARE FACILITY NAME managed safety and health risks in the physical environment in 2017. This evaluation includes an assessment of the Safety Management Plan’s scope, objectives, performance and effectiveness along with the performance of the HEALTHCARE FACILITY NAME safety and health policies and processes. In addition, this evaluation contains several recommendations for improvement in 2018.

3. Scope. There were no changes in—

a. Buildings, grounds, equipment and patient care services used to provide quality healthcare to Soldiers and other recipients.

b. Staff, patients, visitors, vendors, contractors and the general public who use our facilities.

c. Hours of operation. d. Relevant laws, regulations, standards or guidelines. The TJC revised the EC standards and they will become effective in 2018. These revisions will not require major changes to the 2018 management plan.

4. Objectives. The 2017 performance objectives were—

a. Effectively manage safety and health risks through regulatory compliance and by using best industry practices.

b. Optimize resources by using efficient safety and health processes.

c. Improve staff performance through effective safety and health education and training.

3 d. Improve staff and patient satisfaction by providing a safe physical environment.

e. These objectives are consistent with the HEALTHCARE FACILITY NAME 2017 mission and they require no major change.

5. Performance.

a. The primary performance improvement intiative for 2017 was 95% of all mishaps requiring medical treatment or property damage are reported to the Safety Office within 24 hours of the incident. See discussion in the following table and graph for details.

Performance Objective Performance Indicator(s) Performance Result (Examples) (Examples)

Improve Physical, Ethical & Example: Indicator - # Discussion Cultural Environments. reports received by the Example: Effectively Safety Office within 24 -What was your goal? manage safety and health hours of the incident -Describe criteria used to risks through regulatory determine when you compliance and by using Example Performance reached your goal. best industry Improvement (PI) practices/internal processes. Standard: 95% of all -Describe actions taken to Manage risk by promptly mishaps requiring medical achieve your goal. reporting and investigating treatment or property -Discuss the results. mishaps. damage are reported to Consider using graphs, the Safety Office within 24 charts, dashboards, etc. hours of the incident. See example chart below. Optimize financial resources. Example: % reduction in -Was the goal met? Why Example: Optimize civilian worker’s or why not? resources by using efficient compensation -Was the goal sustained? safety and health processes. % reduction military off Specifically reducing loss duty lost time -What was the impact to resulting from workplace % reduction military on the healthcare facility? accidents and incidents. duty lost time -If the goal was not met, $ reduction of incidents what actions are needed involving property damage to achieve it? Improve & Empower Highly Example: % staff Effective Work Teams. competency based folders Example: Improve staff containing documentation performance through showing mandatory safety effective safety and health training is satisfactorily education and training. completed. Specifically, verifying that staff attends mandatory Performance Objective Performance Indicator(s) Performance Result (Examples) (Examples) safety training.

Healthy & Satisfied Families Example: 95% of staff and Beneficiaries. Example: have a positive perception Improve staff and patient of Leadership’s satisfaction by providing a commitment to safety safe physical environment. Specifically, staff feedback shows that Leadership supports the Safety Program.

b. Additional performance improvement initiatives were—

(1) LIST AND DISCUSS.

6. Effectiveness. The following table summarizes the HEALTHCARE FACILITY NAME compliance with the safety and health processes necessary for maintaining an effective Safety Program. Risk Complianc Risk Action Plan Managemen Process e Assessment1 to Correct t Activity

Identify an individual to manage risk, coordinate risk reduction activities, collect deficiency (injuries, problems, user errors, etc.) SAFER Status information and Matrix disseminate summaries of actions and results (EC.01.01.01, Element Plan of Performance (EP).1).

Maintain a comprehensive Safety Management Plan that addresses the specific risks and unique SAFER Status conditions at each Matrix patient care site. The written plan is readily available for review (EC.01.01.01, EP.3).

Maintain education and training programs to teach staff the methods for eliminating hazards and minimizing risks SAFER Teach Status within the workplace, Matrix how to respond to an emergency, and how to report safety hazards (EC.03.01.01, EP. 2)

1 High = Harm could happen at any time; Moderate = Harm could happen occaisionally; Low = Harm could happen, but would be rare; Limited = Unique occurrence that is not representative of routine/regular practice; Pattern = Multiple occurrences with potential to impact few/some patients, vistiors, staff and/or settings; Widespread = Multiple occurrences with potential to impact most/all patients, visitors, staff and/or settings. Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

Implement Conduct and document comprehensive risk assessments to identify, prioritize, and implement corrective action plans to SAFER eliminate safety and Status Matrix health hazards and/or minimize risk. Documentation is readily available for review (EC.02.01.01, EP.1 & 3)

Conduct and document solution-focused risk assessments to manage hazards for which safety and health SAFER Status standards are absent Matrix and a clear resolution is not obvious (EC.02.01.01, EP.1 & 3)

Conduct risk assessments that identify environmental features that may increase or decrease SAFER the risk for suicide. Status Matrix The documentation is readily available for review (National Patient Safety Goals (NPSG).15.01.01)

Maintain grounds and SAFER equipment Status Matrix (EC.02.02.02, EP.5)

Respond to all product Status SAFER Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

notices and recalls Matrix (EC.02.01.01, EP.11)

Manage magnetic resonance imaging (MRI) patient and staff SAFER Status safety risks Matrix (EC.02.01.01, EP.14 &16)

Enforce the Commander’s Smoking Policy. The written SAFER policy is readily Status Matrix available for review (EC.02.01.03, EP.1 & 6)

Maintain interior spaces in a safe manner and according SAFER Status to the needs of the Matrix patients (EC.02.06.01, EP.1)

Maintain lighting that is suitable for care, SAFER Status treatment, and services Matrix (EC.02.06.01, EP.11)

Maintain ventilation, temperature, and humidity levels suitable SAFER Status for care, treatment and Matrix services provided (EC.02.05.01 EP.16)

Maintain patient care Status SAFER areas in a clean and Matrix odor free manner (EC.02.06.01, EP.20) Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

Maintain furnishings and equipment in a SAFER safe manner and in Status Matrix good repair (EC.02.06.01, EP.26)

Follow regulations and SAFER use reputable Matrix standards and guidelines when Status planning design criteria for new or altered space (EC.02.06.05, EP.1)

Conduct a Status preconstruction risk assessment when SAFER planning for demolition, Matrix construction or renovation (EC.02.06.05, EP.2)

Minimize risks in occupied spaces during construction, SAFER Status demolition or Matrix renovation (EC.02.06.05, EP.3)

Conduct structural shielding design assessments before installing new or replacing CT, PET, & NM equipment and SAFER Status modifying rooms where Matrix ionizing radiation will be emitted or radioactive materials will be stored (EC.02.06.05, EP.4) Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

Conduct a radiation protection survey after installation of CT, PET, & NM equipment and after modifying rooms where where ionizing SAFER Status radiation will be emitted Matrix or radioactive materials will be stored to verify adequacy of installed shielding (EC.02.06.05, EP.6)

Include procedures for providing safety in- house during an SAFER emergency in the Status Matrix Emergency Operation’s Plan (EM.02.02.05, EP.1)

Monitor safety during all emergency SAFER Status Respond response exercises Matrix (EM.03.01.03, EP.9)

Report and investigate patient and visitor injuries and occupational injuries SAFER Status and illnesses and Matrix property damage (EC.04.01.01, EP.1, 3, 4, & 5)

Monitor Evaluate the Safety Status SAFER Management Plan Matrix within prescribed time frames. The written evaluation is readily available for review (EC.04.01.01, EP.15) Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

Analyze data to identify and resolve safety SAFER Status issues (EC.04.01.03, Matrix EP.2)

Verify that safety issues are effectively SAFER Improve Status resolved (EC.04.01.05, Matrix EP.1)

7. Recommendations.

a. Based on the risk assessment and monitoring data results, the following performance objectives are recommended to improve the Safety Program in 2018—

(1) LIST AND DISCUSS. Discussion should include─ (a) What is your goal? (b) Is it measurable? (c) Is your goal written in a SMARTER performance measure format? (d) What constraints do you have (time, money, other resources)? (e) What are the steps you will take to meet your goal? (f) How will you prioritize these steps? (g) What data do you need to collect and evaluate? (h) How will you collect and report the data? (i) How often will you collect and report the data? (j) How will you explain your goal to your staff so that they know what is being measured? (k) To accurately compare data overtime, will you need to make adjustments due to changes in variables, such as sample size or quantity?

b. The Safety Manager will implement the action plans by 30 January 2018, collect and analyze data and report the results to the Safety/EC committee CHOOSE FREQUENCY.

8. Conclusion. The Safety Management Plan provides a strong framework for the effective and efficient management of actual and potential safety and health risks at HEALTHCARE FACILITY NAME. This conclusion is derived from the HEALTHCARE FACILITY NAME accomplishments related to activities such as—

a. Identifying and managing safety and health risks b. Conducting safety and health education and training

c. Responding to safety and health accidents, injuries, illnesses, and reports of unsafe/unhealthy working environment

d. Monitoring performance

e. Accomplishing improvements necessary to eliminate hazards, manage risk, and maintain a safe physical environment.

NAME RANK JOB TITLE

Approved: Date: NAME 16 January 2018

Safety/EC Committee Chairperson OFFICE SYMBOL 2 January 2018

SUBJECT: Evaluation of the 2017 Security Management Plan

2. Purpose. The purpose of this evaluation is to measure and document the extent that the HEALTHCARE FACILITY NAME managed security risks in the physical environment in 2017. This evaluation includes an assessment of the Security Management Plan’s scope, objectives, performance and effectiveness along with the performance of the HEALTHCARE FACILITY NAME security policies and processes. In addition, this evaluation contains several recommendations for improvement in 2018.

c. Hours of operation.

d. Relevant laws, regulations, standards or guidelines. The TJC revised the EC standards and they will become effective in 2018. These revisions will not require major changes to the 2018 management plan.

4. Objectives. The 2017 performance objectives were—

a. Effectively manage security risks through regulatory compliance and by using best industry practices.

b. Optimize resources by using efficient security processes.

c. Improve staff performance through effective security education and training. d. Improve staff and patient satisfaction by providing a secure physical environment.

e. These objectives are consistent with the HEALTHCARE FACILITY NAME 2017 mission and they require no major modification.

5. Performance.

a. The primary performance improvement initiative for 2017 was 98% of all background checks will be completed within 30 days of hire. See discussion in the following table and graph for details.

Performance Objective Performance Indicator(s) Performance Result

Improve Physical, Ethical & Example: % background Discussion Cultural Environments. checks completed within Example: Effectively 30 days of hire -What was your goal? manage security risks risks -Describe criteria used to through regulatory Example: 98% of determine when you compliance and by using background checks for reached your goal. best industry new hires will be practices/internal processes. completed within 30 days. -Describe actions taken to Specifically, manage risk achieve your goal. through the prompt -Discuss the results. completion of background Consider using graphs, checks. charts, dashboards, etc. See example chart below. Optimize financial resources. Example: $ spent on key Example: Optimize control/replacement -Was the goal met? Why resources by using efficient or why not? security processes. -Was the goal sustained? Specifically, reducing costs associated with key -What was the impact to control/replacement. the healthcare facility? -If the goal was not met, Improve & Empower Highly Example: % staff, what actions are needed Effective Work Teams. contractors, and to achieve it? Example: Improve staff volunteers who can performance through articulate the process for effective security education reporting and responding and training. Specifically, to a lost or missing child verify that staff can properly code. respond to a lost/missing child code.

Healthy & Satisfied Families Example: % security

14 and Beneficiaries. Example: issues (identified on Improve staff and patient patient surveys/employee satisfaction, by providing a perception surveys) secure physical environment. effectively resolved each Specifically, responding to quarter. staff and patient security concerns

6. Effectiveness. The following table summarizes the HEALTHCARE FACILITY NAME compliance with security processes necessary for maintaining a successful Security Program.

15 Risk Complianc Risk Action Plan to Managemen Process e Assessment2 Correct t Activity

Maintain a comprehensive Security Management SAFER Plan Plan. The written plan Status Matrix is readily available for review (EC.01.01.01, EP.4)

Maintain education and training programs to teach staff the methods for eliminating hazards and minimizing SAFER Teach security risks within Status Matrix the workplace, how to respond to a security emergency, and how to report security issues/concerns (EC.03.01.01, EP.2)

Implement Conduct comprehensive risk assessments to SAFER identify and prioritize Status Matrix security risks for corrective action (EC.02.01.01, EP.1)

Conduct solution- Status SAFER focused risk Matrix assessments to manage hazards for which security standards are absent

2 High = Harm could happen at any time; Moderate = Harm could happen occaisionally; Low = Harm could happen, but would be rare; Limited = Unique occurrence that is not representative of routine/regular practice; Pattern = Multiple occurrences with potential to impact few/some patients, vistiors, staff and/or settings; Widespread = Multiple occurrences with potential to impact most/all patients, visitors, staff and/or settings.

16 Risk Complianc Risk Action Plan to Managemen Process e Assessment Correct t Activity

and a clear resolution is not obvious (EC.02.01.01, EP.1 & 3)

Identify all individuals entering the SAFER HEALTHCARE Status Matrix FACILITY’s buildings (EC.02.01.01, EP.7)

Identify and control access to security SAFER Status sensitive areas Matrix (EC.02.01.01, EP.8)

Develop effective, written procedures for responding to security incidents, including an infant or pediatric SAFER Status abduction. The Matrix emergency response plans are readily available for review (EC.02.01.01, EP.9)

Respond Include procedures for providing internal security during an emergency in the Emergency Operation Status SAFER Plan (EOP) Matrix (Emergency Management, EM.02.02.05, EP.1)

Identify roles that Status SAFER community security Matrix agencies will provide in the event of an emergency and

document this information in the EOP (EM.02.02.05, EP.2)

Coordinate security activities with the community security SAFER Status agencies during an Matrix emergency (EM.02.02.05, EP.3)

During a security incident, follow SAFER Status identified procedures Matrix (EC.02.01.01, EP.10)

Control movement into, out of, and within the HEALTHCARE SAFER FACILITY during an Status Matrix emergency (EM.02.02.05, EP.7. & 8)

Control vehicular access to the HEALTHCARE SAFER Status FACILITY during an Matrix emergency (EM.02.02.05, EP.9)

Monitor security during all emergency SAFER Status response exercises Matrix (EM.03.01.03, EP.9)

Report and investigate security incidents involving patients, SAFER Status staff, or others Matrix (EC.04.01.01, EP.1 & 6)

Evaluate the Security Management Plan within prescribed time SAFER frames. The written Status Matrix evaluation is readily Monitor available for review (EC.04.01.01, EP.15)

Analyze data to identify and resolve SAFER Status security issues Matrix (EC.04.01.03, EP.2)

Verify that security issues are effectively SAFER Improve Status resolved Matrix (EC.04.01.05, EP.1)

7. Recommendations.

a. Based on the risk assessment and monitoring data results, the following performance objectives are recommended to improve the Security Program in 2018—

19 b. The Security Manager will implement the action plans by 30 January 2018, collect and analyze data and report the results to the Safety/EC committee CHOOSE FREQUENCY.

8. Conclusion. The Security Management Plan provides a strong framework for the effective and efficient management of actual and potential security health risks at HEATHCARE FACILITY NAME. This conclusion is derived from the HEALTHCARE FACILITY NAME accomplishments related to activities such as—

a. Identifying and managing security risks

b. Conducting security education and training

c, Responding to security incidents

e. Accomplishing improvements necessary to eliminate hazards, reduce risk, and maintain a secure/safe physical environment.

NAME RANK JOB TITLE

Approved: Date:

NAME 16 January 2017

Safety/EC Committee Chairperson

SUBJECT: Evaluation of the 2017 Hazardous Materials and Waste Management (HMW) Plan

2. Purpose. The purpose of this evaluation is to measure and document the extent that the HEALTHCARE FACILITY NAME managed HMW risks in the physical environment in 2017. This evaluation includes an assessment of the HMW Management Plan’s scope, objectives, performance, and effectiveness along with the performance of the HEALTHCARE FACILITY’s HMW policies and processes associated with hazardous chemicals and waste, hazardous drugs, infectious materials, regulated medical waste (RMW), and ionizing and non ionizing radiation. In addition, this evaluation contains several recommendations for improvement in 2018.

a. Buildings, grounds, equipment, and patient care services used to provide quality healthcare to Soldiers and other recipients.

b. Staff, patients, visitors, vendors, contractors, and the general public who use our facilities.

4. Objectives. The 2017 objectives were—

a. Effectively manage HMW risks through regulatory compliance and by using best industry practices.

b. Optimize resources by using efficient HMW processes.

c. Improve staff performance through effective HMW education and training.

e. These objectives are consistent with the HEALTHCARE FACILITY NAME 2018 mission and they require no major modifications.

5. Performance.

a. The primary performance improvement initiative for 2017 was 98% of work areas audited each quarter will demonstrate that 100% of the required SDS are kept in a readily accessible location within the work area. See discussion in the following table and graph for details.

Performance Indicator(s) Performance Objective SMART Performance Performance Result Measure

Improve Physical, Ethical & Example: % SDS Discussion Cultural Environments. maintained at work areas Example: Effectively 98% of work areas audited -What was your goal? manage HMW risks through each quarter will -Describe criteria used to regulatory compliance and by demonstrate that 100% of determine when you using best industry the required SDS are kept reached your goal. practices/internal processes. in a readily accessible Specifically, implement location -Describe actions taken to procedures to make critical achieve your goal. information related to the -Discuss the results. safe use, storage, and Consider using graphs, disposal of hazardous charts, dashboards, etc. chemicals available to staff. See example chart below. Optimize financial resources. Example: $ spent on -Was the goal met? Why Example: Optimize hazardous waste disposal or why not? resources by using efficient -Was the goal sustained? HMW processes. Specifically, reduce costs -What was the impact to associated with hazardous the healthcare facility? waste disposal. -If the goal was not met, what actions are needed Improve & Empower Highly Example: # staff to achieve it? Effective Work Teams. satisfactorily completing Example: Improve staff annual radiation safety performance through training effective HMW education and training. Specifically, providing personnel working with nuclear and radioactive

22 Performance Indicator(s) Performance Objective SMART Performance Performance Result Measure materials critical safety and health training.

Healthy & Satisfied Families Example: # complaints and Beneficiaries. Example: regarding “green” Improve staff and patient disinfectants satisfaction by providing a safe physical environment. Specifically, reduce staff and patient complaints related to the physical environment.

6. Effectiveness. The following table summarizes the HEALTHCARE FACILITY NAME compliance with the HMW processes necessary for maintaining a successful HMW Program.

Risk Complianc Risk Action Plan to Managemen Process e Assessment3 Correct t Activity

Plan Maintain a Status SAFER comprehensive HMW Matrix Management Plan. The written plan is readily available for

3 High = Harm could happen at any time; Moderate = Harm could happen occaisionally; Low = Harm could happen, but would be rare; Limited = Unique occurrence that is not representative of routine/regular practice; Pattern = Multiple occurrences with potential to impact few/some patients, vistiors, staff and/or settings; Widespread = Multiple occurrences with potential to impact most/all patients, visitors, staff and/or settings.

review (Environment of Care (EC).01.01.01, Elements of Performance (EP).5)

Maintain education and training programs to teach staff the techniques for working safely with HMW, eliminating hazards, SAFER Teach Status minimizing risks within Matrix the workplace, how to respond to an emergency, and how to report hazards (EC.03.01.01, EP.2)

Implement Conduct comprehensive risk assessments to SAFER identify and prioritize Status Matrix HMW hazards for corrective action (EC.02.01.01, EP.1)

Conduct solution- focused risk assessments to manage HMW hazards for which safety and SAFER environmental Status Matrix standards are absent and a clear resolution is not obvious (EC.02.01.01, EP.1 & 3)

Maintain a current, Status SAFER written HMW Matrix inventory. The written inventory is available

for review (EC.02.02.01, EP.1)

Maintain written effective spill response procedures. The SAFER written spill response Status Matrix procedures are available for review (EC.02.02.01, EP.3)

Monitor staff during an actual or simulated SAFER spill to verify that they Status Matrix respond correctly (EC.02.02.01, EP.4)

Develop controls to manage HWM from SAFER Status cradle to grave Matrix (EC.02.02.01, EP.5)

Develop controls to manage radioactive SAFER materials from cradle Status Matrix to grave (EC.02.02.01, EP.6)

Develop controls to manage hazardous SAFER Status energy sources Matrix (EC.02.02.01, EP.7)

Manage the handling and disposal of hazardous drugs (EC.02.02.01, EP.8 SAFER Status and Medication Matrix Management (MM.01.01.03, EP.1, 2, & 3)

Manage the disposal Status SAFER

of regulated medical waste (Infection Matrix Control (IC).02.01.01, EP.6)

Develop controls to manage exposure to SAFER hazardous gases and Status Matrix vapors (EC.02.02.01, EP.9)

Monitor occupational exposures to SAFER hazardous gases and Status Matrix vapors (EC.02.02.01, EP.10)

Maintain permits, licenses, manifests, and MSDS. The SAFER documentation is Status Matrix readily available for review (EC.02.02.01, EP.11)

Label HMW SAFER Status (EC.02.02.01, EP.12) Matrix

Where computed tomography (CT), positron emission tomography (PET), or nuclear medicine (NM) SAFER services are provided, Status Matrix a radiation safety officer reviews staff dosimitery monitoring results quarterly (EC.02.02.01, EP17)

Respond Include procedures for Status SAFER managing HMW in the Matrix

Emergency Operation Plan (Emergency Management (EM).02.02.05, EP.4)

Include procedures for Status radioactive, biological, and chemical isolation SAFER and decontamination Matrix in the Emergency Operations Plan (EM.02.02.05, EP.5)

Report and investigate HMW spills and SAFER exposures Status Matrix (EC.04.01.01, EP.1 & 8)

Evaluate the HMW Management Plan within prescribed timeframes. The SAFER Status written evaluation is Matrix readily available for review (EC.04.01.01, Monitor EP.15)

Monitor response to emergencies involving chemicals, infectious SAFER Status agents, and/or Matrix radiation (EM.03.01.03, EP.9)

Improve Analyze data to Status SAFER identify and resolve Matrix HMW issues (EC.04.01.03, EP.2)

Verify that HMW issues are effectively SAFER Status resolved (EC.04.01.05, Matrix EP.1)

7. Recommendations.

a. Based on the risk assessment and monitoring data results, the following performance objectives are recommended to improve the HMW Program in YEAR—

b. The Environmental Science and Engineering Officer will implement the action plans by 30 January 2018, collect and analyze data, and report the results to the Safety/EC Committee CHOOSE FREQUENCY.

8. Conclusion. The HMW Management Plan provides a strong framework for the effective and efficient management of actual and potential HMW risks at HEALTHCARE FACILITY NAME. This conclusion is derived from the HEALTHCARE FACILITY NAME accomplishments related to activities such as—

a. Identifying and managing HMW risks

b. Conducting HMW and environmental education and training

c. Responding to HMW spills

28 d. Monitoring performance

NAME RANK JOB TITLE

Approved: Date:

SUBJECT: Evaluation of the 2017 Fire Safety Management Plan

1. Reference. The Joint Commission (TJC) SELECT REFERENCE, Oakbrook Terrace, Illinois, YEAR.

2. Purpose. The purpose of this evaluation is to measure and document the extent that the HEALTHCARE FACILITY NAME managed fire safety risks in the physical environment in 2017. This evaluation includes an assessment of the Fire Safety Management Plan’s scope, objectives, performance, and effectiveness along with the performance of the HEALTHCARE FACILITY’s fire safety policies and processes. In addition, this evaluation contains several recommendations for improvement in 2018.

4. Objectives. The 2017 Fire Safety Management Plan objectives were—

a. Effectively manage fire safety risks through regulatory compliance and by using best industry practices.

b. Optimize resources by using efficient fire safety processes and lifecycle management of facilities.

c. Improve staff performance through effective fire safety education and training.

e. These objectives are consistent with the HEALTHCARE FACILITY NAME 2017 mission and they require no major modification.

5. Performance.

a. The primary performance improvement initiative for 2017 was 98% of life safety deficiencies will be corrected within 60 days after identification. A time-limited waiver will be requested within 30 days following and on-site survey for all LSC deficiencies that cannot be corrected within the 60 day time-frame. See discussion in the following table and graph for details.

Performance Objective Performance Indicator Performance Result

Accountable, Reliable, and Example: % LSC Discussion Effective Health Services. deficiencies corrected ≤ 60 Example: Effectively days following -What was your goal? manage fire safety risks identification during an on- -Describe criteria used to through regulatory site survey. determine when you compliance and by using reached your goal. best industry Example: 98% of practices/internal processes. identified LSC deficiencies -Describe actions taken to Specifically, managing risk will be corrected ≤ 60 days achieve your goal. through the prompt after identification during -Discuss the results. correction of Life Safety an on-site survey. Consider using graphs, Code (LSC) deficiencies. charts, dashboards, etc. See example chart below. Conserve Resources. Example: % reduction in Example: Optimize the # failures for each root -Was the goal met? Why resources by using efficient cause category or why not? fire safety processes and -Was the goal sustained? lifecycle management of facilities. Specifically, -What was the impact to investigate, identify the root the healthcare facility? cause of equipment failures, -If the goal was not met, and prevent reoccurrence. what actions are needed to achieve it? Build and Prepare the Team. Example: % Staff who Example: Improve staff respond correctly during a performance through fire drill/emergency effective fire safety education and training. Specifically, verifying that staff respond correctly during an actual or simulated fire emergency. Performance Objective Performance Indicator Performance Result

Consistent Patient Example: # staff Experience. Example: complaints regarding false Improve staff and patient alarms satisfaction by providing a safe physical environment. Specifically, reducing the number of complaints due to false alarms.

6. Effectiveness. The following table summarizes the HEALTHCARE FACILITY NAME compliance related to the fire safety processes necessary for maintaining a successful Fire Safety Program—

Risk Complianc Risk Action Plan to Managemen Process e Assessment4 Correct t Activity

Maintain a comprehensive Fire Safety Management Plan. The written plan SAFER Plan is readily available for Status Matrix review (Environment of Care (EC).01.01.01, Elements of Performance (EP).6)

Teach Implement effective Status SAFER

4 High = Harm could happen at any time; Moderate = Harm could happen occaisionally; Low = Harm could happen, but would be rare; Limited = Unique occurrence that is not representative of routine/regular practice; Pattern = Multiple occurrences with potential to impact few/some patients, vistiors, staff and/or settings; Widespread = Multiple occurrences with potential to impact most/all patients, visitors, staff and/or settings. Risk Complianc Risk Action Plan to Managemen Process e Assessment Correct t Activity

education and training programs to teach staff the methods for eliminating fire hazards and minimizing risks within Matrix the workplace, how to respond to a fire emergency, and how to report fire safety hazards (EC.03.01.01, EP.2)

Implement Conduct global risk assessments to identify and prioritize SAFER Status fire hazards for Matrix corrective action (EC.02.01.01, EP.1)

Conduct focused risk assessments to eliminate fire hazards for which safety SAFER standards are absent Status Matrix and a clear resolution is not obvious (EC.02.01.01, EP.1 & 3)

Minimize the potential for harm from fire, SAFER smoke, and products Status Matrix of combustion (EC.02.03.01, EP.1)

Enforce the Commander’s SAFER Status Smoking Policy Matrix (EC.02.03.01, EP.6)

Maintain free and Status SAFER Risk Complianc Risk Action Plan to Managemen Process e Assessment Correct t Activity

unobstructed access to all exits Matrix (EC.02.03.01, EP.4)

Develop and disseminate a written Fire Response Plan that describes staff roles regarding sounding of alarms, containing smoke and SAFER fire, use of fire Status Matrix extinguishers, and relocation and evacuation procedures. The written plan is readily available for review (EC.02.03.01, EP.9)

Conduct fire drills at requisite frequencies of which 50% are unannounced. SAFER Status Documentation is Matrix readily available for review (EC.02.03.03, EP.1, 2, & 3)

Monitor staff response SAFER to fire alarms Status Matrix (EC.02.03.03, EP.4)

Evaluate and Status SAFER document fire safety Matrix equipment, building features, and staff response during fire drills. Written evaluations are readily available for review (EC.02.03.03, Risk Complianc Risk Action Plan to Managemen Process e Assessment Correct t Activity

Maintain fire safety equipment and building features. Maintenance SAFER documentation is Status Matrix readily available for review (EC.02.03.05, EP.1 through EP.20, 25 & 27)

Designated individuals perform a building assessment to determine LSC compliance and manage the SAFER Status Statement of Matrix Conditions. Documentation is readily available for review (LS.01.01.01, EP.1, & 2)

Maintain current and accurate drawing denoting fire safety features and square SAFER footage Status Matrix Documentation is readily available for review (LS. 01.01.01, EP.3.

Meet 60 day time Status SAFER frame to resolve LSC Matrix deficiencies listed on a Survey-Related PFI or request a time-limited waiver within 30 days of the survey when Risk Complianc Risk Action Plan to Managemen Process e Assessment Correct t Activity

corrective action(s) will exceed 60 days. (EC.01.01.01, EP.4)

Implement interim life safety measures (ILSM) when the LSC is not met or during periods of SAFER Status construction. The Matrix written ILSM policy is readily available for review (LS.01.02.01, EP.1 through 15)

Include horizontal, vertical, and total evacuation procedures in the SAFER Status Emergency Operation Matrix Plan (Emergency Management (EM).02.02.11, EP.3)

Monitor evacuation procedures during Respond SAFER emergency response Status Matrix exercises (EM.03.01.03, EP.9 )

Report and investigate fire safety management SAFER problems, Status Matrix deficiencies, and failures (EC.04.01.01, EP.1 & 9) Risk Complianc Risk Action Plan to Managemen Process e Assessment Correct t Activity

Evaluate the Fire SAFER Safety Management Matrix Plan within prescribed timeframes. The Monitor Status written evaluation is readily available for review (EC.04.01.01, EP.15)

Analyze data to identify and resolve SAFER Status fire safety issues Matrix (EC.04.01.03, EP.2) Improve Verify that fire safety issues are effectively SAFER Status resolved Matrix (EC.04.01.05, EP.1)

7. Recommendations.

a. Based on the 2017 risk assessment and monitoring data results, the following performance objectives are recommended to improve the Fire Safety Program in 2018

(2) LIST AND DISCUSS. b. The Facility and Safety Managers will implement the action plans by 30 January 2018, collect and analyze data, and report the results to the Safety/EC Committee CHOOSE FREQUENCY.

8. Conclusion. The Fire Safety Management Plan provides a strong framework for the effective and efficient management of actual and potential fire safety risks at HEALTHCARE NAME. This conclusion is derived from the HEALTHCARE NAME accomplishments related to activities such as—

a. Identifying and managing fire and life safety risks

b. Conducting fire and life safety education and training

c. Managing life safety system failures and building deficiencies

NAME RANK JOB TITLE

Approved: Date:

SUBJECT: Evaluation of the 2017 Medical Equipment Management Plan

2. Purpose. The purpose of this evaluation is to measure and document the extent that the HEALTHCARE FACILITY NAME managed medical equipment risks in the physical environment in 2017. This evaluation includes an assessment of the Medical Equipment Management Plan’s scope, objectives, performance and effectiveness along with the performance of the HEALTHCARE FACILITY NAME medical equipment policies and processes. In addition, this evaluation contains several recommendations for improvement in 2018.

4. Objectives. The 2017 Medical Equipment Plan objectives were—

a. Effectively manage medical equipment risks through regulatory compliance and by using best industry practices.

b. Optimize resources by using efficient medical equipment processes and lifecycle management of equipment.

c. Improve staff performance through effective medical equipment education and training.

d. Improve staff and patient satisfaction by providing a safe physical environment. e. These objectives are consistent with the HEALTHCARE FACILITY NAME 2018 mission and they require no major modifications.

5. Performance.

a. The primary performance improvement initiative for 2017 was 95% of equipment requiring DD Forms 2163 have current, legible stickers attached to the devices.

Performance Objective Performance Indicator Performance Result

Improve Physical, Ethical & Example: % devices that Discussion Cultural Environments. have current Department Example: Effectively of Defense (DD) Forms -What was your goal? manage medical equipment 2163, Medical Equipment -Describe criteria used to risks through regulatory Verification/Certification determin when you compliance and by using stickers reached your goal. best industry practices (internal processes). Example: 95% of -Describe actions taken to Specifically, making sure that equipment requiring DD achieve your goal. all medical equipment 2163s will have current, -Discuss the results. requiring calibration legible stickers attached to Consider using graphs, verification/certification are the devices charts, dashboards, etc. inspected, calibrated, and See example chart below. tagged appropriately. -Was the goal met? Why or why not? Optimize financial resources. Example: # man hours -Was the goal sustained? Example: Optimize spent maintaining resources by using efficient equipment -What was the impact to medical equipment the healthcare facility? processes and lifecycle -If the goal was not met, management of equipment. what actions are needed Specifically, making sure the to achieve it? department is sufficiently staffed to maintain the medical equipment included in the inventory.

Improve & Empower Highly Example: # of corrective Effective Work Teams. maintenance activities Example: Improve staff resulting from user error or performance through abuse effective medical equipment education and training. Specifically, identifying gaps

40 Performance Objective Performance Indicator Performance Result in user’s knowledge of medical equipment.

Healthy & Satisfied Families Example: # staff and and Beneficiaries. Example: customer service Improve staff and patient complaints related to satisfaction by providing a medical equipment alarms safe physical environment. received each quarter Specifically, monitoring the number of customer complaints.

6. Effectiveness. The following table summarizes the HEALTHCARE FACILITY NAME achievements related to the medical equipment processes necessary for maintaining a successful Medical Equipment Management Program—

Risk Complianc Risk Action Plan Managemen Process e Assessment5 to Correct t Activity

Maintain a comprehensive Medical Equipment Management Plan. SAFER Plan Status The written plan is Matrix readily available for review (EC.01.01.01, EP.7)

5 High = Harm could happen at any time; Moderate = Harm could happen occaisionally; Low = Harm could happen, but would be rare; Limited = Unique occurrence that is not representative of routine/regular practice; Pattern = Multiple occurrences with potential to impact few/some patients, vistiors, staff and/or settings; Widespread = Multiple occurrences with potential to impact most/all patients, visitors, staff and/or settings. Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

Maintain education and training programs to teach staff the methods for eliminating hazards and minimizing risks regarding the use of SAFER Teach medical equipment, Status Matrix how to respond to an equipment failure, and how to report equipment safety hazards (EC.03.01.01, EP.2)

Educate staff about the purpose and proper operation of alarm SAFER Status systems for which they Matrix are responsible (NPSG.06.01.01, EP.4)

Implement Conduct global risk assessments to identify and prioritize equipment SAFER Status hazards for corrective Matrix action (EC.02.01.01, EP.1)

Conduct focused risk Status SAFER assessments to Matrix eliminate equipment hazards or manage risk when hazards cannot be eliminated (EC.02.01.01, EP.1 & 3)

42 Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

Maintain a current, Status accurate medical equipment inventory. SAFER Documentation is Matrix readily available for review (EC.02.04.01, EP.2)

Identify high-risk equipment (including life support equipment) for which there is risk of serious injury or death SAFER to a patient or user Status Matrix should the equipment fail. Documentation is readily available for review (EC.02.04.01, EP.3)

Define medical Status equipment maintenance strategies in writing. SAFER Documentation is Matrix readily available for review (EC.02.04.01, EP.4)

Define frequencies for Status SAFER inspecting, testing, and Matrix maintaining equipment in writing. Documentation is readily available for review (EC.02.04.01, EP.4) Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

Maintain written SAFER procedures to follow Matrix when medical equipment fails. Status Documentation is readily available for review (EC.02.04.01, EP.9)

Define quality control Status and maintenance activities and SAFER frequencies to maintain Matrix quality of CT, PET, MRI, and NM images (EC.02.04.01, EP.10)

Perform safety, operational, and functional checks on all SAFER Status new equipment before Matrix use (EC.02.04.03, EP.1)

Perform and document inspections, tests, and maintenance of high risk/life support SAFER equipment. Status Matrix Documentation is readily available for review (EC.02.04.03, EP.2)

Perform and document Status SAFER inspections, tests, and Matrix maintenance of non- high-risk/non-life support equipment. Documentation is readily available for review (EC.02.04.03,

Perform testing and maintenance of all sterilizers. SAFER Documentation is Status Matrix readily available for review (EC.02.04.03, EP.4)

Perform equipment maintenance and biological testing of water used in SAFER hemodialysis. Status Matrix Documentation is readily available for review (EC.02.04.03, EP.5)

Adhere to the performance, maintenance, and testing of electrical equipment used in the patient care vicinity per NFPA 99-2012, Chapter 10 (EC.02.04.03, EP.14)

Maintain the quality of CT, PET, MRI, and NM SAFER images Status Matrix produced(EC.02.04.03, EP.17)

Measure the radiation Status SAFER dose produced by CT Matrix imaging equipment for CT protocols: adult brain, adult abdomen, pediatric brain, and Risk Complianc Risk Action Plan Managemen Process e Assessment to Correct t Activity

pediatric abdomen by a diagnostic medical physicist annually. Documentation is available for review (EC.02.04.03, EP.19)

Conduct annual performance evaluations on CT , MRI, NM, and PET imaging equipment and image acquisition display monitors by a SAFER diagnostic medical Status Matrix physicist, MRI scientist, or nuclear medicine physicist. Documentation is available for review (EC.02.04.03, EP.20, 21, 22, 23 & 24)

Maintain policies and procedures for managing clinical alarms. Documentation SAFER is readily available for Status Matrix review (National Patient Safety Goals (NPSG) 06.01.01, EP.1, 2, & 3 & 4)

Respond Include plans for Status SAFER managing/sharing Matrix medical equipment during an emergency in the Emergency Operation Plan (Emergency Management (EM).02.02.03, EP.4

and 5)

Report and investigate medical/laboratory equipment SAFER management problems, Status Matrix failures and use errors (EC.04.01.01, EP.1 & 10)

Evaluate the Medical Equipment Management Plan within prescribed time SAFER Status frames. The written Matrix evaluation is readily available for review (EC.04.01.01, EP.15)

Analyze data to identify and resolve medical SAFER Monitor Status equipment issues Matrix (EC.04.01.03, EP.2)

Verify that medical equipment issues are SAFER Improve Status effectively resolved Matrix (EC.04.01.05, EP.1)

7. Recommendations.

a. Based on the 2017 risk assessment and monitoring data results, the following performance objectives are recommended to improve the Medical Equipment Program in 2018—

b. The Chief, Medical Equipment Maintenance will implement the action plans by 30 January 2018, collect and analyze data and report the results to the Safety/EC committee CHOOSE FREQUENCY.

8. Conclusion. The Medical Equipment Management Plan provides a strong framework for the effective and efficient management of actual and potential risks associated with the use of medical equipment at the HEALTHCARE FACILITY NAME. This conclusion is derived from the HEALTHCARE FACILITY NAME accomplishments related to activities such as—

a. Identifying and managing medical equipment risks

b. Conducting medical equipment repair by qualified technicians

c. Providing technician and equipment user education and training

d. Responding to manufacturer recalls and notifications and customer complaints

e. Monitoring performance

f. Accomplishing improvements necessary to eliminate hazards, minimize risk, and procure and maintain safe medical equipment.

48 NAME RANK JOB TITLE

Approved: Date: NAME 16 January 2018

SUBJECT: Evaluation of the 2017 Utility Management Plan

2. Purpose. The purpose of this evaluation is to measure and document the extent that the HEALTHCARE FACILITY NAME managed utility system risks in the physical environment in 2017. This evaluation includes an assessment of the Utility Management Plan’s scope, objectives, performance and effectiveness along with the performance of the HEALTHCARE FACILITY NAME utility management policies and procedures. In addition, this evaluation contains several recommendations for improvement in 2018.

4. Objectives. The 2017 objectives were—

a. Effectively manage utility system risks through regulatory compliance and by using best industry practices.

b. Optimize resources by using efficient utility system processes and lifecycle management of equipment.

c. Improve staff performance through effective utility system education and training.

d. Improve staff and patient satisfaction by providing a safe physical environment.

50 e. These objectives are consistent with the HEALTHCARE FACILITY NAME 2018 mission and they require no major modification.

5. Performance.

a. The primary performance improvement initiative for 2017 was facility personnel will respond to 98% of trouble alarms located in critical care areas within X minutes. See discussion in the following table and graph for details.

Objective Indicator Performance

Improve Physical, Ethical & Example: # time to Discussion Cultural Environments. respond to trouble alarms. Example: Effectively -What was your goal? manage utility system risks Example: -Describe criteria used to through regulatory Facility personnel will determine when you compliance and by using respond to 98% of trouble reached your goal. best industry practices alarms located in critical (internal processes). care areas within ≤ X -Describe actions taken to Specifically, promptly minutes. achieve your goal. responding to emergency -Discuss the results. alarms. Consider using graphs, charts, dashboards, etc. Optimize financial resources. Example: % preventive See example chart below. Example: Optimize maintenance completed resources by using efficient on time -Was the goal met? Why utility system processes and or why not? lifecycle management of -Was the goal sustained? equipment. Specifically, making sure that all utility -What was the impact to systems receive required the healthcare facility? tests, inspections, -If the goal was not met, maintenance within what actions are needed prescribed time frames. to achieve it? Improve & Empower Highly Example: % staff that can Effective Work Teams. articulate general Example: Improve staff information on utility performance through system safety effective utility system education and training. Specifically, identifying gaps in user’s knowledge of utility systems within their work areas. Objective Indicator Performance

Healthy & Satisfied Families Example: # customer and Beneficiaries. Example. ventilation/odor complaints Improve staff and patient received each quarter satisfaction by providing a safe physical environment. Specifically, monitoring the number of customer complaints.

6. Effectiveness. The following table summarizes the HEALTHCARE FACILITY NAME achievements related to utility system processes necessary for a successful Utility Management Program—

Risk Risk Action Plan Managemen Process Status Assessment6 to Correct t Activity

Maintain a comprehensive Utility Management Plan. The written plan is readily Plan available for review Status SAFER Matrix (Environment of Care (EC).01.01.01, Elements of Performance (EP).8)

Teach Maintain education and Status SAFER Matrix training programs to teach staff the methods for eliminating hazards and

6 High = Harm could happen at any time; Moderate = Harm could happen occaisionally; Low = Harm could happen, but would be rare; Limited = Unique occurrence that is not representative of routine/regular practice; Pattern = Multiple occurrences with potential to impact few/some patients, vistiors, staff and/or settings; Widespread = Multiple occurrences with potential to impact most/all patients, visitors, staff and/or settings. 52 Risk Risk Action Plan Managemen Process Status Assessment to Correct t Activity

minimizing risks related to the utility systems within the workplace, how to respond to utility system failures, and how to report utility system safety hazards (EC.03.01.01, EP.2)

Implement Conduct global risk assessments to identify and prioritize utility system Status SAFER Matrix hazards for corrective action (EC.02.01.01, EP.1)

Conduct focused risk assessments to eliminate utility system hazards or Status SAFER Matrix manage risk when hazards cannot be eliminated (EC.02.01.01, EP.1)

Ensure utility systems meets patient care and Status SAFER Matrix operational needs (EC.02.05.01, EP.1)

Maintain a current, accurate inventory of operating components of the utility systems based on risk for infection, occupant needs, and Status SAFER Matrix systems critical to patient care (high-risk/life support). Documentation is readily available for review (EC.02.05.01, EP.2 & 3)

Evaluate new types of Status SAFER Matrix utility systems and their Risk Risk Action Plan Managemen Process Status Assessment to Correct t Activity

components before initial use to determine whether they should be included in the inventory. Documentation is readily available for review (EC.02.05.01, EP.2)

Identify high-risk operating components of utility systems on the inventory for which there is risk of serious harm or death to Status SAFER Matrix the patient or staff should the component fail. Documentation is readily available for review (EC.02.05.01, EP.3)

Define utility system maintenance strategies in writing. Documentation is Status SAFER Matrix readily available for review (EC.02.05.01, EP.4)

Define frequencies for inspecting, testing, and maintaining utility systems in writing. Documentation Status SAFER Matrix is readily available for review (EC.02.05.01, EP.4)

Label utility system controls to facilitate partial or complete emergency Status SAFER Matrix shutdowns (EC.02.05.01, EP.8)

Maintain procedures for Status SAFER Matrix responding to utility system disruptions.

54 Risk Risk Action Plan Managemen Process Status Assessment to Correct t Activity

Documentation is readily available for review (EC.02.05.01, EP.9)

Maintain procedures for shutting off malfunctioning systems and notifying staff Status SAFER Matrix in affected areas (EC.02.05.01, EP.10)

Maintain procedures for performing clinic interventions during utility Status SAFER Matrix system disruptions (EC.02.05.01, EP.11)

Follow local procedures for responding to utility Status SAFER Matrix system disruptions (EC.02.05.01, EP.13)

Minimize pathogenic biological agents in cooling towers, domestic hot and cold water systems and Status SAFER Matrix other aerosolizing water systems (EC.02.05.01, EP.14)

Maintain appropriate Status SAFER Matrix pressure relationships, air- exchange rates, and filtration efficiencies in positive and negative pressure isolation rooms, operating rooms, special procedures rooms, delivery rooms, laboratories, pharmacies, and sterile supply rooms (EC.02.05.01, EP.15) Risk Risk Action Plan Managemen Process Status Assessment to Correct t Activity

Maintain required pressure relationships, temperature, and humidity in non-critical care areas (general care nursing units, clean and soiled utility rooms in acute care areas, laboratories, pharmacies, diagnostic and treatment areas, food preparation areas, and other support departments) (EC.02.05.01, EP.16)

Maintain diagrams mapping the distribution of the utility systems. Status SAFER Matrix Documentation is readily available for review (EC.02.05.01, EP.17)

Maintain medical gas storage rooms and transfer and manifold rooms Status SAFER Matrix according to NFPA 99- 2012, 9.3.7 (EC.02.05.01, EP.18)

Maintain the emergency power supply system equipment and environment according to Status SAFER Matrix the manufacturer’s recommendations and NFPA 99-2012, 9.3.10 (EC.02.05.01, EP.19)

Maintain a Type 1 or Type Status SAFER Matrix 3 essential electrical system, according to NFPA 99-2012, Chapter 6 (EC.02.05.03, EP.1)

Provide a emergency power within 10 seconds for:  alarm systems  exit route and sign illumination  emergency communication systems  elevators designated to provide patient service during interruption of normal power  critical care and other areas (blood, bone and tissue storage; medical air compressors; and Status SAFER Matrix medical and surgical vacuum systems; intensive care, emergency rooms, operating rooms, recovery rooms, obstetrical delivery rooms, nurseries, and urgent care areas) that could result in patient harm due to loss of power  emergency lighting at emergency generator locations (EC.02.05.03, EP.1 through 6, 10, & 11).

Maintain a labeled, remote Status SAFER Matrix manual stop station at emergency generator locations to prevent inadvertent or unintentional operation Risk Risk Action Plan Managemen Process Status Assessment to Correct t Activity

(EC.02.05.03, EP.10)

Maintain a battery powered remote annunciator outside the Status SAFER Matrix emergency power location (EC.02.05.03, EP.10)

Provide emergency power for elevators designated to provide service during Status SAFER Matrix interruption of normal power (EC.02.05.03, EP.11)

Manage risks associated with air-quality requirements, infection control, utility Status SAFER Matrix requirements, noise, odor, dust, vibration and other hazards (EC.02.05.05, EP.1)

Test utility system components on the inventory before initial use. Status SAFER Matrix Documentation is readily available (EC.02.05.05, EP.2)

Inspect, test, and maintain Status SAFER Matrix  high-risk (life support) components  non-high-risk components listed on the inventory  infection control system componets Documentation is readily available for review (EC.02.05.05, EP.4 - 6)

Maintain electrical system(s) according to Status SAFER Matrix NFPA 99-2012, Chapters 6 (EC.02.05.05, EP.7)

Maintain heating, ventilation, and air conditioning systems Status SAFER Matrix according to NFPA 99- 2012, Chapter 9 (EC.02.05.05, EP.7)

Inspect, test and maintain the emergency power systems  battery powered lights (monthly and annually)  SEPSS (monthly or quarterly)  EPSS (weekly inspections and monthly and 36 month Status SAFER Matrix tests)  automatic transfer switches (ATS) (monthly)  fuel quality (annually) Documentation is readily available for review (EC.02.05.07, EP.1 through 10)

Inspect, test and maintain Status SAFER Matrix critical components of piped medical gas and vacuum systems (source, distribution, inlets/outlets, and alarms) Documentation is readily available for review (EC.02.05.09, EP.1) Risk Risk Action Plan Managemen Process Status Assessment to Correct t Activity

Protect above ground bulk oxygen systems with a Status SAFER Matrix locked enclosure (EC.02.05.09, EP.2)

Maintain an emergency oxygen supply connection that allows a temporary Status SAFER Matrix auxillary source to connect to it (EC.02.05.09, EP.3)

Test piped medical gas and vacuum systems for purity, correct gas, and proper pressure when they Status SAFER Matrix are installed, modified, or repaired. Documentation is readily available for review (EC.02.05.09, EP.4)

Make sure main supply valves and area shutoff valves for piped medical gas and vacuum systems Status SAFER Matrix are accessible and clearly identify what the valves control (EC.02.05.09, EP.5)

Maintain compressed gas cylinders according to Status SAFER Matrix NFPA 99-2012, Chapter 11 (EC.02.05.09, EP.6)

Maintain gas and vacuum Status SAFER Matrix systems and gas equipment according to NFPA 99-2012, Chapters 5 & 11 (EC.02.05.09, EP.7

Make sure lighting is suitable for care, treatment Status SAFER Matrix and services (EC.02.06.01, EP.11)

Keep areas used by patients clean and free of Status SAFER Matrix offensive odors (EC.02.06.01, EP.20)

Develop plans for alternative means of providing electricity, water, fuel, medical gas/vacuum systems, vertical and horizontal transport, Heating Ventilation and Air Condition (HVAC), and Status SAFER Matrix steam for inclusion in the HEALTHCARE FACILITY’s emergency operations plan (Emergency Mangement Respond (EM).02.02.09, EP.2 through 7)

Report and investigate utility system management problems, Status SAFER Matrix failures, and use errors (EC.04.01.01, EP.1 & 11)

Evaluate the Utility Management Plan within prescribed time frames. Status SAFER Matrix The written evaluation is readily available for review (EC.04.01.01, EP.15)

Monitor Analyze data to identify Status SAFER Matrix and resolve utility system issues in the Safety/EC Risk Risk Action Plan Managemen Process Status Assessment to Correct t Activity

Committee meetings (EC.04.01.03, EP.2)

Analyze data to identify and resolve medical Status SAFER Matrix equipment issues (EC.04.01.03, EP.2) Improve Verify that utility system issues are effectively Status SAFER Matrix resolved (EC.04.01.05, EP.1)

7. Recommendations.

a. Based on the 2017 risk assessment and monitoring data results, the following performance objectives are recommended to improve the Utility Management Program in 2018—

(1) LIST AND DISCUSS. Discussion should include: (a) What is your goal? (b) Is it measurable? (c) Is your goal written in a SMARTER performance measure format? (d) What constraints do you have (time, money, other resources)? (e) What are the steps you will take to meet your goal? (f) How will you prioritize these steps? (g) What data do you need to collect and evaluate? (h) How will you collect and report the data? (i) How often will you collect and report the data? (j) How will you explain your goal to your staff so that they know what is being measured? (k) To accurately compare data overtime, will you need to make adjustments due to changes in variables, such as sample size or quantity?

b. The Facilities Manager will implement the action plans by 30 January 2018, collect and analyze data, and report the results to the Safety/EC committee CHOOSE FREQUENCY.

62 8. Conclusion. The Utility Management Plan provides a strong framework for the effective and efficient management of actual and potential risks associated with the use of utility systems at HEALTHCARE FACILITY NAME. This conclusion is derived from the HEALTHCARE FACILITY NAME accomplishments related to activities such as—

a. Identifying and managing utility system risks

b. Conducting utility system repairs

c. Conducting utility system user education and training

d. Responding to customer complaints

e. Monitoring performance

f. Accomplishing improvements necessary to eliminate hazards, manage risk, and procure and maintain safe utility systems.

NAME RANK JOB TITLE

Approved: Date: