TJC Environment of Care Survey Tool for the Hospital 2009
Area: Surveyor 1: Date: Surveyor 2:
I. The organization plans activities to minimize risk in the Environment Of Care. M NA
1. 2. Staff can locate their site specific Fire Plan. Emergency Response guides are posted
EC 01.01.01 NS
In RED EM book
II. The organization manages safety and security risk.
1. 2. All employees are wearing their photo ID badges above the waist. In high security areas (e.g. ED, mother/baby, etc.) security measures are in place and not turned off or otherwise circumvented. In pediatric areas staff can articulate steps taken to prevent missing or abducted children.
EC.02.01.01 M NM
No propped doors, cameras are not missing, automatic door closers are working, etc.
In all areas staff can articulate their response to a Code Pink In all areas staff can articulate their response to a Code Gray. Staff can articulate what steps to take if they witness suspicious activity or violent behavior or if they receive any threats. Staff knows what to do if they see anyone other than a
Parents/legal guardians must stay with children, transporters must sign kids in and out, stairwells are card access only, ask about front desk monitoring at night Get age, sex and location last seen, call 911, OA Monitor all exits, do not approach suspects—call info in Call 911, OA. IF code gray is not in your area then stay away from area of Code Gray, close doors, do not confront anyone Call 911. All 911 phone calls should ultimately be documented in the SRS Call 911
uniformed law enforcement officer carrying a weapon.
III. The organization prohibits smoking. EC.02.01.03 M
1. 2. Staff can articulate the smoking policy Smoking policy is being followed.
It is the : Tobacco Free Environment Policy no smoking in the hospital
IV. The organization manages risks related to hazardous materials and wastes. A. Chemicals M NM NA
1. 2. 3. 4. Staff can locate Material Safety Data Sheets for chemicals used in their area. Staff can locate Material Safety Data Sheets for all medications found in their area that are not in pill form. Staff who works with high risk drugs (such as chemotherapy or riboviran) can locate the Hazardous Drug Policy on-line. Hazardous drugs are being disposed in accordance with policy. Staff can articulate how to handle a hazardous chemical or drug spill in their area. Staff who perform High Level Disinfection can articulate what precautions they need to take to prevent or minimize exposure. In areas that perform HLD or labs eyewashes are available, installed correctly and checked weekly. All chemicals are labeled correctly.
For most inpatient units these are in the OAs office, on line. Drug MSDS can be obtained from Pharmacy or online It’s in the DUHS Safety Manual--appendix Slow roll out. Look for new boxes. If present ask staff what goes in there and how they know which drugs are affected. Small spills—use spill kit obtainable from pharmacy (for chemo). Large spills or hazardous spills— evacuate area and call 911 Neutralex available? Full PPE (gowns and full face protection) and Nitrile gloves.
7. 8. 9.
Chemical name, concentration (if applicable), Hazard info, expiration date (if applicable).
Oxygen cylinders are stored correctly—i.e. secured, separated by type and whether or not they are full or empty. 10. No food or drinks are found in proximity to chemicals or blood or body fluids. 11. Staff can articulate how to use and are appropriately using
If at nurses stations then there should be no lab or clinical equipment in this area. (blood tubes, glucometers, supplies, etc.) Check needleboxes for non safety and inactivated
safety devices to prevent blood or body fluids. 12. Staff can articulate what to do in the event of a blood or body fluid exposure. 13. Staff can locate the the Blood Borne Pathogen ECP. 14. Refrigerators that contain blood or body fluids are labeled with a biohazard sign. 15. All containers of blood, body fluids or pathological specimens are labeled appropriately. 16. Regulated medical wastes are disposed of properly. 17. Used surgical trays in soiled utility rooms have been correctly stripped and packaged 18. Needle boxes are secured and not overfilled. 19. Staff can articulate how to manage a known or suspected TB patient. 20. Staff can articulate who to call if they think they may have been exposed to TB. 21. Staff can articulate what type of respiratory equipment they should wear when working with a known or suspected TB patient. 22. Staff can locate the TB ECP. B.
safety devices (peek in lid-don’t open) Call BBF hotline at 115, off site 684-8115, then fill out SRS within 24 hours www.safety.duke.edu, on line manuals, DUHS, under Biological Safety
BBF require biohazard sticker, if in formalin then must have formalin sticker NOT in regular trash, linens, etc. As discussed—should not be put in soiled room with paper drapes, etc all wadded up on them New emphasis—in CLINiCAL areas moving away from unsecured needleboxes (not in labs), Isolation Rooms, order PAPRs if not fit tested or need to wear a PAPR, Call Infection Control EOHW, us or Infection Control Fit tested-appropriate mask, Not fit tested or couldn’t be--PAPR www.safety.duke.edu, on line manuals, DUHS, under Biological Safety Hung up not folded
23. Radiation shielding PPE is stored appropriately 24. Dosimeter badges are worn outside the shielding PPE, on the collar.
V. The organization manages fire risks EC.02.03.01 M
1. 2. 3. 4. RACE cards are posted Employees can articulate RACE Employees can articulate what a Code Red means. Employees can articulate their fire code or can locate it
It is the Fire Code Look at smoke detectors or Evac Charts! Also in
5. 6. 7. 8.
quickly (building, floor, zone). Employees can articulate PASS. Employees can locate their fire extinguishers and pull stations Fire extinguishers and pull stations are not blocked Means of egress for the area are unobstructed
NO STORAGE of Equipment in halls. E.g. if EVS cart is in use, may be in hall, ditto for galley carts—if tech is in process of serving food, otherwise no. Chart rack must be up unless they are in use (by medical team).
9. Means of egress are clearly and correctly marked 10. Exit doors are not blocked. 11. Doorways to main egress corridors are not propped or tied open. 12. Laundry and trash chutes are closed and locked. 13. Items are at least 24 inches from the ceiling in nonsprinkled areas and 18 inches from the sprinkler heads in sprinkled areas 14. Combustibles are not stored next to ignition sources 15. Employees can articulate where they would move to in the event of a fire. 16. If there is any construction going on in the area Fire Safety has been notified and Interim Life Safety measures have been implemented. 17. Staff can articulate how to discard battery operated cautery devices
Check mechanical rooms when possible-E&O has keys Laterally first at direction of Fire Department/Fire Safety or OA If you have any questions call FS from the unit and ask them Break off tips using forceps and wearing eye protection. Put tips in needlebox, handle in traxh
VI. The organization manages medical equipment risks
1. 2. All clinical equipment has a current and readable PM tag on it. Staff can articulate what steps to take if a piece of medical equipment fails or malfunctions while in use.
EC.02.03.03 M NM
Stop, tag, call, fill out SRS
VII. The organization manages risks associated with its utility systems. M NM
1. 2. 3. Staff can locate the cut off valves for oxygen, air and vacuum. Medical gas shut offs are correctly labeled and the rooms they serve are identified Staff can articulate what to do in a power failure.
EC.02.03.05 NA NS
Inpatient areas should say that they have an emergency generator so they would continue on until told otherwise by administration.
There is 36 inches clearance in all planes in front of electrical panels
1. 2. Electrical panels that are in public access areas are closed & locked. Panels are labeled and have no open slots.
Yes this will be an NS if they are locked!
1. 2. 3. 4. 5. 6. 7. 8. 9.
The organization establishes and maintains a safe, functional environment. M NM NA
Patient areas are clean and attractive All supplies are stored 4-6 inches off the floor to facilitate cleaning. There are no trip or slip hazards. Keys to bathrooms are readily available. Observations show protection of patient confidentiality and privacy. Staff can articulate the weight limits of the beds, stretchers, chairs etc. in their work area. Furnishings are safe and in good repair. Medications are secured EVS rooms are locked in pediatric areas
Look for obvious dirt/dust
Electrical cords, spills, etc.. Look under desks to be sure cords are bundled and up off floor. Ask to see them. If unit is not too busy can activate BR alarms and see if anyone comes. Charts closed, computers logged off, PHI not left out in open
Med cart drawers locked, no meds left out unattended
IX. The organization establishes a process(es) for continually monitoring, internally reporting, and investigating occupational illness and staff injuries EC.04.01.01 M NM NA NS Answers
1. 2. 3. Staff can articulate how to report an unsafe condition or a staff, patient or visitor injury Staff can articulate what training they have received in the use of patient lift equipment. Staff can articulate who to contact if they have a ergonomic concern of have suffered an injury possibly related to ergonomic stressors. SRS
After notifying supervisor can call Ergo—number on ER guide
X. The organization has an Emergency Management Plan EM.02.01.01 M NM
1. 2. 3. 4. 5. 6. 7. 8. 1. Staff can locate their Emergency Management Subplan Staff can articulate HICS Staff can correctly identify HICS codes (may use available resources) and their response to various codes Code Triage National Weather Service Announcement (tornado). Code Black Code Purple Code Orange Staff can articulate what to do when they receive a new container Staff can articulate what to do if a container is delivered damaged or breached (open), including who to notify. Staff can show surveyor their designated holding area. Staff can articulate how to dispose of empty containers No containers are being reused (except EVS).
Red book Hospital Incident Command System Name badge attachment, charts etc.
XI. Container Mangement
Verify container content, integrity of seal(s), expiration date, patient info if applicable, additives and person responsible DO NOT USE, place in designated holding area for unusable goods and notify manager (who will notify Director of Procurement). Deface or remove any PHI, deface label, discard cap and container separately (don’t cap container).
3. 4. 5.