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JCAHO EOC Hospital Survey Tool - Occupational _ Environmental - DOC


									                                 TJC Environment of Care Survey Tool for the Hospital 2009
                         Area:                                  Date:                           Manager:                        COD:

                                            Surveyor 1:                     Surveyor 2:                         Score:

                                                                         (revision 3/25/2009)

I. The organization plans activities to minimize risk in the Environment Of Care.                      EC 01.01.01
                                                          M                 NA                           NS                              Answers
1.     Staff can locate their site specific Fire Plan.                                                               In RED EM book

2.     Emergency Response guides are posted
II. The organization manages safety and security risk.                  EC.02.01.01
                                                                        M       NM              NA         NS                            Answers
1.      All employees are wearing their photo ID badges above
       the waist.
2.      In high security areas (e.g. ED, mother/baby, etc.) security                                                 No propped doors, cameras are not missing,
       measures are in place and not turned off or otherwise                                                         automatic door closers are working, etc.

3.     In pediatric areas staff can articulate steps taken to                                                        Parents/legal guardians must stay with children,
       prevent missing or abducted children.                                                                         transporters must sign kids in and out, stairwells
                                                                                                                     are card access only, ask about front desk
                                                                                                                     monitoring at night
4.     In all areas staff can articulate their response to a Code                                                    Get age, sex and location last seen, call 911, OA
       Pink                                                                                                          Monitor all exits, do not approach suspects—call
                                                                                                                     info in
5.     In all areas staff can articulate their response to a Code                                                    Call 911, OA. IF code gray is not in your area then
       Gray.                                                                                                         stay away from area of Code Gray, close doors, do
                                                                                                                     not confront anyone
6.      Staff can articulate what steps to take if they witness                                                      Call 911. All 911 phone calls should ultimately be
       suspicious activity or violent behavior or if they receive any                                                documented in the SRS
7.      Staff knows what to do if they see anyone other than a                                                       Call 911
        uniformed law enforcement officer carrying a weapon.
 III. The organization prohibits smoking. EC.02.01.03
                                                                        M   NM   NA   NS                        Answers
 1.     Staff can articulate the smoking policy                                            It is the : Tobacco Free Environment Policy
 2.     Smoking policy is being followed.                                                  no smoking in the hospital
 IV. The organization manages risks related to hazardous materials and wastes.
                    A. Chemicals                         M       NM        NA         NS                        Answers
1.     Staff can locate Material Safety Data Sheets for chemicals                          For most inpatient units these are in the OAs
       used in their area.                                                                 office, on line.
2.     Staff can locate Material Safety Data Sheets for all                                Drug MSDS can be obtained from Pharmacy or
       medications found in their area that are not in pill form.                          online
3.     Staff who works with high risk drugs (such as chemotherapy                          It’s in the DUHS Safety Manual--appendix
       or riboviran) can locate the Hazardous Drug Policy on-line.
4.     Hazardous drugs are being disposed in accordance with                               Slow roll out. Look for new boxes. If present ask
       policy.                                                                             staff what goes in there and how they know which
                                                                                           drugs are affected.
5.     Staff can articulate how to handle a hazardous chemical or                          Small spills—use spill kit obtainable from pharmacy
       drug spill in their area.                                                           (for chemo). Large spills or hazardous spills—
                                                                                           evacuate area and call 911 Neutralex available?
6.      Staff who perform High Level Disinfection can articulate                           Full PPE (gowns and full face protection) and Nitrile
       what precautions they need to take to prevent or minimize                           gloves.
7.     In areas that perform HLD or labs eyewashes are available,
       installed correctly and checked weekly.
8.      All chemicals are labeled correctly.                                               Chemical name, concentration (if applicable),
                                                                                           Hazard info, expiration date (if applicable).
9.   Oxygen cylinders are stored correctly—i.e. secured,
    separated by type and whether or not they are full or
10. No food or drinks are found in proximity to chemicals or                               If at nurses stations then there should be no lab or
    blood or body fluids.                                                                  clinical equipment in this area. (blood tubes,
                                                                                           glucometers, supplies, etc.)
11. Staff can articulate how to use and are appropriately using                            Check needleboxes for non safety and inactivated
    safety devices to prevent blood or body fluids.                                        safety devices (peek in lid-don’t open)
12. Staff can articulate what to do in the event of a blood or                             Call BBF hotline at 115, off site 684-8115, then fill
    body fluid exposure.                                                                   out SRS within 24 hours
13. Staff can locate the the Blood Borne Pathogen ECP.                           , on line manuals, DUHS,
                                                                                           under Biological Safety
14. Refrigerators that contain blood or body fluids are labeled
    with a biohazard sign.
15. All containers of blood, body fluids or pathological                                   BBF require biohazard sticker, if in formalin then
    specimens are labeled appropriately.                                                   must have formalin sticker
16. Regulated medical wastes are disposed of properly.                                     NOT in regular trash, linens, etc.
17. Used surgical trays in soiled utility rooms have been                                  As discussed—should not be put in soiled room
    correctly stripped and packaged                                                        with paper drapes, etc all wadded up on them
18. Needle boxes are secured and not overfilled.                                           New emphasis—in CLINiCAL areas moving away
                                                                                           from unsecured needleboxes (not in labs),
19. Staff can articulate how to manage a known or suspected                                Isolation Rooms, order PAPRs if not fit tested or
    TB patient.                                                                            need to wear a PAPR, Call Infection Control
20. Staff can articulate who to call if they think they may have                           EOHW, us or Infection Control
    been exposed to TB.
21. Staff can articulate what type of respiratory equipment                                Fit tested-appropriate mask, Not fit tested or
    they should wear when working with a known or suspected                                couldn’t be--PAPR
    TB patient.
22. Staff can locate the TB ECP.                                                 , on line manuals, DUHS,
                                                                                           under Biological Safety
 B.     Radiation
23. Radiation shielding PPE is stored appropriately                                        Hung up not folded
24. Dosimeter badges are worn outside the shielding PPE, on
    the collar.
 V. The organization manages fire risks EC.02.03.01
                                                                        M   NM   NA   NS                         Answers
 1.     RACE cards are posted
 2.     Employees can articulate RACE
 3.     Employees can articulate what a Code Red means.                                    It is the Fire Code
 4.     Employees can articulate their fire code or can locate it                          Look at smoke detectors or Evac Charts! Also in
       quickly (building, floor, zone).                                                        Fire Plan
5.     Employees can articulate PASS.
6.     Employees can locate their fire extinguishers and pull
7.     Fire extinguishers and pull stations are not blocked
8.     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
12. Laundry and trash chutes are closed and locked.
13. Items are at least 24 inches from the ceiling in non-
    sprinkled areas and 18 inches from the sprinkler heads in
    sprinkled areas
14. Combustibles are not stored next to ignition sources                                       Check mechanical rooms when possible-E&O has
15. Employees can articulate where they would move to in the                                   Laterally first at direction of Fire Department/Fire
    event of a fire.                                                                           Safety or OA
16. If there is any construction going on in the area Fire Safety                              If you have any questions call FS from the unit and
    has been notified and Interim Life Safety measures have                                    ask them
    been implemented.
17. Staff can articulate how to discard battery operated                                       Break off tips using forceps and wearing eye
    cautery devices                                                                            protection. Put tips in needlebox, handle in traxh
VI. The organization manages medical equipment risks                   EC.02.03.03
                                                                       M      NM     NA   NS                         Comments
1.     All clinical equipment has a current and readable PM tag
       on it.
2.     Staff can articulate what steps to take if a piece of medical                           Stop, tag, call, fill out SRS
       equipment fails or malfunctions while in use.

VII. The organization manages risks associated with its utility systems.         EC.02.03.05
                                                          M         NM             NA        NS                         Answers
1.     Staff can locate the cut off valves for oxygen, air and
2.     Medical gas shut offs are correctly labeled and the rooms
       they serve are identified
3.     Staff can articulate what to do in a power failure.                                         Inpatient areas should say that they have an
                                                                                                   emergency generator so they would continue on
                                                                                                   until told otherwise by administration.
4.     There is 36 inches clearance in all planes in front of
       electrical panels
                                                                        M   NM     NA       NS                          Answers
1.     Electrical panels that are in public access areas are closed
       & locked.
2.     Panels are labeled and have no open slots.                                                  Yes this will be an NS if they are locked!
VIII.      The organization establishes and maintains a safe, functional environment.      EC.02.06.01
                                                            M        NM        NA           NS                          Answers
1.     Patient areas are clean and attractive                                                      Look for obvious dirt/dust
2.     All supplies are stored 4-6 inches off the floor to facilitate
3.     There are no trip or slip hazards.                                                          Electrical cords, spills, etc.. Look under desks to be
                                                                                                   sure cords are bundled and up off floor.
4.     Keys to bathrooms are readily available.                                                    Ask to see them. If unit is not too busy can activate
                                                                                                   BR alarms and see if anyone comes.
5.     Observations show protection of patient confidentiality                                     Charts closed, computers logged off, PHI not left
       and privacy.                                                                                out in open
6.     Staff can articulate the weight limits of the beds,
       stretchers, chairs etc. in their work area.
7.     Furnishings are safe and in good repair.
8.     Medications are secured                                                                     Med cart drawers locked, no meds left out
9.     EVS rooms are locked in pediatric areas

 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.     Staff can articulate how to report an unsafe condition or a                               SRS
             staff, patient or visitor injury
 2.     Staff can articulate what training they have received in the
             use of patient lift equipment.
 3.     Staff can articulate who to contact if they have a                                        After notifying supervisor can call Ergo—number
             ergonomic concern of have suffered an injury possibly                                on ER guide
             related to ergonomic stressors.
 X. The organization has an Emergency Management Plan EM.02.01.01
                                                    M     NM                  NA         NS                             Answers
 1.     Staff can locate their Emergency Management Subplan                                       Red book
 2.     Staff can articulate HICS                                                                 Hospital Incident Command System
 3.     Staff can correctly identify HICS codes (may use available                                Name badge attachment, charts etc.
        resources) and their response to various codes
 4.     Code Triage
 5.     National Weather Service Announcement (tornado).
 6.     Code Black
 7.     Code Purple
 8.     Code Orange
 XI. Container Mangement
1.      Staff can articulate what to do when they receive a new                                   Verify container content, integrity of seal(s),
       container                                                                                  expiration date, patient info if applicable, additives
                                                                                                  and person responsible
2.     Staff can articulate what to do if a container is delivered                                DO NOT USE, place in designated holding area for
       damaged or breached (open), including who to notify.                                       unusable goods and notify manager (who will notify
                                                                                                  Director of Procurement).
3.     Staff can show surveyor their designated holding area.
4.     Staff can articulate how to dispose of empty containers                                    Deface or remove any PHI, deface label, discard
                                                                                                  cap and container separately (don’t cap container).
5.     No containers are being reused (except EVS).


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