EOC Hospital Survey Tool

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					        TJC Environment of Care Survey Tool for the Hospital 2011

      Area:                               Date:                          Manager:                             COD:

         Surveyor:                                    Score:

#                    Question                     M    NM   NA   #                  Question                   M     NM   NA
   The organization manages safety and security risk.            The organization manages risks associated with its
                         EC.02.01.01                             utility systems. EC.02.03.05
     Employees wear their photo ID                                     There is 36 inches clearance in all
1                                                                21
     badges above the waist.                                           planes in front of electrical panels.
     In high security areas, security                                  Electrical panels in public access
2                                                                22
     measures are in place.                                            areas are closed & locked.
The organization manages risks related to                              Panels are labeled and have no
hazardous materials and wastes. EC.02.02.01                            open slots.
     Food /drinks are not found in areas                               Medical gas shut offs are correctly
3    with chemicals or blood or body                             24 labeled and the rooms they serve
     fluids.                                                           identified.
     Chemicals are labeled correctly.                            The organization establishes and maintains
     (including EVS chemicals)                                   a safe, functional environment.         EC.02.06.01
     In areas that perform HLD or labs,
                                                                      Supplies are stored off the floor to
5    eyewashes are available, installed                          25
                                                                      facilitate cleaning.
     correctly and checked weekly.
     The blue pharmacy waste bins are
6                                                                26   There are no trip or slip hazards.
     being used correctly.
     Regulated medical wastes are                                     Nursing pull cords are functional
7                                                                27
     disposed of properly.                                            and operational.
     Needle boxes are secured and not                                 In pediatric areas, EVS rooms are
8                                                                28
     overfilled.                                                      locked.
     Refrigerators that contain blood or
                                                                      Observations show protection of
9    body fluids are labeled with a                              29
                                                                      patient confidentiality and privacy.
     biohazard sign.
     All transport containers of blood,
     body fluids or pathological
10                                                               30   Medications are secured.
     specimens are labeled with
     biohazard sticker.
                                                                      All areas in clinic or unit are clean
11    Oxygen cylinders are secured.                              31
                                                                      and attractive.
      Areas where oxygen cylinders are
12    stored are correctly labeled, “full/in-                                      Soiled Utility Rooms
      use”, and/or “empty/return”.
                                                                      Laundry and trash chutes are
     The organization manages fire risks EC.02.03.01             32
                                                                      closed and locked.
      Fire extinguishers and pull stations
13                                                               33   Soiled utility rooms are clean.
      are not blocked.
14    RACE cards are posted.                                     34 Soiled utility rooms are uncluttered.
      Means of egress for the area are                           The organization has an Emergency Management
      unobstructed.                                              Plan EM.02.01.01
      Means of egress are clearly and                                Emergency Response Guides are
16                                                               35
      correctly marked.                                              posted.
17    Exit doors are not blocked.                                36 Bathrooms keys are available.
      Doorways to main egress corridors                          The organization manages medical equipment risks
      are not propped or tied open.                              EC.02.03.03
      Items are at least 18 inches from the                          All clinical equipment has current
19                                                               37
      ceiling in sprinkled areas.                                    and readable PM tags.
      Combustibles are not stored next to
      ignition sources.
Can staff articulate correct answers to the following questions?
#                   Question                  M   NM   NA   #                 Question                 M   NM   NA
                                                                 Where would you find the
The organization has an Emergency Management Plan                Bloodborne Pathogens Exposure
                                                            52   Control Plan on-line? TB ECP?
                                                                 Show me.

     Where is the unit’s site specific Fire                      How would you manage a known
37                                                          53   or suspected TB patient?
     Plan? Are Parts I and II present?
     In pediatric areas, what steps are                          Who would you call for suspected
38   taken to prevent missing or abducted                   54   TB exposures?
                                                                 What type of respiratory equipment
     What would be your response to a                            is worn by employees for TB
39                                                          55
     Code Pink?                                                  isolation patients?
     What steps would you take if you                            Where would you find the Material
40   witnessed suspicious activity, or                      56   Safety Data Sheets for chemicals
     violent behavior?                                           or medications used in your area?
                                                                 Do you work with hazardous
     What is Code Red, Orange, Black,                            drugs? (e.g. chemo) If so, can you
41                                                          57
     Triage?                                                     locate the Hazardous Drug Policy
                                                                 Do you have hazardous chemical
42   What does RACE mean?                                   58   or drug in your area? If so, how do
                                                                 you handle a spill.
                                                                 Do you perform High Level
43   What does PASS mean?                                   59   Disinfection? If so, what
                                                                 precautions would you take?
     Where are the nearest fire                                  How would you report an unsafe
44   extinguishers and pull stations?                       60   condition, or a staff, patient or
                                                                 visitor injury?
     Where would you move to in the                              What steps are taken to prevent
45   event of a fire?                                       61   the inappropriate reuse of
     What is the fire code for your
     location? Or where can you locate it                   The organization manages risks associated with its
     quickly (building, floor, zone)?                                 utility systems. EC.02.03.05

     What is Hospital Incident Command                           Where are the cut off valves for
47   System?                                                62
The organization manages risks related to hazardous              What would you do in the event of
materials and wastes. EC.02.02.01                                a power failure?
    Management: Can you provide your
                                                            The organization manages medical equipment risks
48 Safety training and EOHW
    compliance data?                                                           EC.02.03.03

     Management: What are the actual                             What steps would you take if a
49   compliance rates for the area? Are                     64   piece of medical equipment fails or
     they above 90%?                                             malfunctions while in use?
     What safety devices to prevent
50   accidental needlesticks are in your                                              Other
     unit? How do you use them?
     What number do you call if you had
51   blood or body fluid exposure?                          65   Other issues?


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