Guide to JCAHO Environment of Care Standard 1.10.1
© 2005
Joint Commission on Accreditation of Healthcare Organizations.
Any use of any or all of the Joint Commission standards
and elements of performance beyond this particular tool
is strictly forbidden without the written permission
of the Joint Commission. Citations from JCAHO standards are ©2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. These pages do not reflect any changes in the standards made after 2005. |
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Introduction Table of Contents Checklist for 1.10.1
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Environment of Care Standard 1.10: The hospital manages safety risks. Element of Performance 1: Written Safety Plan The hospital develops and maintains a written management plan describing the processes it implements to effectively mange the environmental safety of patients, staff and other people coming to the hospital's facilities. |
The comprehensive written General Safety Plan should include a statement of commitment to the health and safety of staff, patients, visitors and the community, as well as to the protection of the environment. The Plan should include its objectives, scope, and responsible individuals. This page describes specific processes that should be included in the plan to actively reduce risk of exposure to potentially hazardous conditions and operations that could result in injury, illness, property loss or environmental damage.
Other specific plans should be referenced in the General Safety plan. For example, the Hazardous Materials and Waste Management Plan, EC1.10.1, includes elements specific to that topic. Implementation of these plans is covered under EC3.10.3.
Evidence of
compliance and of environmental improvement criteria are included
for the following topics:.
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General Safety Management Plan
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The
Plan outlines processes for the organization to comply
with all applicable laws and regulations.
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The facility has conducted a risk assessment that identifies and classifies activities to reduce the risk of worker injuries. | |||
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The Plan
includes periodic Safety Tours that identifies deficiencies
in comprehensive environmental management programs.
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The
responsibilities of the Safety Officer, or equivalent,
and members of the Safety Committee are clearly outlined
in the plan.
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The
Safety Committee approves the Safety Plan, and the approval
is recorded in meeting minutes and is updated annually.
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Safety Coordinator and Committee have committed resources for appropriate environmental management and waste reduction strategies. | |||
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Facility has developed an Environmental Management System (EMS) and/or is ISO 14000 certified, and maintains the certification | |||
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The Safety Officer and Committee has used an environmental improvement project as a Performance Improvement initiative to improve safety. | |||
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Facility uses environmental improvement projects as Performance Improvement (PIs) Initiatives:
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See Plan EC3.10.1 and Implementation EC3.10.3 for details on planning and implementation for hazardous materials and waste (including universal wastes), and for specific materials of concern.
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The Safety Plan includes the following elements of environmental safety: |
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--
an assessment and inventory of hazardous materials
and wastes of concern that also
covers:
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detailed provisions for specific materials of concern,
including:
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specifications
for managing:
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provisions for weekly environmental inspections for
hazard surveillance. At a minimum, the provisions
should ensure that the inspections will identify deficiencies
in chemical handling and in hazardous materials and
waste storage. Where possible, the provisions
should spell out measures for immediate corrective
action once deficiencies have been identified.
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--
specification
of actions to be taken in response to fire, explosion,
or any unplanned releases of hazardous waste. This
is required if the facility's Hazardous Waste Generator
Status is Large Quantity Generator (LQG), and is
strongly encouraged for other facilities.
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--provisions
for communicating hazardous chemical handling and use
requirements to employees.
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a Community Right-to-Know plan.
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The Plan includes provisions for reducing use of hazardous materials through purchasing policies and procedures that prefer less hazardous materials. | |||
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The Safety Plan includes the following elements of Regulated Medical (Infectious) Waste (RMW) safety: |
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--a
Bloodborne Pathogens (BBP) Exposure Control Plan
that includes processes to protect worker health
and safety while managing potentially infectious
materials.
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--processes
to protect employee and community health in areas
of packaging, labeling, and transporting RMW according
to Department of Transportation requirements.
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Facility has formulated a comprehensive medical waste minimization plan that includes staff education, signage, handling, monitoring and problem identification strategies. Also, might include choosing reusable medical devices and supplies over disposables, reducing the volume of laboratory samples. |
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--education
programs for:
that reduce the risk of injury, improve compliance and environmental performance.
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--an education and training program that is well documented, organized and accessible to appropriate personnel. | |||
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--training
at new employee orientation, and annually thereafter,
that addresses competency in Hazard Communications
and Bloodborne Pathogens Exposure Control Plan.
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--employee
training in hazardous waste issues, including:
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The
facility provides a comprehensive
training program covering:
Also, the program might include training on when it is appropriate to choose reusable medical devices and supplies over disposables, reducing the volume of laboratory samples and of material that must be handled as infectious waste. |
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