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JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENTPLAN OUTLINE

If Present

P r!"seo To ensure that buildings, grounds, equipment and systems pose no

hazards to occupantsPrevent accidents

aintain sa!e conditions !or patients, !amilies, visitors, and sta!! "educe and combat hazards and ris#s

G"a#s $measurable !or %hat is to be accomplished or maintained $ annuallyupdated&

Res!"ns$%#e $nd$&$d a# designated %ith scope o! authority de!inedo 'a!ety o!!icer designated %ith quali!ications including training and

e(perienceo

"esponsibilities de!inedInclude relationship o! sa!ety o!!icer to department and otherleaders

R$s' assess(ento )acility*%ide inspection process !or current in!ormationo +ocation o! up*to*date building plans $ blue prints&o "is# assessment sa!ety and security using a structured !ormat

e!ine process !or %ho and %hen and ho% and %here reported$Could be the ongoing hospital building inspection or a morestructured approach&

escribe ho% data !rom ris# assessment is used to support goals!or the plan and policy and procedure development

Fa)$#$t* Ins!e)t$"ns - periodico Process de!ined, !requency, ho% !indings are summarized and analyzed

and !indings trac#ed !or improvement. 'tate %here !acility inspectionresults are reported and the !requency o! the report.

o e!ine %ho conducts !acility inspections, such as the /sa!ety o!!icer0 %ithclinical and support sta!! as part o! team, department directors such asdirectors o! laboratory, radiology, administration

o 1se o! chec#list !or the inspections $attach to plan&o 'tate ho% data are used to ma#e improvements

Pre&ent$&e safet* !r"+ra( strate+$eso 'a!ety prevention strategies and practices are in place to support sa!e

environment and comply %ith la% and regulationIdenti!y supporting policies and proceduresIdenti!y country la%s2regulatory sa!ety requirements

o 'tatement about use o! periodic sa!ety round inspections to identi!y andta#e to reduce evident ris#s

JCI 'a!ety and 'ecurity Plan - 3utlineP.

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JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENTPLAN OUTLINE

If Present

)eedbac# to department2units and response2corrective action e(pectations

Initiate corrective actions2 %or# requests2 etc.

"eporting process - submit aggregate !indings to hospital sa!etycommittee

o 1se o! e(ternal revie%s to identi!y sa!ety ris#s and ta#ing o! actions

o Construction and renovations5 Preventive ris# assessment and interim plans during construction and renovations

'upporting policies"is# assessment toolsConstruction permits

o 'ecurity and sa!ety !or vulnerable patient populations such as in!ants,elderly, disabled, abuse cases !or protection, and other vulnerable patient

populationsIdenti!y supporting policies that address ho% you provide sa!etyand security, such as in!ant abduction policy

o 'ecurity procedures !or identi!ied sensitive areas such as E , 3",Pharmacy, "adiology, +aboratory, " storage, Cashier, 6uman"esources

A)t$&e safet* !r"+ra( - ,es)r$%e t e strate+$es f"r t e f"##" $n+/

o anagement o! sa!ety incidents !or sta!!, visitors, and patients

'tatement that describe integration o! employee and patientsa!ety data $usually !rom incident reports& integrated into sa!ety

program $re!erence incident reporting policy&

o Integration %ith In!ection Control program data on sa!ety ris#s

)or e(ample, needle stic# in7uries or 8lood 8orne Pathogene(posures

o escribe ho% laboratory and radiology sa!ety program data are integratedinto sa!ety program and reporting !requency to 'a!ety Committee$re!erence sa!ety program policies&

o "eporting and response process To sa!ety o!!icer To 'a!ety Committee

o Include responsibilities and training o! independent entities

Pre&ent$&e se) r$t* !r"+ra( strate+$es

JCI 'a!ety and 'ecurity Plan - 3utlineP. 9

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JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENTPLAN OUTLINE

If Present

Plans to reduce evident ris#s based upon the inspections and drills

o In!ant abduction drills

o 'ecurity guard procedure

o Identi!y supporting policies and procedures

Access to hospital

o Identi!ication o! security sensitive areas

o Control o! entrances and e(its

o

Chec# points in hospital

o A!ter*hours chec#s

o 'urveillance o! loc#ing entrances a!ter hours

o "e!erence supporting policies

Coordination %ith local police department

o Communication, phone numbers

Identi!ication system $badges& !or sta!!, visitors, vendors2 contractors,volunteers and patients

o Process2 technical5 8adges and pictures, s%ipe cards !or sta!!

o 8adges !or visitors, vendors2 contractors

o :olunteers identi!ication process

o 'creening visitors, !amilies, vendors a!ter hours

o "e!erence supporting policies

"emote monitoring systems such as surveillance cameras2 tele monitors

o Interior monitoring * corridors2 areas

o E(terior monitoring * par#ing lots, garages

JCI 'a!ety and 'ecurity Plan - 3utlineP. ;

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JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENTPLAN OUTLINE

If Present

o 'ecurity surveillance monitoring area'ta!!ing and bac#*up tapes

A)t$&e se) r$t* !r"+ra( strate+$es

o anagement o! incidents5 sta!!, visitors, and patients

o 'ecurity alert codes - see policy

o Incident reports< !ormat or !orm

o Identi!y supporting policies and procedures !or above

o

"eporting and response process

To security o!!icer

To sa!ety committee

R"#e "f Safet* C"(($ttee to support maintain a sa!e and secure environmento "e!erence any document or policy describing the committee

M"n$t"r$n+ data 0(eas res1 f"r $(!r"&e(ents $n t e safet* and se) r$t*!r"+ra(

o e!ine monitoring measures * could be use o! inspection !indings orsomething !rom incident reports such as visitor !alls or the!ts

o e!ine collection, aggregation, report structure, reporting process and!requency $according to schedule &

o )lo% or integration o! data and analysis to =uality ImprovementCommittee

Tra$n$n+ ed )at$"n !r"+ra(o Education o! sta!! at initial hire and annual therea!ter !or sa!ety and

security a%arenessIntegrate training topics !rom monitoring !indings, roundsdata, other reports into the 'a!ety Committee

odi!ication o! training according to sa!ety and security ris#sthat are departments2 service speci!ic

o :endor, contractor, volunteer requirements !or training related to their 7obs and roles

3n initial visitAny annual training $such as !or volunteers &

JCI 'a!ety and 'ecurity Plan - 3utlineP. 4

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JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENTPLAN OUTLINE

If Present

o Patient educationTopics !or patient handboo# on 'a!ety program includingInternational Patient 'a!ety >oals

'peci!ic sa!ety and security in!ormation !or sensitive areassuch as ne%born nursery, ?IC1, 3bstetrics, psychiatry, E" o Include training o! independent entities

Ann a# !r"+ra( !#an e&a# at$"no 'tatement describing the process !or the annual evaluation including

use o! e(isting surveillance and rounding data, per!ormanceimprovement data, sta!! training !indings, annual ris# re*assessment,revie% o! program goals, and recommendations !or program or policyand training changes.

JCI 'a!ety and 'ecurity Plan - 3utlineP. @