Símbolos y abreviaciones
1.3 Objetivos particulares
2.1.3 Presencia del arsénico
This chapter focuses on providing a safe environment for patients, families, staff and visitors. Hospitals work to provide a safe, functional, and supportive environment for patients, families, staff, and visitors. To reach this goal, the physical facility, medical and other equipment, and people must be effectively managed. In particular, management must strive to:
• reduce and control hazards and risks; • prevent accidents and injuries; and • maintain safe conditions.
Effective management includes planning, education, and monitoring as follows:
• The leaders plan the space, equipment, and resources needed to safely and effectively support the clinical services provided.
• All staff members are educated about the facility, how to reduce risks, and how to monitor and report situations that pose risk.
• Performance criteria are used to monitor important systems and identify needed improvements.
Laws, regulations, and inspections by local authorities determine in large part how a facility is designed, used, and maintained. All organizations, regardless of size and resources, must comply with these requirements as part of their responsibilities to their patients, families, staff, and visitors.
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STANDARD AND SCORING
REQUIREMENTS
M
NM
N/A
Leadership and Planning
FSE.1 M
The hospital complies with relevant laws, regulations, and facility inspection requirements.
Measurable Elements:
M 1. The hospital’s leaders know what laws, regulations, and other requirements apply to the hospital’s facilities. M 2. The leaders implement the applicable requirements or
approved alternatives.
M 3. The leaders ensure the hospital meets the conditions of facility inspection reports or citations.
FSE.2 M
The hospital develops and maintains a written plan(s) describing the processes to manage risks to patients, families, visitors and staff.
Measurable Elements:
1. To manage the risks within the environment in which patients are treated and staff work requires planning. The hospital develops one master plan or individual plans that include, as appropriate to the organization: M a) Safety—The degree to which the hospital’s
buildings, grounds and equipment do not pose a hazard or risk to patients, staff, and visitors.
b) Security—Protection from loss, destruction, tampering, or unauthorized access or use.
M c) Hazardous materials—Handling, storage, and use of radioactive and other materials are controlled, and hazardous waste is safely disposed.
d) Emergencies—Response to epidemics, disasters, and emergencies is planned and effective.
M e) Fire safety—Property and occupants are protected from fire and smoke.
M f) Medical equipment—Equipment is selected, maintained, and used in a manner to reduce risks M g) Utility systems—Electrical, water, and other utility
systems are maintained to minimize the risks of operating failures.
2. Such plans are written and are up-to-date in that they reflect present or recent conditions within the hospital’s environment. There is a process for their review and updating.
FSE.3 One or more qualified individuals oversee the planning, implementation, and documentation of the program to manage the risks in the care environment.
Measurable Elements:
1. Program oversight includes:
a) planning all aspects of the program;
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STANDARD AND SCORING
REQUIREMENTS
M
NM
N/A
b) implementing and documenting the components for each plan with the program;
c) educating staff;
d) testing and monitoring the program;
e) periodically reviewing and revising the program; f) annual reports to the governing body on the
effectiveness of the program.
2. Program oversight and direction are assigned to one or more qualified individuals.
3. The individual(s) is qualified by experience or training. 4. When appropriate to the hospitals size and complexity,
a facility/environment risk committee may be formed and given responsibility for overseeing the program and program continuity.
5. Each of the seven components of the plan to manage risks within the environment are reviewed al least annually, with improvements identified, assigned with a timeline for corrective action, and documented.
FSE.4 M
The hospital plans and implements a program to provide a safe and secure physical environment.
Measurable Elements:
M 1. The hospital has a program to provide a safe and secure physical facility.
M 2. The program ensures that all staff, visitors, volunteers, vendors, and subcontractors are identified and all security risk areas are monitored and kept secure. M 3. The program is effective in preventing injury and
maintaining safe conditions for patients, families, staff, and visitors.
M 4. The program includes safety and security during times of construction and renovation.
FSE.5 M
The hospital inspects all patient care buildings and has a plan to reduce evident risks and provide a safe physical facility for patients, families, staff, and visitors.
Measurable Elements:
M 1. The hospital has a documented, annual, accurate inspection of its physical facilities.
2. The hospital has a prioritized plan to reduce evident risks based on the inspection.
3. The hospital is making progress in carrying out the plan.
FSE.6 M
The hospital plans and budgets for upgrading or replacing key systems, buildings, or components based on the facility inspection and in keeping with law and regulation.
Measurable Elements:
M 1. The hospital plans and budgets to meet applicable laws, regulations, and other requirements.
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STANDARD AND SCORING
REQUIREMENTS
M
NM
N/A
2. The hospital plans and budgets for upgrading or replacing systems, buildings, or components needed for the continued operation of a safe and effective facility.
Hazardous Materials
FSE.7 M
The hospital has a plan for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and waste.
Measurable Elements:
M 1. The hospital identifies hazardous materials and waste and has a current list of all such materials within the organization.
2. The plan includes safe handling, storage, and use of hazardous materials.
3. The plan includes reporting and investigation of spills, exposures, and other incidents.
M 4. The plan includes the proper handling of waste within the organization and disposal of hazardous waste in a safe and legal manner
M 5. The plan includes access to material safety data sheets, the proper personal protective equipment, and procedures during use, spill, or exposure.
M 6. The plan identifies documentation requirements including any permits, licenses, or other regulatory requirements.
M 7. The plan includes labeling hazardous materials and waste.
M 8. The plan includes proper disposal of medical waste. 9. The plan is implemented and documented.
Emergency Management
FSE.8 The hospital develops and maintains an emergency management plan and program to respond to likely community emergencies, epidemics, and natural or other disasters.
Measurable Elements:
1. The hospital has identified the major internal and external disasters and major epidemic events which pose significant risks of occurring, and has developed a plan for responding.
2. The plan is tested annually with improvement opportunities identified and assigned timeline for action documented.’
3. Staff members participate in at least one emergency- preparedness test per year.
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STANDARD AND SCORING
REQUIREMENTS
M
NM
N/A
Fire Safety
FSE.9 M
The hospital plans and implements a program to ensure that all occupants are safe from fire, smoke, or other emergencies in the facility.
Measurable Elements:
M 1. The hospital plans a program to ensure that all occupants of the organization’s facilities are safe from fire, smoke, or other non-fire emergencies.
M 2. The program includes the identification and reduction of fire risks.
M 3. The program includes the assessment of fire risks when construction is present in or adjacent to the facility. M 4. The program includes the early detection of fire and
smoke.
M 5. The plan includes the abatement of fire and containment of smoke.
M 6. The program includes the safe exit from the facility when fire and non-fire emergencies occur.
7. The program includes the education of staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and safely manage medical gases.
FSE.10 M
The hospital regularly tests its fire and smoke safety plan.
Measurable Elements:
M 1. Fire detection and abatement systems are inspected, tested, and maintained at a frequency determined by the manufacture and local regulations.
M 2. The fire and smoke safety evacuation plan is tested at least twice a year.
M 3. Staff members are trained to participate in the fire and smoke safety plan.
M 4. Inspection, testing, and maintenance of equipment and systems are documented.
FSE.11 M
The hospital develops and implements a plan to limit smoking by staff and patients to designated non–patient care areas of the facility.
Measurable Elements:
M 1. The hospital has implemented a policy and plan to eliminate or limit smoking.
M 2. The plan applies to all individuals within the facility and on the grounds.
M 3. There is a process to grant patient exceptions to the plan.
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STANDARD AND SCORING
REQUIREMENTS
M
NM
N/A
Medical Equipment
FSE.12 M
The hospital plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results.
Measurable Elements:
M 1. There is an inventory of all medical equipment. M 2. Medical equipment is regularly inspected.
3. Medical equipment is tested when new and according to manufacture recommendation thereafter with documentation of testing for each piece of equipment. 4. There is a preventive maintenance program.
5. Qualified individuals provide these services. FSE.13
M
The hospital has a product/equipment recall system.
Measurable Elements:
M 1. There is a product/equipment recall system in place.
M 2. Policy or procedure addresses removal from service of any product or equipment any use of any product or equipment under recall ‘
3. The policy or procedure is implemented and documented.
Utility Systems
FSE.14 M
Potable water and electrical power are available 24 hours a day, seven days a week, through regular or alternate sources, to meet essential patient care needs.
Measurable Elements:
M 1. Potable water is available 24 hours a day, seven days a week.
M 2. Electrical power is available 24 hours a day, seven days a week.
M 3. The hospital has identified the areas and services at greatest risk when power fails or water is contaminated or interrupted.
M 4. The hospital plans alternate sources of power and water in emergencies.
M 5. The hospital regularly tests alternate sources of water and electricity following applicable regulatory policies or laws. M 6. The hospital documents the results of such tests.
M 7. Water used in chronic renal dialysis is tested regularly. FSE.15
M
Electrical, water, waste, ventilation, medical gas, and other key systems are regularly inspected, maintained, and, when appropriate, improved.
Measurable Elements:
M 1. Utility, medical gas, ventilation, and other key systems are identified by the hospital.
M 2. Key systems are regularly inspected.
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REQUIREMENTS
M
NM
N/A
M 3. Key systems are regularly tested. M 4. Key systems are regularly maintained.
5. Key systems are improved as appropriate.
6. Monitoring data are collected and documented for the utility management program.
Staff Education
FSE.16 Staff members, volunteers, and contract workers are trained and knowledgeable about their roles in the hospital’s plans for fire safety, security, hazardous materials, and emergencies. Measurable Elements:
1. For each of the seven components of the hospital’s facility management and safety program, there is planned education to ensure that staff members can effectively carry out their responsibilities.
2. The education includes visitors, vendors, contract workers, and others as appropriate to the organization and multiple shifts of staff.
TOTAL PERCENT OF COMPLIANCE