Safety & Security Bill Kemp Manager, Department of Public Safety Providence Little Company of Mary Medical Center 26-September-2013.

Safety & SecurityBill Kemp Manager,Department of Public SafetyProvidence Little Company of Mary Medical Center26-September-2013

Introduction

• PLCMMCT 28 years• Security Management Role 22 years• Disaster Management Role 16 years• Safety Management Role 13 years• Service at LCM, SPH & BHH• 2 years K9 – Explosives Detection• Personal Professional focus in Terrorisms and

Active Shooter

Chapter Purpose

Section addresses identifying and managing risks in the physical environment

Systematic approach involving proactive evaluation of the harm that could occur.

Responsible Parties:

1) An individual(s) identified by Leadership as responsible for:

Managing risks

Coordinating risk reduction activities

Collecting deficiency information

Disseminating summaries of actions and results

Chapter Purpose

2) An individual(s) identified by Leadership to intervene:

When environmental conditions immediately threaten life or health, or

Threaten to damage equipment or property

Identify the individual(s) by Name and Title

Responsible Parties: (Cont’d)

Issues to consider:

OSHA & CDPH

Identifying & Managing RisksSystematic approach to identify risks

Identify risks that are common to all areas

Identify risks that are specific areas

Identify risks that frequently occur

Rate the likelihood or frequency of each risk occurring

Utilize your EoC Committee members

Utilize staff and leaders from identified departments

Identify protective measures in place needed for each risk factor

Identify gaps or deficiencies for risk factors

Document on-going improvements

Subject Matter Experts (SME’s)

2013 PLCMMCT Safety & Security Risk Assessment for Hazards and Protective Measures

UNIT/AREA NEEDLES / SHARPS TB EXPOSURE CHEMICAL EXPOSURE LASER ASSAULT BLOOD / BODY FLUID LIFTING PATIENT LIFTING MATERIAL THEFT INFANT / PEDS SECURITY STFERGO(CT)

BURNS FIRE GAS VAPOR FUME ELECTRICAL FAILURE ASBESTOS RADIATION ELOPEMENT EYE WASH NEED

NOISELEVEL

ADMITTING         E/S       P/E     S   T/P             

34

ADMINISTRATION                          T/P          

   29

ACCTS PAYABLE                          T/P          

   28

ANESTHESIA                          T/P   E      

   37

AOUT/P/E T/P/E       T/P/E T/P/E   P         T/P          

   38

BIO MEDICAL                          T/P          

   34

BLOOD BANKT/P/E   T/P/E     T/P/E               T/P           E

 47

BUSINESS SVCS                      S   T/P          

   29

BUSINESS OFFICES                      S   T/P          

   31

CARDIAC CATH LABT/P/E T/P/E   T/P/E     T/P/E             T/P       T/P/E  

   41

CARDIAC ANGIO REHAB  T/P/E                       T/P       T/P/E  

   32

CASE MGMT  T/P/E                       T/P          

   29

CAFETERIA                          T/P          

   27

CENTRAL SUPPLY              T/P           T/P          

   38

COMMUNITY RELATIONS                          T/P          

   28

CONFERENCE ROOMS                          T/P          

   27

CONSTRUCTION              T/P           T/P          

   32

DATA PROCESSING                      S   T/P          

   31

DIALYSIST/P/E         T/P/E T/P/E             T/P          

   36

DRS LOUNGE                          T/P          

   25

EEG                          T/P          

   29

ECHO                          T/P          

   32

EKG / CARDIO                          T/P          

   32

EMERGENCY SVCST/P/E T/P/E T/P/E   T/P/E T/P/E T/P/E T/P           T/P   E   T/P/E P

   50

EMPLOYEE HEALTH                          T/P          

   32

ENDOSCOPY    T/P/E     T/P/E               T/P           E

 39

ENVIRONMENTAL SVCS                    T     T/P          

   37

FACILITIES SVCS                          T/P   E      

   32

FINANCE                      S   T/P          

   29

FOOD & NUTRITION                          T/P          

   35

FOUNDATION                          T/P          

   38

GIFT SHOP                          T/P          

   27

ICUT/P/E T/P/E       T/P/E T/P/E             T/P   E   T/P/E  

   43

INFO. SYSTEMS                          T/P          

   32

HUMAN RESOURCES                          T/P          

   29

INFECTION CONTROL                          T/P   E      

   22

H.I.S.                          T/P          

   28

KITCHEN                    E/T     T/P          

 P/E/S 33

LABORATORYT/P/E T/P/E T/P/E     T/P/E               T/P S         E

 46

  RISK FACTOR FOR HAZARDS PROTECTIVE MEASURES AFFORDED EACH AREA

  1 VIRTUALLY NO RISK 

C CHANGE IN PROCESS REQUIRED   

Risks identified through data collection, facility/departmental history, known factors and potential risks.

  2 MINIMAL RISK 

T TRAINING REQUIRED   

  3 MODERATE RISK 

P POLICY & PROCEDURE REQUIRED   

  4 HIGH RISK 

E PPE / SAFETY EQUIPMENT REQUIRED 

 5 SEVERE RISK W/ HISTORY

 S Surveillance / Monitoring

                                      Revised 7/09, 1/10, 1/11, 1/12, 1/13, 8/13    

UNIT/AREA

ADMITTING

ADMINISTRATION

ACCTS PAYABLE

ANESTHESIA

AOU

BIO MEDICAL

BLOOD BANK

NEEDLES / SHARPS

TB EXPOSURE

CHEMICAL EXPOSURE

LASER ASSAULT BLOOD / BODY FLUID

        E/S  

T/P/E T/P/E       T/P/E

T/P/E   T/P/E     T/P/E

34

29

28

37

38

34

47

135 133 105 80 89 129

RISK FACTOR FOR HAZARDS  

1 VIRTUALLY NO RISK 

2 MINIMAL RISK 

3 MODERATE RISK 

4 HIGH RISK 

5 SEVERE RISK W/ HISTORY

PROTECTIVE MEASURES AFFORDED EACH AREA 

C CHANGE IN PROCESS REQUIRED 

T TRAINING REQUIRED 

P POLICY & PROCEDURE REQUIRED 

E PPE / SAFETY EQUIPMENT REQUIRED 

S Surveillance / Monitoring    

Risks identified through data collection,

facility/departmental history, known factors

and potential risks.

2012 Updates:Assaults - AOU, Case Mgmt., Oncology, 4th Med reduced from Min Risk (2) to Virtually No Risk (1). No events over last 2 years in these areas.2013 Updates:Assaults - Admitting - Employee domestic violence issue. Safety Plan with employee, installation of panic alarms, increased surveillance by Public Safety

Proactive EvaluationEC.04.01.01

The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following:

Injuries to patients or others within the hospital's facilities

Occupational illnesses and staff injuries

Incidents of damage to its property or the property of others

Hazardous materials and waste spills and exposures

Fire safety management problems, deficiencies, and failures

Medical or laboratory equipment management problems, failures, and use errors

Utility system management problems, failures or use errors

Proactive EvaluationEC.04.01.01 (Cont’d)

EP 12:

The hospital conducts environmental tours every six months in patient care areas to evaluate the effectiveness of previously implemented actives intended to minimize or eliminate environment of care risks

EP 13:

The hospital conducts annual environmental tours in non-patient care areas to evaluate the effectiveness of previously implemented actives intended to minimize or eliminate environment of care risks

Proactive EvaluationEnvironmental Safety Rounds

Team Approach – EoC members

Each member completes a rounding log

ENVIRON/MENT OF CARE ROUNDS Y N PARTIAL NA COMMENTS

MEDICAL EQUIPMENT MANAGEMENT

1. Staff can ID who does maintenance on medical equipment

1. Staff can ID what to do when equipment is not working1. Staff can ID how to initiate equipment repair request

1. Staff can articulate process for obtaining Emergency After-hours service.

1. Staff can ID BEC sticker

1. Staff can articulate how they know equipment has been checked

1. Staff can ID when due for next PM1. Staff can articulate what to do if PM sticker is expired1. Preventive Maintenance (PM) sticker current

1. Medical equipment is attended in hallway and not stored in the hallway.

1. Medical equipment clean

1. Alarm ports not covered with tape1. Defibrillator logs are current and completeADDITIONAL FINDINGS

Proactive EvaluationMembers determine what items to survey on:

Standards in their area of the EoC

Known or on-going issues

Hot topics for TJC

Upcoming hot topic

Members finding non-compliant issues are responsible for:

Documenting on Rounding Form

Placing a work order for correction (documenting W. O. number on form)

Discussing finding with Unit Manager/Supervisor (documenting on form)

Turning completed Rounding Form to the Safety Officer

Issues listed on the Safety & Security Risk Assessment

Proactive EvaluationSafety Officer’s Responsibility

Receive all Rounding forms and review.

Note trends or patterns for reporting to the EoC Committee

Assist Department Mangers in identifying strategies to correct trends or patterns.

Maintain records on Safety Rounds for Survey

Disseminating Actions & Results

Code Y

ellow

Comm

and C

enter

Loca

tion

Decon

Loca

tion

PIO N

ame

PIO Jo

b

Not Par

ticiap

ted in

Disa

ster D

rill (

Last

6 mon

.)

Loca

tion o

f Man

power

Poo

l

Code P

urple

Code S

ilver

Bio-m

ed M

gr.

Med

. Equ

ip. N

ot Stor

ed in

Hall

s

Not Par

ticipa

ted in

Fire

Dril

l (La

st 6 m

on.)

Fire D

oor B

urn-

throu

gh T

ime

Hallway

Clud

dere

d

Closes

t Sm

oke C

ompa

rtmen

t

Disaste

r Man

ager

Who

Con

ducts

Fire

Dril

ls

02 T

anks

chain

ed

Exit D

oors

Bloc

ked

Storag

e 18"

from

Spr

inkler

s

Bio-M

ed P

M S

ticke

rs C

urre

nt

Code G

ray

0

5

10

15

6 Month Trending (Jan-Jun)

Incorrect Partial

EoC Reporting Tool

Proactive Evaluation

Little Company Mary Hospital

(2nd Friday each month) PATIENT CARE AREAS NON-PATIENT CARE AREAS

Environment

al Roun

ds2012-2013

July 7, 2012 9:00am 1st Ortho Med/Surg ICU 2nd Floor TCU 2nd Floor              

August 12, 2012 9:00am 3rd Women's Health- North 3rd Women's Health- East 3rd Women's Health- West PEDs NICU    

September 9, 2012 9:00am 4th Med/Surg- North 4th Med/Surg- East 4th Med/Surg- West 2nd OR PAR    

October 14, 2012 9:00am 4th AOU Emergency Department G.I. Lab   Pharmacy Admitting Chapel Human Resources  

November 11, 2012 9:00am 4th Med/Card Imaging PT/OT OutPt DX FMC Administration Laboratory Pathology  

December 9, 2012 9:00am 3rd L/D Hannon         Dietary Environmental Services Plant Operations/ Grounds Central Supply

January 13, 2013 9:00am 1st Ortho Med/Surg ICU 2nd Floor TCU 2nd Floor              

February 10, 2013 9:00am 3rd Women's Health- North 3rd Women's Health- East 3rd Women's Health- West PEDs NICU    

March 10, 2013 9:00am 4th Med/Surg- North 4th Med/Surg- East 4th Med/Surg- West 2nd OR PAR    

April 14, 2013 9:00am 4th AOU Emergency Department G.I. Lab      

May 12, 2013 9:00am 4th Med/Card Imaging PT/OT OutPt DX FMC    

June 9, 2013 9:00am 3rd L/D Hannon                  

Environment

al Roun

ds2013-2014

July 14, 2013 9:00am 1st Ortho Med/Surg ICU 2nd Floor TCU 2nd Floor              

August 11, 2013 9:00am 3rd Women's Health- North 3rd Women's Health- East 3rd Women's Health- West PEDs NICU    

September 8, 2013 9:00am 4th Med/Surg- North 4th Med/Surg- East 4th Med/Surg- West 2nd OR PAR    

October 13, 2013 9:00am 4th AOU Emergency Department G.I. Lab   Pharmacy Admitting Chapel Human Resources  

November 10, 2013 9:00am 4th Med/Card Imaging PT/OT OutPt DX FMC Administration Laboratory Pathology  

December 8, 2013 9:00am 3rd L/D Hannon         Dietary Environmental Services Plant Operations/ Grounds Central Supply

January 12, 2014 9:00am 1st Ortho Med/Surg ICU 2nd Floor TCU 2nd Floor              

February 9, 2014 9:00am 3rd Women's Health- North 3rd Women's Health- East 3rd Women's Health- West PEDs NICU    

March 9, 2014 9:00am 4th Med/Surg- North 4th Med/Surg- East 4th Med/Surg- West 2nd OR PAR    

April 13, 2014 9:00am 4th AOU Emergency Department G.I. Lab      

May 11, 2014 9:00am 4th Med/Card Imaging PT/OT OutPt DX FMC    

June 8, 2014 9:00am 3rd L/D Hannon                  

Schedule in advance – Publish for Team

Hot Topics

Most challenging requirements for the first half of 2013

Non-compliance rate Standards and NPSGs

Hospital

54% LS.02.01.20 The hospital maintains the integrity of the means of egress.

46% EC.02.05.01 The hospital manages risks associated with its utility systems.

45% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

Published August 2013

Hot Topics

Non-compliance rate Standards and NPSGs

Ambulatory Care

No Environment of Care EP’s Listed

Critical Access Hospitals

53% EC.02.03.05 The critical access hospital maintains fire safety equipment and fire safety building features .

49% LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

47% EC.02.05.01 The critical access hospital manages risks associated with its utility systems.

43% LS.02.01.01 The critical access hospital maintains the integrity of the means of egress.

What does the future hold?

Future FocusEC.02.01.01

The hospital manages safety and security risks

EP 3 – the hospital takes action to minimize or eliminate identified safety and security risks in the physical environment

EP 7 – The hospital identifies individual entering its facilities

EP 9 – The hospital has written procedures to follow in the event of a security incident, ……

EP 10 – When a security incident occurs, the hospital follows its identified procedures.

H&S Code 1157.7 (AKA – AB508) {CDPH Licensing Surveys}

Future Focus

Active Shooter Events

46 + shooting events at hospitals in 2012

Unofficial tally by Linked-in IAHSS Group members

Continued media coverage of active shooter events

Navy Ship Yard – Washington DCSandy Hook Elementary – Connecticut

Future FocusEC.02.01.01 - EP 3

The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

Procedures for protecting Staff and their co-workers when a Restraining Order is issued by the Court

Procedures when family members of a patient make threats

Procedures when discharging employees with high risk for violence

Issues to consider:

Future FocusEC.02.01.01 - EP 7

The hospital identifies individuals entering its facilities.

Are you monitoring all entrances 24/7

Are staff educated on how to recognize the potential for violence

Are Security staff trained in behavioral clues for individual carrying concealed weapons

If individuals are removed from the facility are there procedures to identify them and prevent re-entry

Issues to consider:

Future FocusEC.02.01.01 - EP 9

The hospital has written procedures to follow in the event of a security incident, …….

Does your facility have a Code Silver or similar policy?

Have staff been trained on what to do in the event of a Code Silver

At the Code Silver location

Away from the Code Silver location

Have trained staff been tested on their response (Drilled)

Are drills coordinated with local Law Enforcement

Have Security staff been tested on their response (Drilled)

Issues to consider:

Best Practice for Compliance

Develop a policy which outlines staff and Security’s roles and responsibilities both at the location of an active shooter location and away from the location.

Train all staff on this P&P

Drill with Staff and Security

Drill with Staff, Security and Local Law Enforcement

TRAIN SECURTIY DISPATCH/PBX PERSONELL

Locations w/o facility jargon

Directions from each entrance to all locations

Drill with Security and Local Law Enforcement (entrances, stairwells, elevators)

Best Practice for Compliance

Active Shooter Statistics

40 – 40 – 10 – 10

100%

4 per minute

Dispatch/PBX is critical to the fastest response by PD

Standard PD A.S. Response

Because the plan says – don’t make it so

Directions from each entrance to all locations

Best Practice for Compliance

Why the training is critical

Chris Riccardi’s favorite saying

Fight or Flight

Empowers staff to move out of FREEZE

Reacting reduces

Number of targets available to the shooter

The number of minutes the shooter has until PD arrives

Future FocusActive Shooter Events

46 + shooting events at hospitals in 2012

Unofficial tally by Linked-in IAHSS Group members

Continued media coverage of active shooter events

Navy Ship Yard – Washington DCSandy Hook Elementary – Connecticut

EC.02.01.01 - EP 10

When a security incident occurs, the hospital follows its identified procedures.

Hopefully your facility will never have an active shooter event

Documentation of your drills will support that you follow your procedures

Questions