Guide to JCAHO Environment of
Care Standard 1.10.1
Please note: this page is under development. Contact
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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.
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. |
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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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= Compliance |
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= Environmental Improvement |
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=
Tools and Resources |
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General
Safety Management Plan
Hazardous
Materials and Waste
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:
- appropriate
risk assessments
- compliance
requirements
- education
and training requirements
- safe
handling (including labeling, use, storage, spill
prevention, and waste management)
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--
detailed provisions for specific materials of concern,
including:
- asbestos
- mercury
- pesticides
- petroleum
products and used oil
- pharmaceuticals
(chemotherapeutics)
- radioactive
materials and waste
- solvents
- a
variety of chemicals used in
- boiler
rooms
- laboratories
- pharmacies
- paint
shop
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--
specifications
for managing:
- employee
safety
- hazard
identification
- community
safety and security
- personal
protective equipment
- spill
clean up
- employee
training
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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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- Sample
Hazardous Materials Management Plan - to
be linked
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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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Regulated
Medical (Infectious) Waste
Training
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