ENVIRONMENT OF CARE
The environment of Care standards aren’t just about compliance or accreditation—they’re the way to sustain a safety culture for staff, patients, and visitors.
To provide true value, staff and leaders must think of these standards as a way to lay the foundation for a safe and responsive setting. It is the plan for managing the safety of anyone coming to your facility. It should include the inside and outside of the physical grounds, risk reduction, colleague and client/patient injury, product recalls, and safety teams.
As we explore each area, we will cover specifics such as the need for a designated Safety Officer and, if appropriate, a safety team, a reporting process for safety hazards and maintenance work requests, incident reporting, and damaged or damaged or non-functioning equipment notification. First Aid, Blood Spill, and Chemical Spill kits should be located throughout a facility. These are all examples of the necessary steps to create a safe environment.
The Joint Commission’s Environment of Care (EC) standards require organizations to develop management plans in six functional areas:
- Hazardous materials and waste
- Fire safety
- Medical equipment
Let’s take a look at these in more detail.
How an organization plans for, responds to, and recovers from emergency-related events is critical. Depending on the size and type of setting, examples of events that a facility might need to be prepared for include:
- Patient surge, Patient triage, Patient Identification, Patient tracking
- Response Guides (Codes plus Dept. specific)
- Hospital Incident Command in the event of an emergency
- Fatality Management
- Volunteer Management
- Utilities (generators, water, etc..)
- Safety & Security (traffic, access control, etc..)
A few more general safety areas include ensuring that personal protective equipment is available and the staff is trained to use them properly. These should be maintained so that they are ready when needed. Also, floor surfaces should be clear and dry. Postings regarding how to report incidents and workplace tolerance can be helpful.
Safety Team: An established team with scheduled, regular meetings should be ongoing, if appropriate. Minutes should be taken at each meeting. Experience has shown that items discussed and left open and not discussed again without closure will get facilities into trouble.
Security includes the processes implemented to effectively manage the security of everyone within the facility. This could include:
- Access control
- Panic/Intrusion Alarms
- Infant Security
- Visitor access (after-hours)
- Vehicle security
- Call boxes
- Workplace Violence identification/response training
- Security audit/Risk assessment
- Policy enforcement-weapons, zero tolerance, background checks upon hire
- Establishing protocols for the buddy system
- HIPPA and EMTALA reviews
- VIP/Media policy
- Posting such as Property Subject To Search By Security and No Photography On-Premises
The Security Management Plan outlines several measures the organization takes to ensure patient, employee, and visitor safety. These measures are facility-specific—the following offer general guidelines. Please request further information from your specific facility.
- All employees should display their identification badges, if provided, while on property.
- Vendors, visitors, and outsourced service providers should sign in at the Reception Desk upon arrival and sign out when they leave.
- NO weapons of any sort should be allowed on the property.
- When making a 911 Emergency Call, the specific address and exact location should be given.
Various security measures exist to increase overall safety and security within the buildings and the surrounding outdoor environment.
Some of these include:
- Exterior lighting
- Identification of ‘high-risk’ areas requiring additional security (medical record areas, medication rooms, business office)
- Security rounds
- Visitor sign-in and identification
- Surveillance cameras
- Employee identification (picture ID badges)
- Management of access to keys and/or door code locks, etc.
All staff should be taught to log off when they leave a system. If privacy hoods are in place, they should be left in place. Passwords should not be shared.
The workplace should be free from violence or threats of violence. While we can’t predict when violence will occur, some warning signs may help recognize the potential for violence in patients, co-workers, or others coming into the organization.
- Chronic or acute mental illness
- History of violent behavior
- Drug or alcohol problems
- Medical condition or medication side-effects
- Recent divorce or separation
Violence can often be avoided if necessary precautions are taken. When dealing with patients and visitors:
- Wear clothing such as low-heeled shoes to reduce the risk of injury
- Avoid wearing jewelry to work
- Keep keys and pens, which may be used as weapons, out of sight
- Report all threats to your supervisor
- Use the “buddy” system anytime you think that your safety may be at stake
Defuse the Situation:
Staff must know how to defuse a potentially violent situation.
- Back off; give the person plenty of space.
- Speak in a calm voice
- Work to build trust
- Let the person talk about why they are upset.
- Listen carefully
- Help define the problem by asking for examples of what the person means.
- Explore solutions by asking open-ended questions
- Provide clear, responsive feedback
It is a best practice for every organization to adopt a “zero tolerance” policy for workplace violence. Any employee, regardless of position in the organization, should be disciplined up to and including termination for violating the workplace violence policy.
- Violent acts, such as hitting, shoving, or stabbing
- Possession of weapons on the property, such as a bomb or gun
- Verbal or nonverbal threats, such as “I’ll take care of you,” or shaking fists, or waving a knife
- Intentional damage to property, such as slamming doors, hitting walls, or breaking equipment
Property – Employees should have NO expectation of privacy for organizational property.
An active shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearm(s), and there is no pattern or method to select victims.
To preserve life and address the reality of an active shooter event, guidelines should be established to guide the response to this event to maximize survivability. Most importantly, quickly determine the most reasonable way to protect your own life.
Upon discovery of an active shooter situation, as soon as possible and when safe to do so, notify law enforcement (911) and provide overhead announcements, if available.
The phone call to 911 (from the area where they are safely concealed) should provide the following information:
- Description of the suspect and possible location.
- Number and types of weapons.
- Suspect’s direction of travel.
- Location and condition of any victims
Depending on your plan and type of administration, Safety & Security Officers and/or the Administrator/Person in Charge should meet and guide law enforcement officers, if possible, and as appropriate. The goal of law enforcement is to locate, isolate, and neutralize the shooter as quickly as possible to prevent additional deaths or injuries.
A plan should address the following:
- Have an escape route and plan in mind
- Evacuate regardless of whether others agree to follow
- Leave your belongings behind
- Help others escape, if possible
- Prevent individuals from entering an area where the active shooter may be
- Keep your hands visible
- Follow the instructions of any police officers
- Do not attempt to move wounded people
- Call 911 when you are safe
If evacuation is impossible, find a place to hide where the active shooter is less likely to see you.
- Direct personnel into resident rooms or other adjacent rooms, close the door, and attempt to barricade the door.
A hiding place should:
- Be out of the active shooter’s view
- Protect if shots are fired in your direction (i.e., locating into a resident bathroom and locking the door, staying as low to the floor as possible, and remaining quiet and still)
- Not trap you or restrict your options for movement
To prevent an active shooter from entering your hiding place:
- Lock the door
- Blockade the door with heavy furniture
If the active shooter is nearby:
Lock the door
- Silence your cell phone and/or pager
- Turn off any source of noise (i.e., radios, televisions)
- Hide behind large items (i.e., cabinets, desks)
- Remain quiet
If evacuation and hiding out are not possible:
- Remain calm
- Dial 911, if possible, to alert police to the active shooter’s location
- If you cannot speak, leave the line open and allow the dispatcher to listen
Take action against the active shooter – As a last resort, and only when your life is in imminent danger.
Florida Statute section 394.458 states that “except as authorized by law,” it is a third-degree felony for any person to bring, carry, possess, or transport a “firearm or other dangerous weapons” Upon the grounds of any “hospital (or mental health facility) providing mental health services.”
If a client arrives with a weapon, this needs to be confiscated and immediately removed from the premises by an adult family member or the police department. In the absence of an arrest and criminal charge against the person sent for evaluation under Florida’s Baker Act, the Sheriff may not retain firearms confiscated from such persons and retained by that office once the client is released and a request is made.
A lockbox can be provided, and weapons can be locked in vehicles if brought on-premises. Signs should be posted regarding facilities-specific policies.
The receiver of a bomb threat call must remain calm so that as much as possible can be recalled of what was said by the caller. Take notes and try to keep the person talking so he or she may give some indication as to identities, such as race, age, or knowledge of the facility, that might indicate if he or she is or has been an employee of the location or other factors. Do not be in a hurry to end the call. Let the caller terminate the call.
The person receiving the call should try to obtain information about the bomb by asking about its location, timing devices, and packaging.
Notification of the receipt of a bomb threat phone call should be accomplished in a manner that avoids being overheard by other personnel in the vicinity. Only designated personnel should be notified to avoid undue apprehension from other employees and patients.
Keep in mind that if some suspicious item is found through a search or located in the caller’s direction, do not touch or move the object. Notify the person in charge who should alert the fire or police officers on the scene.
Any employee who receives a bomb threat call should follow the specific facilities’ policies and procedures given for handling bomb threat calls and, after the conversation, should notify their immediate supervisor.
All employees are reminded to avoid undue apprehension, maintain confidentiality, and report the threat in an area where the report will not be overheard.
Security is of particular concern to everyone in today’s uncertain world. All employees must do their part to maintain the integrity of the Security Management Plan and report any potential areas of security violation and/or vulnerability.
HAZARDOUS MATERIALS AND WASTE
Hazardous materials are any items that may be considered infectious or any chemical with properties that may be flammable, combustible, damaging to skin or organs, or producing dangerous fumes.
Managing hazardous materials and waste at a facility is an important area. These can include items such as:
- Infectious (biohazardous)
- Hazardous (flammable, corrosive, toxic, reactive)
The areas of concern include:
- Surveying atmospheres/Passive employee monitoring
- MRI safety
- Security of compressed gas
- Annual training
- After-hours emergency response
- EPA notifications
- Pharmaceutical waste management
- Monitoring- training/competencies
- Hazcom/DOT Training
- Risk Assessments
Hazard Communication (Chemical Safety)
A hazard communication program is designed to provide pertinent information to employees working with or around hazardous chemicals. There are three components to the hazard communication program:
- Labels / Storage
- Material Safety Data Sheets (MSDSs)
The first component deals with label requirements. All chemicals in use must be properly labeled and stored in a safe area. No chemicals are to be stored under sinks.
Material Safety Data Sheets (MSDSs)
The second component of hazard communication involves MSDSs. An MSDS is a document provided by the manufacturer, importer, or distributor of the hazardous chemical(s). It provides information on the hazards associated with hazardous chemicals and recommendations for safe use, handling, and disposal. The MSDSs must be available within the work area.
The MSDS is divided into sections. Each section is dedicated to a specific topic (i.e., Reactivity, Fire & Explosion Data, Health Hazards, etc.) Some of the sections are listed below:
- Name of Chemical
- Chemical Components
- Associated Hazards
- Physical Characteristics
- First Aid/Emergency Response
- Spill and Leak Handling
- Disposal Practices
- Personal Protective Equipment
It is also important to know the hazards (symptoms of overexposure) of the chemicals in the work area to work safely with the chemical(s) or to make determinations regarding overexposure. This information is also available on the MSDS.
All staff should be regularly trained in hazard communication.
An organization is responsible for protecting patients, visitors, and employees from the potential adverse effects of fire emergencies. To fulfill this responsibility, an extensive fire safety (life safety) policy, procedure, and education program should be developed.
A comprehensive fire safety plan is more than just periodic fire drills. It involves managing all aspects of fire safety, including items such as:
- Fire Drills
- Preventive Maintenance
- Fire response
- Life Safety building safeguards (equipment, firewalls, fire doors, emergency lighting, etc..)
- Interim Life Safety Measure Assessments
- Life Safety Deficiencies
Recommendations in the area of fire safety include reviewing plans for improvement with the safety team, training kitchen staff in the use of fire extinguishers, protocols for gas valve shut-off devices, and fire drills for staff, including weekend staff, as the most important area, prevention.
The most important part of fire safety is prevention. The following are some guidelines or tips on how to prevent fires.
- Never overload electrical circuits. Use heavy-duty surge protectors with in-line circuit breakers in areas where multiple receptacles are needed.
- Never leave open flames unattended.
- Store flammable/combustible materials in appropriate containers and away from heat and ignition sources.
- Dispose of trash (paper, cardboard, and other combustible materials) promptly. Maintain good housekeeping.
- All space heaters must be listed underwriter’s Laboratory (UL) and equipped with a tip-over cut-off switch.
Employees and visitors should observe a no-smoking policy within the organization (no smoking indoors). Smoking can be permitted in designated areas. No smoking should be permitted near building entrances /exits. Compliance with the smoking policy should be continually monitored, and strategies developed to address non-compliance.
The following guidelines can be established for personal safety during a fire emergency.
- Keep fire exits and stairwells free from any obstruction.
- Identify the primary and secondary evacuation routes and keep those routes unobstructed.
- Understand the use and know the location of fire extinguishers and fire alarm pull stations (if available).
- All staff should participate in scheduled fire drills.
911 should be called in case of a fire.
A common code for fire safety is R-A-C-E. The RACE acronym stands for:
Remove anyone from immediate danger.
Sound the alarm with a manual pull station.
Confine Close all doors and windows.
Extinguish/evacuate Know locations and how to use fire extinguishers.
Staff should be continuously aware of those patients or peers needing assistance in the case of an emergency so that their evacuation can be made as quickly as possible when necessary.
It is also very important that employees understand their responsibilities and know all evacuation routes if an evacuation is necessary due to a fire emergency. Listed below are some of the key points to remember:
- When patients are evacuated from their rooms, check to ensure that the room is vacant, then close the door.
- Assist those requiring additional help to safely leave the building.
- Do not use elevators if present during a fire emergency.
- Use primary or secondary evacuation routes to vacate the premises.
- Avoid stairwells; first, try to evacuate using connecting corridors.
- Roll call is to be taken at the designated “safe” area to ensure all have safely been evacuated.
All employees must know how to respond in the event of a fire emergency.
Processes to ensure patient care equipment’s effective, safe, and reliable operation should be established. The areas of concern include:
- Preventive Maintenance
- Physical risk
- Safe Medical Device Act
A plan should detail the staff’s education on devices, what to do if a piece of medical equipment injures someone, an alert system or process for recalls, and how to handle equipment failures.
Utility management includes the effective, safe, and reliable operation of utility systems, including the electrical (generators), heating, ventilation, air conditioning (HVAC), plumbing systems, medical gas system, communications systems (excluding telephones), and preventive maintenance.
- Involve subject matter experts in plan development.
- Clearly outline the plan’s objectives and scope.
- Clearly describe a method for monitoring performance.
- Outline a process for determining plan effectiveness.
- Detail the annual evaluation process.
- Create supplemental information.
- Create a process for ensuring that the policy reflects practice.
- Consider other standard chapters.
- Respect the strictest authority having jurisdiction.
The Environment of Care Plan’s goal is to promote a safe, functional, and supportive environment within an organization to preserve quality and safety. A secure, operative environment is created when risks are managed. When staff is educated about the elements of a safer environment, they are more likely to follow processes for identifying, reporting, and taking action on environmental risks.