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U.S. Department of Health and Human Services
Indian Health Manual

National Council Of Healthcare Safety And Engineering Professionals – Charter

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
Rockville, Maryland 20857

Refer to: OQ/OEHE

INDIAN HEALTH SERVICE CIRCULAR NO. 25-18

Sec.

1. Purpose
2. Scope
3. Membership
4. Responsibilities
5. Supersedure
6. Effective Date
  1. Purpose. The purpose of the Indian Health Service (IHS) National Council of Healthcare Safety and Engineering Professionals (NCHSEP) is to conduct risk management and perform root cause analyses on various systems related to the Agency's environment of care and life safety compliance at health care facilities. This council will create, reorganize, and optimize health care physical environment systems to enhance compliance with regulatory, Federal, and consensus standards related to the physical and functional aspects of the health care environment. The NCHSEP will include strategic planning to improve environmental health and increase reliability within all health care facility infrastructure and engineering components.
  2. Scope. The NCHSEP supports a system-wide culture of safety. Patient and workforce safety are principal elements in all operations and reflected in all actions with a goal of zero preventable harm.
  3. Membership. The NCHSEP is a permanent member of the IHS National Combined Councils (NCC) made up of Federal IHS employee representatives who possess expertise and knowledge in matters relating to Healthcare Engineering, Clinical Engineering, and Occupational Safety and Health within the Indian Health System. The NCHSEP operates under the guidance and authority of the IHS’s Deputy Director of Quality Healthcare and Enterprise Risk Management (DDQHERM), and the Director of the Office of Environmental Health and Engineering (DOEHE). The NCHSEP has two components: An Executive Committee and a General Board. Every two years, the NCHSEP will determine the number of members, and their responsibilities needed to accomplish the council's purpose. The Executive Committee and the General Board members will make recommendations to determine the need for ad hoc subcommittees and the subcommittee’s memberships.
    1. Executive Committee. The NCHSEP Executive Committee includes elected and appointed representatives. The Executive Committee structure may be redesigned as needed to meet its intended purpose based on the functional and outcome needs of the NCHSEP. The Executive Committee includes the following positions with voting rights unless otherwise noted:
      1. Senior Sponsor(s) Headquarters (HQ) DOEHE and the DDQHERM or designees;
      2. Director of Office of Quality (DOQ) or designee;
      3. Office of Quality (OQ) Environment of Care and Life Safety Coordinator Staff;
      4. HQ Office of Environmental Health and Engineering (OEHE) Institutional Environmental Health Program Manager;
      5. HQ OEHE Engineering staff member or designee;
      6. Chairperson;
      7. Vice Chairperson;
      8. Secretary;
    2. General Board Members. The NCHSEP Executive Committee solicits General Board members from IHS Area Offices and Service Units. For each Area Office that contains at least one IHS Federal direct service facility, the Area Director will appoint at least one Area-level NCHSP lead (engineer or safety professional) and/or one Service Unit level representative, for a total of up to two per Area. The following are positions which are eligible to serve as the council's General Board members:
      1. Area OEHE Institutional Environmental Health Staff.
      2. Area OEHE Engineering Staff.
      3. Area Staff with collateral duties in Institutional Environmental Health and/or Healthcare Facilities Engineering.
      4. Service Unit Representatives in Healthcare Engineering and Occupational Safety and Health staff.
      5. Office of Quality and OEHE subject matter experts (SMEs). The OEHE SMEs may include staff from the Environmental Health Support Center and/or the OEHE Division of Engineering Services.
      6. Ad hoc non-voting members will be allowed to attend by invite from the NCSHEP executive committee members.
    3. Elections. The Chairperson is selected by majority vote of the NCHSEP and approved by the DDQHERM, DOEHE, and DOQ. The Vice Chairperson and Secretary will be chosen by consensus of the NCHSEP Executive Committee and General Board members. All members in the NCHSEP will hold 2-year terms and may hold consecutive terms. The DOQ will select the OQ Staff Member as a standing member for the duration of the assignment. The DOEHE will select the OEHE staff members.
  4. Responsibilities
    1. Executive Committee.
      1. Annually review and update the recommendations identified by the Environment of Care and Life Safety (EC/LS) Workgroup that preceded this council, which is led by the OQ Division of Quality Assurance and Patient Safety's Life Safety Code and Environment of Care Coordinator.
      2. Identify existing health care physical environment, life safety, occupational safety, and health data to develop standardized metrics and dashboards for analyzing the following: national standards, future Agency goals, future program goals, and program benchmarking.
      3. Align the standardized metrics identified by NCHSEP and use them for monitoring compliance with accreditation, regulations, laws, and standards; the following may be used as contributing data sources: Computer Maintenance Monitoring System (CMMS), Building Automation System (BAS), Healthcare Facilities Data System (HFDS), and other reporting measures related to health care engineering and occupational safety and health.
      4. Recommend the use of improvement science methods to maximize
        high-quality, safe, patient care; workforce safety; and operational efficiency.
      5. Support the change management process and implementation in Engineering and Occupational Safety and Health improvement activities by addressing IHS policies and/or accreditation requirements, regulatory standards, and best management professional practices.
      6. Support and participate in quality of care, workforce safety, physical environment, and patient/clinical safety webinars and training events for IHS staff.
    2. Chairperson. The Chairperson of the NCHSEP will:
      1. Act as liaison for the council in all communications with the IHS Director, through the DDQHERM and Director, DOEHE, and key management staff as appropriate;
      2. Coordinate the development of NCHSEP-specific reports, position statements, and recommendations;
      3. Report HQ-specific information and issues of Agency-wide significance to the NCHSEP membership;
      4. Preside over NCHSEP meetings held in person, by teleconference, or virtually through videoconference;
      5. Represent the position(s) of the NCHSEP at IHS leadership meetings or other meetings as required and;
      6. Attend NCC annual meetings to present high priorities to NCC.
    3. Vice Chairperson. The NCHSEP Vice Chairperson presides in the absence of the NQC Chairperson and will:
      1. Assume the duties of the NCHSEP Chairperson in the event of his or her absence;
      2. Serve in any capacity as requested by the NCHSEP Chairperson or the NCHSEP Executive Committee; and
      3. Develop, at the guidance of the council, a yearly evaluation that will be formulated into a yearly effectiveness report and submitted annually.
    4. Secretary. The NCHSEP Secretary will:
      1. Assume the duties of the NCHSEP Chairperson in the event that both the NCHSEP Chairperson and the NCHSEP Vice Chairperson are unavailable;
      2. Coordinate the preparation of meeting agendas and communicate information to the NCHSEP Executive Committee;
      3. Per records management requirements, record, maintain, and distribute meeting minutes within 30 days following the meeting to the Executive Committee and post meeting minutes to the IHS Agency-wide data sharing location;
      4. The NCHSEP will conduct an annual performance evaluation to assess the outcomes and effectiveness of its actions. The performance evaluation will be reviewed at the annual IHS NCC meeting; the evaluation will be formulated into a yearly effectiveness report and submitted annually to the executive committee; and
      5. Serve in any capacity as requested by the Chairperson, Vice Chairperson, or the Executive Committee.
    5. General Board Members.
      1. Develop and recommend to the DDQHERM and DOEHE, through guidance with the Division of Environmental Health Services, DFO, Environmental Health Support Center (EHSC), and the OQ, solutions to improve and support quality and safety as it relates to health care facilities construction/improvement, health care engineering, occupational safety & health, health care physical environment safety reporting, data systems, improvement, and management issues that affect the health care and safety of American Indian and Alaska Native patients served by the IHS and the IHS workforce;
      2. Identify activities in the field and headquarters offices that are already supporting elements of the NCHSEP and receive brief updates through a standardized agenda;
      3. Provide advisory support to and advocate for IHS Service Units and Area Offices, identifying opportunities for improvement and implementing new quality requirements;
      4. Make recommendations on policies that affect the quality and conditions of the health care physical environment and its impact on Occupational Safety and Health for IHS employees and American Indians and Alaska Natives;
      5. Provide effective engineering and safety leadership to support health care quality improvement, a safe and functional physical environment, and workforce safety; and
      6. Make recommendations on requests by stakeholders for health care quality improvement-related engineering and occupational safety and health activities. It will also assist in the development of improvement activities utilizing existing national quality measures, best management professional practices, and resources to support the IHS mission, in compliance with applicable health care facilities engineering codes, including National Fire Codes, International Building Code, Facilities Guidelines Institute, CMMS, American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE), Mechanical, and Electrical codes All improvement-related activities will be appropriately cross-referenced within all applicable software platforms that track Healthcare Engineering data and updated accordingly.
    6. Senior Sponsors. Senior Sponsors will provide Executive Leadership and quality improvement feedback.
    7. Meetings.
      1. Scheduled Meetings: The NCHSEP will meet at least quarterly via video conference but may have additional meetings as needed.
      2. Concurrent Meeting: The NCHSEP will meet during the annual IHS NCC meetings.
      3. Additional Meetings: To achieve the NCHSEP's goals, additional meetings will be scheduled as necessary or at the request of the NCHSEP Executive Committee, the DDQHERM, the DOQ, or the DOEHE.
      4. Voting: The NCHSEP Executive Committee and General Board are the voting members. Decisions will be made by majority vote at the meetings.
      5. Ad Hoc Subcommittees: Ad Hoc subcommittees will be established through a collaborative effort between the Executive Committee, General Board members, other National Council members, and SMEs. Ad hoc subcommittees will be instituted to support EC/LS workgroup recommendations and any identified priorities through risk identification techniques. The Executive Committee or General Board members will lead ad hoc subcommittees and report to the NCHSEP. Council members will volunteer to be a part of the subcommittees as appropriate.
  5. Supersedure. None
  6. Effective Date. This IHS Circular is effective upon date of signature

/P. Benjamin Smith/
P. Benjamin Smith, M.B.A., M.A.
Acting Director
Indian Health Service

Distribution:  IHS-wide
Date: 07/21/2025