Part 1, Chapter 9: Manual Appendix 1-9-E

Each IHS facility shall have written policy and procedures describing the hazard surveillance program.  The following model program may be adapted for local use.

1. Background.

   The Indian Health Service, the Joint Commission on Accreditation of Healthcare Organizations, and the Occupational Safety and Health Administration require the establishment of a system to identify, investigate, track, and correct conditions potentially hazardous to patients, visitors, employees, or the building.  The system must also assess employee knowledge of the facility's safety and health policies and procedures.

2. Policy.

   This policy establishes a facility based subcommittee to perform routine hazard surveillance for each hospital and health center.

3. Procedures.
   1. The team shall be composed of, at a minimum, representatives from environmental health, facility management, and nursing (particularly when evaluating patient care areas).  One team member must be the safety officer, and representation from administration is encouraged.
   2. The scope of work shall include at a minimum: general safety, fire and life safety (e.g. egress, detectors, alarms, extinguishing systems, smoke and fire exits, internal and external disaster preparedness, etc.), electrical safety, lock-out/tag-out safety, vision safety, video display terminal (VDT) worksite environmental and ergonomic reviews, hearing conservation, confined spaces, hazardous materials and wastes management, and protection from occupational exposure to biological hazards, e.g., tuberculosis and bloodborne pathogens.
   3. Hazard surveillance surveys of patient care areas shall be conducted at least twice a year.  Non-patient care areas shall be surveyed at least annually.
   4. Adverse safety and health conditions shall be referred to the safety or infection control committees for action.
      1. Items will be assigned a code and entered into the appropriate facility tracking system.
      2. Building deficiencies that are not safety or health hazards shall be tracked through the facility preventive maintenance system.
      3. Conditions will be evaluated for their impact on health and safety.  Recommendations will be based on the priority ranking.  See section D. for the method of evaluating the relative seriousness of hazards.
      4. The appropriate reference shall be cited when identifying hazardous conditions, e.g., a required exit obscured by file cabinets would be a violation of NFPA 101, 5-5.2.
   5. The safety or infection control committee will identify the department(s) responsible for correction and monitoring.  All necessary documentation will be forwarded to the affected department for appropriate follow-up.
   6. All items will be tracked until corrected or resolved.
   7. Summaries of actions will be documented in committee minutes.
4. Survey Priority Setting.

   Major Risk Management Factors.

   Recommendations should be assigned a priority based on an assessment of risk.  Establishing levels of priority is a complex task, often requiring professional judgment.  Attempts must be made to weigh risk factors analytically to determine the order of priority.

   Applicable standards and regulations, along with professional judgment should be used in combining one factor from each of the above groups to achieve a priority value of A, B, or C.

   These values represent high, medium, or low impact on health or safety.  Each of the above risk factors should not be assigned the same weight in determining the priority value.  Obviously, risks that affect such factors as injury, litigation, or frequency of occurrence should be rated higher than cost.  Cost is included to help in determining priority of correction if all other factors are equal.  Also, it is often more difficult to determine which issues should be assigned a "moderate" priority than those which are perceived as "high" or "low" since these are often gray areas.

   The following demonstrates some examples of the use of this system.

   1. Potential Severity or Injury or Illness.
      1. Potentially Fatal
      2. Potentially Disabling
      3. Minor
      4. None
   2. Relative Risk of Injury/Illness Occurrence or Other Negative Outcome.
      1. Continuously present
      2. Frequently present
      3. Occasionally present
      4. Rarely present
   3. Cost of Correction.
      1. No cost
      2. Within operating budget
      3. Minor capital improvement (Less than $200,000)
      4. Major capital improvement (More than $200,000)
   4. Other Negative Outcomes.
      1. Potential loss of JCAHO or other accreditation, major fine or litigation
      2. Type I recommendation (Contingency), moderate risk of fine or litigation
      3. JCAHO recommendation, low risk of fine or litigation
      4. Minor recommendation, no risk of fine or litigation

   Analysis of Factors.

   Each situation should be assigned a degree of hazard of "A - High," "B - Moderate," or "C - Low." This ranking scheme roughly corresponds to OSHA's hazard rating of "Imminent," "Severe," and "Less than Severe."  Some examples of analysis of factors are as follows:

   Class A Recommendation - High Priority

   
   

   Top priority = (1)a. + (2)a. +(3)a. + (4)a.

   
   

   Class B Recommendation - Moderate Priority

   
   

   (1)c. or (4)c. + (2)b. or (2)c. + (3)a.

   
   

   Class C Recommendation - Low Priority

   
   

   (1)d. or (4)d. + (2)d. + (3)d.

   
   

   Other Combinations = Professional Judgment

5. Safety Tracking System.

   Each OSH program shall establish a tracking system to ensure that identified hazards are appropriately addressed.  The following "Safety Tracking System" log requires the following entries:

   1. Code.

      Each hazard should be assigned a code by the local OSH officer to assist in tracking.  Some structural hazards may require several years to abate.  Therefore a coding system that includes the fiscal year plus three digits is recommended.  For example, the first hazard identified in fiscal year 1994 would be coded as 94-001.

   2. Item/Issue.

      Each hazardous condition should be described in sufficient detail for comprehension.

   3. Recommendation/Action.

      Hazardous conditions should be assigned to a committee, e.g., OSH, Infection Control, or Quality Improvement, or to an individual. The committee or individual shall assign a priority, (e.g., A, B, or C) to the hazardous condition and develop a corrective action plan.

      Recommendations may be the result of an interpretation or application of a code, standard, or guideline.  The committee's or individual's interpretation may be questioned by the recipient of the report.  This often occurs when a recommendation will require an expenditure of funds.  The source of each recommendation should be clearly stated, including the specific number, section, paragraph, etc.  The actual code citation should be used in framing the corrective action plan.

   4. Outcome.

      The results of implementation of the action plan shall be described.  The individual assigned the responsibility to evaluate the results of the action plan shall determine the need to monitor (M) the situation or consider the situation closed (C).  If the action plan is determined to be unsuccessful, the issue must be referred to a committee or an individual for reconsideration and development of a new action plan.