Guide to JCAHO Environment
of Care Standard 1.10.1
Please note: this page is under development. Contact
(603) 795-9966,
if you have questions or suggestions.
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.
© 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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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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