sitefm managing an effective safety committee

The Standard for Healthcare Facility

Management Compliance

Online Webinar Series

Managing an Effective Safety Committee

Host:

Martyn BufflerVice President, Sales and MarketingEmail: [email protected]: 512-480-0883 x125SiteFM

Faculty:

Tom Zahorsky CHFM, CHSP-FSMVice President of Client ServicesEmail: [email protected]: 281-362-1686SiteFM

Thank you for joining us today!

Agenda

• Introductions (5 minutes)

• Managing an Effective Safety Committee (40 minutes)

• Next Steps (5 minutes)

• Q&A

Housekeeping

• We will be in webinar mode – all lines muted

• Please enter questions in the control panel

• If you have technical difficulty press *0 for operator assistance.

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Value to Attendees

• Please submit questions during the presentation to be

read during the Q&A session at the end of the

presentation

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survey

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Tom Zahorsky CHFM, CHSP-FSM

• VP of Client Services, SiteFM

• 35+ Years in Healthcare Facilities Management

• Former Joint Commission Life Safety Surveyor

• Former OSHA Voluntary Protection Program (VPP) STAR Worksite Coordinator

Faculty Background

Seminar Objectives

At the end of today’s program you will be able to discuss:

• What is an Effective Safety Committee?

• Who should be on the committee

• How a structured meeting facilitates effectiveness

• How to avoid the “hi-jacked meeting”

• The impact of a Safety Committee on the organization

Problem Identification

• As in the Safety Committee process itself, the first step is to identify problems.

• Let’s evaluate our Safety Committee in light of common challenges to committee function.


• Problem 1: An overwhelming amount of information to manage

– Safety Committee Inspections/Environmental Tours

– Incident reports

– Patient complaints/concerns

– Patient satisfaction reports

– Employee satisfaction reports

– Employee injury rate

– Medical staff complaints/concerns

– External reviews (TJC, DSHS)


• Problem 2: Missing Essential Elements

– Lack of Administrative Support

• No attendance at meetings

• No funding

– Lack of involvement

• Committee members

• Hospital Staff

– Lack of knowledge

• No funding for education

• No involvement


• Problem 3: The typical Safety Committee

– A large group of people

– Little or no formal Safety training

– Unclear goals and objectives

– Misunderstood process

– Meets because they are required to

– Focused on satisfying “requirements”

• We will look at ways to address these issues

• First, let’s see where our committee stands today


Committee Evaluation

• Does the committee know the strengths and weaknesses of the safety program?

• Does the committee collect and utilize data in a meaningful way?

• Does the committee provide recommendations for improvements in safety?

• Does the committee follow through?

• Does the committee have an impact on the level of safety in the organization?

• Does the committee utilize meaningful performance indicators to monitor their impact on safety in the organization?


• Evaluate your committee based on those criteria

• Then compare your committee to the following definition of “An Effective Safety Committee”


An effective Safety Committee is one that has a

significant, positive impact on safety in the organization

and knows what that impact is through measured

performance indicators.

An Effective Safety Committee

What is needed to have An Effective

Safety Committee?

An Effective Safety Committee

An Effective Safety Committee has:

• Leadership Involvement

• Administrative Support

• Engaged membership

• Effective Flow of Information (input)

• A Structured Meeting Process

• Effective Problem Identification and Evaluation Process

An Effective Safety Committee creates:

• Recommendations and Actions

• Effective Communications

• Effective Means of Measuring Improvement

• Effective Use of the Annual Evaluation Process

Leadership Involvement

• TJC Standards Require Leadership Involvement

– Standard LD.03.01.01 - Leaders create and maintain a culture of safety and quality throughout the [organization].

– Standard LD.03.02.01 - The [organization] uses data

and information to guide decisions and to understand

variation in the performance of processes supporting

safety and quality.

• TJC Standards Require Leadership Involvement

– Standard LD.03.03.01 - Leaders use [organization]-wide planning to establish structures and processes that focus on safety and quality.

– Standard LD.03.04.01 - The [organization]

communicates information related to safety and quality

to those who need it, including staff, licensed

independent practitioners, patients, families, and

external interested parties.

Leadership Involvement

Administrative Support

• Chair appointed annually in writing by CEO

• Membership chosen by Chair, appointed by CEO annually

• Stated commitment to safety

• Participation

– Meeting attendance

– Support For Recommendations

Committee Membership

• Committee members must come from Administrative, Clinical, Ancillary and Support roles

• Committee members should all have a defined role

• Committee members should all serve a specific purpose– Weigh in on issues from their perspective

– Take ownership of issues for their discipline

– Report to committee

– Work on Action Items on behalf of the committee

• CNO or COO

• ICU or other Nursing Director

• Emergency Department Staff

• Lab, Radiology, Oncology

• Risk Manager, Employee Health Rep.

• Security, Engineering, Bio-Med

• Education

• Departments with Safety Issues

– EVS, Food Service, ICU, Lab – ad hoc guests

Committee Membership

Managing Information

• Determine what information is needed by the committee

• Avoid duplicated efforts. If QAC addresses an issue, it does not need re-work in Safety Committee

• Assign responsibility for the compilation and reporting of information to committee

• Spread the workload. Use most appropriate resources

The ICES

Information Collection

And Evaluation System

Effective Information Collection And Evaluation

System (Process)

– Performance indicator data for all 7 areas

– Incident reports/summaries

– Newsletters, periodicals – relevant updates

– Employee suggestions

– Other information relative to safety

The ICES

Sample Medical Center

Information Collection and Evaluation System

(ICES)

Adminstration

and Dept. Dirs

Staff Updates

Action Plans

Safety Committee

Collects and

Evaluates Data

Safety Management

Patient Safety

Employee Safety

Hazard Surviellance

Product Recalls

Security Management

Security Incidents

Performance Indicators

Security Drills

Emergency

Management

HVA, Plans

Drills, Events, Critiques

Equipment & Supplies

Hazmat & Waste

Management

Spills/Incidents

MSDS Maintenance

Right To Know

Medical Equipment

Management

Bio-Medical

Diagnositc Imaging

Life Safety

Management

Fire Drills

BMP

Fire Safety Equipment

Utility Management

Utility Incidents


Infection Control

Education

Staff Knowledge

and Training in All

Areas

Safety Committee

Chair Report to

Leadership

Committee

Recomendations

Others Assigned

Action Plans

Feedback on

Implementation

The Structured Meeting Process

• Standardized Agenda

• Stick to the Agenda

• Prevent the “Hi-Jacked Meeting”

• Include Committee Education

• Monitor all Old Business

• Monitor all Performance Indicators

• Incident Reports for all Areas

• Save “New Business” until last


• Recognize that when the sentence starts with “we need to…” that is not problem identification

• We often tend to start at the point of offering solutions without taking the time to state the problem

• Stating the problem is the first step

• Only then can all committee members give thought to what may have caused the problem

Problem Evaluation

• Reporting statistics is only the starting point

• Analysis must work to determine what happened, why, (when, where and who may also be important) i.e. – Root Cause

• Most significantly, how can a recurrence by prevented?

Problem Evaluation to

Recommendation

• A Near Miss –sometimes we get lucky, but that doesn’t mean we would want to let that happen again.

Recommendations and Actions

• Once ICES information is analyzed, committee makes recommendations for improvement

• Formal, informal (formal = PI)

• Recommendations include what, who and when

• How will success be measured?

• Track to completion – hold accountable

Effective Communication

• Minutes

• Action Plans

• Notices/Reminders

• Reports to Leadership

Meeting Minutes

• Capture Topic, Conclusions, Recommendations and Planned Actions

• Assure follow up, follow through

• Use “Old Business” to track to completion

• Use P.I. to track formal improvement activities

• Do not drop incomplete items

SAMPLE MEDICAL CENTER

Minutes of the Safety Committee Meeting

Meeting Date

PRIVILEGED AND CONFIDENTIAL

Standard Hospital confidentiality statement here

1. Call to Order - A regular meeting of the Safety Committee was called to order this date, at (time of meeting) in (location of meeting) at

Sample Medical Center, with the following:

Members Present: Guests:

Members Absent:

- Safety Officer – Chair - Chief Operating Officer - Chief Nursing Officer

- Education Director - E.D./Emergency Prep

- Bio-Med Lead

Guest speakers Invited attendees for special focuses or investigations

– Radiation Oncology

– Human Resources

– Plant Operations - Utilities – Cardio/Pulmonary/Lab

– Materials Management – Risk Management

- Employee Health Nurse

TOPIC DISCUSSION RECOMMENDATION/ACTION FOLLOW-UP

2. Education

Presentation

Subject of educational presentation

For Information only

None required

3. Review of Minutes The minutes of the meeting of (date of last meeting) were reviewed.

The minutes were approved as written.

None

4. Old Business

Items not closed at last meeting that are not addressed in the seven disciplines below.

Meeting Minutes

Action Plans - Notices

• In addition to minutes

• Assure awareness of planned actions

• Use as Reminders

• Offer assistance but don’t take ownership

• Encourage Response or Require response


Action Plans - Notices

Sample Medical Center Safety Committee Action Items Date:

Act

2day Topic Responsible Status Listed Target

Date Completed Comments

� Topic from Safety

Committee Minutes

Person

assigned

Open,

Closed

Date

Identified

To be

completed

Actual

Completion

Supplementary information, progress

notes

Report to Leadership

• Governing Board

• Senior Management

• Department Directors

• Summary of minutes – significant issues only

• Spare the details – inform and involve

• State why it is important to the audience

Accountability for Action

• Essential to the stimulus of change

• Other priorities will distract

• Reminders, notices, awareness


• Encourage, be positive, show value of actions but at the same time;

• Be firm

Measured Results

• Did the actions recommended by committee have the desired impact?

• How is this measured?

• Could be as simple as yes/no

• Could be a trend

• Could evolve into a Performance Indicator


• Performance indicators are meaningful when they measure progress towards achieving goals set by the committee

• At least one for each of the seven disciplines of the EOC or;

• More than one in a particularly problematic area

Safety Management

Monitor the knowledge of employees in the safety components of annual re-training. Test

scores from each of the EOC Categories are at least 95% taken by random sampling.

• Safety Management

• Employee Safety Management

• Security Management

• Emergency Management

• Hazardous Materials and Waste Management

• Life Safety Management

• Medical Equipment Management

• Utilities Management

National Patient Safety Goal Compliance Rate

Inpatient Fall Rate (falls/1000 patient days)

Employee Safety – Lost Time Injury Rate is Below State Average for SIC Code

Employee Safety – Needle stick or other injury rate below prior year (per 100,000 worked hours)

Hazard Surveillance – percent of probes found to be in compliance

Product Recalls – percent of recalls and notices responded to by deadlines

Security Management

Security Incidents per month by type

Security - % of CCTV system operational monthly

Security – staff scores on security drills

Security – response time to events of different types

Security – number of incidents of different types compared to year prior

Emergency Management

Emergency Preparedness scored staff performance on drills

Percent of HRSA Grant Funded Supplies Locatable

Percent of Emergency Contacts Valid During Random Test Calls (after hours)

Hazardous Materials and Waste Management

Hazardous Materials % accuracy of MSDS books random sample

Hazardous Materials & Waste – lbs. Infectious waste/patient day prior year comparison

Fire Prevention and Life Safety

Life Safety – staff score at least 95% on fire drill performance

Life Safety – all staff participate each year

Life Safety – BMP compliance rates > 95%

Medical Equipment Management

Medical Equipment Management – percent PM completed monthly

Medical Equipment Management – percent repairs completed (m)

Medical Equipment Management – average turn around time

Medical Equipment Management – User Error Rate as % of reported equip. failures

Perform

ance Indicators

for the EOC

SiteFM™

Annual Evaluation

• Evaluate last year’s performance indicators

• Compare to established goals

• Determine actual effectiveness of programs, recommendations and actions

• Determine need to continue or change

• Evaluate new developments

• Recommend goals for new year

• Recommend measures of performance

Conclusion

• A committee that has a measurable impact on the level of safety in the organization provides an environment that stimulates both change and staff involvement

• Having structure in the meeting process and follow through on actions contributes to having that impact

• Involvement then becomes its own reward

Webinar Offerings

• SiteFM provides these free webinars as a courtesy to our industry

• Life Safety Drawings for Accreditation – Thursday, February 20, 2014

• Interim Life Safety Measures

– Thursday, March 20, 2014

• Register at www.SiteFM.com

• These programs can be presented for your state Healthcare Facilities Management association

• Thank you for taking the time out of your busy day to spend with us

• We hope that this presentation was worthwhile

• Please feel free to contact us

• Questions and Answer session will take place following a brief re-cap

Thank You

SiteFM Work Order ManagerHelps you manage the EOC Process

• Full WO-CMMS with Compliance

Management Features &

Functionality

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and Inspections on Mobile Devices

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Measure what matters

• Combines Inspection Software with

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• Provides valuable data for

documentation and improvement.

Next Steps

• Please fill out the post-webinar survey to

receive a copy of the presentation

• Sign up for a SiteFM product demonstration for:

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•SiteFM Life Safety Drawing Manager

•SiteFM Vision

• Please share this information with your peers.

Thank you!

The SiteFM team…..

The Standard for Healthcare Facility

Management Compliance

Questions and Answers

Tom Zahorsky CHFM, CHSP-FSM

Vice President of Client Services

Email: [email protected]

Phone: 281-362-1686

SiteFM

Martyn Buffler

Vice President, Sales and Marketing

Email: [email protected]

Phone: 512-480-0883 x125

SiteFM