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approved by the Environment of Care/Safety Committee and subsequently <br /> presented to the Governing Board via the annual Environment of Care Report. <br /> The Performance Indicators may include one or more of the following: <br /> 1. Staff knowledge and skills <br /> 2. Level of participation <br /> 3. Monitoring and inspection activities <br /> 4. Emergency and incident reporting <br /> 5. Inspection, preventive maintenance, and testing of equipment <br /> A performance target indicating the desired outcome will be established for each <br /> Performance Indicator. The Performance Indicators will be monitored and analyzed <br /> by the appropriate sub-committee. Recommendations for resolving issues will be <br /> forwarded to the Environment of Care/Safety Committee as applicable. <br /> Based on this ongoing monitoring, the Environment of Care/Safety Committee <br /> identifies and communicates one or more Performance Improvement activities at <br /> least annually to the hospital's leaders for consideration and inclusion in the affiliate's <br /> priority setting for improvements. <br /> The vehicle for reporting Performance Indicators is the Environment of Care/Safety <br /> Committee Environment of Care Report. <br /> C. Hazard Surveillance Surveys are conducted every six months for all clinical <br /> areas and annually for all support service areas. These surveys will include <br /> identification of hazardous materials and waste issues. <br /> D. An annual audit of department specific hazardous materialstwastes and policies <br /> and procedures are performed by the department manager/director, or <br /> designee, and is documented. Results are reviewed and deficiencies are <br /> corrected. <br /> E. An annual program review is conducted to audit program compliance. It is <br /> performed by the Hazardous Materials Coordinator, or designee, and <br /> documented. <br /> F. Hazardous material drills are conducted on an annual basis to assess and <br /> improve staff response to a hazardous materials or waste spill or exposure. <br /> G. Quarterly reports summarizing significant issues, trends and actions are <br /> submitted by the sub- committee for review by the Environment of Care/Safety <br /> Committee. Upon approval, these reports are forwarded to the Governing Board <br /> for review and comment. <br /> H. Annually, the Hazardous Materials and Waste Management Program is <br /> evaluated based on its objectives, scope, performance and effectiveness. The <br /> Safety Coordinator initiates an annual evaluation of the Hazardous Materials and <br /> Waste Management Program by reviewing various indicators, records and <br /> reports regarding the overall performance of the Program. This evaluation is <br /> submitted to the Environment of Care/Safety Committee for approval and then <br /> forwarded to Administration, Quality Management, and the Sutter Valley Area <br /> Governing Board for review and comment. <br /> EDUCATION <br /> A. Education is one of the important elements of a successful Hazardous Materials <br /> and Waste Management Program. Education is determined by problems <br /> identified in the performance improvement activities of each department and the <br /> Hazardous Materials and Waste Management Page 8 of 9 C.00 <br />