COMPLIANCE INFO_1983-2005 - Laserfiche WebLink

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rA The Safety Committee report summarizes performance compared to the performance improvement standard. If deficiencies are identified, a plan of action is developed to address the deficiency. The Safety Committee is responsible for evaluating the relevance of performance improvement standards. When no findings occur for a period of a year, the Safety Committee recommends the development of a new measure. The performance improvement measurement process is one part of the evaluation of the effectiveness of the Hazardous Materials and Waste Management program. A performance improvement standard has been established to measure one important aspect of the Hazardous Materials and Waste Management program. Compliance with this standard is considered an essential part of meeting the overall objective of providing quality support of patient care. The current performance improvement standard for Hazardous Materials and Waste Management program is that 95% of current and active employees attend mandatory annual training. EMERGENCY PROCEDURES The Safety Officer/ Facilities manager has overall responsibility for coordinating the development of emergency procedures within the Hazardous Materials and Waste Management program including emergency procedures. San Joaquin General Hospital has an organized spill response that requires additional training for employees who respond to hazardous materials incidents. A variety of personal protective equipment is maintained for use by the spill team. Current equipment includes brooms, shovels, spill kits, waste containers and protective clothing. Members of the spill team receive training in proper methods to clean-up spills. Major spills are handled by the community fire department HAZMAT response team. Author: Hospital Engineering Reference: Joint Commission on Accreditation of Healthcare Organizations; Title 22 Approvals: Safety Committee cc: All Hospital Departments