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OEH&S JCAHO
The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) conducts periodic
inspections of institutions that provide healthcare services to the
public including UCSF Stanford Healthcare and Langley Porter Psychiatric
Institute. The healthcare organization is inspected and results are
compared to JCAHO standards. The evaluation includes a review of written
documents provided by hospital administration, a building tour to
observe physical aspects of the facility, and staff interviews to
determine how programs described in the written documents are implemented.
The surveyors assimilate information gathered during the inspection
and make one of seven accreditation decisions for each organization:
1. Accreditation with
Commendation
2. Accreditation
3. Accreditation with
Type I Recommendations
4. Provisional Accreditation
5. Conditional Accreditation
6. Preliminary Nonaccreditation
7. Not Accredited
The Office of Environmental
Health and Safety, the UCSF Stanford Healthcare Environment of Care
Committee, and the Langley Porter Psychiatric Institute Safety Committee
have implemented a program to address the JCAHO titled the Management
of the Environment of Care. This standard defines criteria that,
if implemented, will provide a safe, functional, and effective environment
for patients, staff members, and visitors. JCAHO expects that the
healthcare organization will have a management plan and processes
in place to address:
- Safety Management
- Security
- Hazardous Materials
and Hazardous Waste Management
- Emergency Preparedness
- Fire and Life Safety
- Medical Equipment Management
- Utility Systems Management
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OEH&S provides technical
support as administrative policies and procedures are developed and
implemented to meet the requirements of both JCAHO standard and environmental
health and safety regulations. Some services provided by OEH&S
to support the Environment of Care Program are:
- Member of the Environment
of Care Committee and Safety Committee that ensures that JCAHO issues
and environmental health and safety regulations are addressed.
- Serve on Subcommittees
and Task Groups Develop and develop programs to address the Environment
of Care.
- Conduct inspection rounds
as part of the inspection team.
- Member of the training
team that provides new employee orientation on a monthly basis.
- Provide Annual Safety
Review training to all employees to maintain and improve the knowledge
and skills on environmental health and safety issues.
- Manage Employee Exposure
Monitoring Programs to evaluate employee exposures to chemicals
and radiation.
- Manage the pick up and
final disposal of radioactive, chemical, chemotherapy, and medical
wastes.
- Conduct respirator fit
tests and train employees on the use of respiratory protection when
it is required to protect employees from airborne hazards.
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