File Name: EC_Environment of Care Plan

Environment of Care Plan

[Logo] TITLE IDENTIFICATION NUMBER

Environment of Care Plan [Number]
ORGANIZATION(S) LEVEL CATEGORY POSTING DATE
[Organization name] ☐ System ☐ Clinical [MM/DD/YYYY]
☐ Organization ☐ Management EFFECTIVE DATE
[MM/DD/YYYY]
☐ Division ☐ Regulatory
☐ Department
REVIEW CYCLE ☐ 1 year ☐ 3 years REPLACES
LAST REVIEW DATE: [MM/DD/YYYY] TITLE: Environment of Care Plan
EFFECTIVE DATE(S): [MM/DD/YYYY]

PLAN MISSION STATEMENT

Consistent with the mission, vision, and values of Community Hospital to provide safe care, this plan
establishes the parameters of a safe physical environment. It addresses both specific
responsibilities and general safety.

PURPOSE
To reduce risk of injury or harm related to the environment of care (EC).

SCOPE
Applies to all buildings and outdoor areas owned by Community Hospital.

Applies to all six functional areas of the environment of care: safety, security, hazardous materials
and waste, fire safety, medical equipment, and utilities.

Applies to EC-related risks to patients, staff, visitors, volunteers, and everyone else who uses the
organization’s facilities.

RESPONSIBILITIES AND REPORTING STRUCTURE

The chief executive appoints the EC Committee, EC chairperson, safety officer, and Safety Committee
chairperson.

The EC Committee, EC chairperson, safety officer, and Safety Committee chairperson develop,
implement, and monitor the Safety Management Plan.

EC Committee members include, at a minimum, the safety officer, facilities manager, fire safety
officer, and representatives from leadership, administration, infection control, security, emergency
management, information technology, and clinical departments within the organization.

The EC Committee does the following:

• Meets at least quarterly.
• Reports significant findings and recommends actions to the governing body, medical staff,
hospital administration, and, when deemed necessary, all departments.

The safety officer does the following:

• Directs the safety program.
• Directs ongoing, organizationwide performance improvement activities related to the EC
management programs.
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File Name: EC_Environment of Care Plan

• Organizes and implements the Safety Committee.

• Intervenes whenever conditions exist that pose a threat of damage to equipment or property.
• Evaluates information submitted to the Safety Committee.

The Safety Committee does the following:

• Meets at least six times a year.
• Inspects all areas of the organization to identify safety hazards.
• Intervenes whenever conditions exist that may pose an immediate threat to life or health.
• Develops policies and procedures.
• Understands applicable safety regulations.
• Evaluates the effectiveness of the safety program and its components on an annual basis.

Department directors and/or managers do the following:

• Implement and enforce employee workplace safety.
• Use appropriate safety program guidelines provided by the EC Committee and the Safety
Committee to ensure staff awareness and effective implementation.
• Follow up with employees who miss safety education program sessions.

Each employee does the following:

• Attends safety education programs.
• Understands how the material relates to his or her specific job requirements.
• Follows the safety guidelines established in the Safety Management Plan.

OBJECTIVES
1. Develop and implement department-specific safety policies and education.
2. Monitor, track, and trend employee injuries throughout the organization.
3. Use environmental tour data effectively.
4. Develop and implement employee and contractor knowledge of the Safety
Management Plan.

PROCESSES
Risk Assessments
Risk assessments proactively evaluate the impact of proposed changes to new or existing areas of
the organization. The purpose is to reduce the likelihood of future incidents that have the potential to
result in harm, injury, or other loss to patients, employees, or hospital assets.

The Safety Committee performs the following activities:

• Receives reports of potential safety issues.
• Discusses potential safety issues, including relevant data and possible actions to mitigate
the risk.
• Advises management on actions to mitigate identified risks.
• Documents the risk assessment process in its minutes.
• Provides a report to the EC Committee, when appropriate.

Incident Reporting and Investigation

The Safety Management Plan documents patient and visitor incidents, employee incidents, and
property damage. The purpose is to identify trends or patterns in incidents to develop changes that
control or prevent future occurrences.

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File Name: EC_Environment of Care Plan

The Public Safety Department performs the following activities:

• Documents patient and visitor incidents on the Occurrence Report.
• Completes Public Safety Incident Reports.
• Directs reports of patient and visitor incidents to the Risk Management Department.
• Directs reports of employee injuries and incidents to the Workers’ Compensation
Department.
• Directs reports of property damage to the manager of public safety.

The Employee Health, Workers’ Compensation, Risk Management, and Public Safety departments
perform the following activities:
• Analyze incident reports.
• Report findings of that analysis to the Safety Committee.

Environmental Tours
The safety officer participates in the management of environmental tours. The purpose of
environmental tours is to observe and evaluate the current conditions in the EC.

Those who participate in the environmental tour perform the following activities:
• Evaluate employee knowledge and skills.
• Observe current practices.
• Evaluate environmental conditions.
• Report results of the tour to the EC Committee and Safety Committee.

The EC Committee performs the following activities:

• Reviews results of environmental tours.
• Provides an overview of environmental tour findings to leadership and other groups,
including but not limited to the Patient Safety Committee and the Performance Improvement
Committee.*

Safety Recalls
Information about recalled products, blood, food, supplies, medications, and equipment is collected
and distributed by the Safety Management Alert System. The purpose is to minimize the risk of a
recalled item causing harm to an individual.

The Medical Equipment Management Committee and Safety Committee perform the following:
• Review recall and alert compliance.

Designated departments perform the following:

• Develop approved implantable device tracking methods to include all information required by
the Food and Drug Administration.

Policies and Procedures

Safety-related policies and procedures provide guidance on both systemwide and department-level
safety issues. These are reviewed at least every three years or more often if required by regulatory
standards. The purpose is to establish standardized expectations to decrease the variations in
processes that can cause risk.

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File Name: EC_Environment of Care Plan

The safety officer performs the following activities:

• Coordinates the development of systemwide safety policies and procedures.
• Assists department managers in the development of new department-level safety policies
and procedures.
• Distributes systemwide safety policies and procedures to all departments.
• Ensures enforcement of all safety policies and procedures.

Department directors and/or managers perform the following activities:

• Manage the development of safety policies and procedures specific to their departments.
These include but are not limited to safe operations, use of hazardous equipment, and use of
personal protective equipment.
• Distribute department-level safety policies and procedures to their employees.
• Ensure enforcement of all safety policies and procedures.

Each employee performs the following:

• Follows all safety policies and procedures, both systemwide and at the department level.

Grounds and Equipment

The Buildings Operations Department schedules and performs maintenance of hospital grounds and
external equipment. Policies and procedures for this function are located in the Building Operations
Department.

ORIENTATION AND EDUCATION

New Employee Orientation
All new employees participate in the Safety Education/Orientation and Training Program. This
includes the following components:
• General safety information and training provided as part of the New Employee Orientation
Program
• Department-specific safety training
• Job-specific safety training
• Ongoing safety education programs required for all employees on an annual basis

Annual Continuing Education

Community Hospital uses self-directed, computer-based learning modules to provide its Annual
Continuing Education Program. Modules are reviewed regularly and revised as necessary, and new
modules are developed when the need is identified.

Department directors or managers determine whether modules are used by individual employees or
as a guide for group instruction.

All employees are required to participate in annual safety training education.

Department-Specific Training
Department directors and/or managers ensure that new employees are oriented to department-
specific safety policies and procedures and specific job-related hazards.

Contract Employees
Department directors and/or managers perform safety management assessment and education for
contract employees at the time of assignment.

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File Name: EC_Environment of Care Plan

PERFORMANCE MONITORING
The Safety Committee chairperson oversees development of performance monitors for this
committee. These performance monitors are used to measure the following:
• Compliance identified during environmental tours
• Compliance for systemwide product/medication/equipment recall activity
• Compliance with annual safety education requirements

The Safety Committee does the following:

• Reports data from these performance monitors according to the following parameters:
o At least quarterly to the EC Committee
o Biannually to the Hospital Performance Improvement Committee
• Compiles performance indicators and reports them annually to the following groups:
o Patient Safety Council
o Governing Council
o Medical Executive Committee
o Care Excellence Committee
o Board or board-related committee
• Analyzes data from all the EC performance monitors at least annually.
• Selects at least one recommendation for an EC-related performance improvement activity
based on that analysis.
• Reports the recommendation(s) to leadership.

ANNUAL EVALUATION
The safety officer does the following:
• Coordinates an annual evaluation for each of the six functions associated with managing the
EC (safety, security, hazardous materials and waste, fire safety, medical equipment, and
utilities). The evaluation examines the following aspects of the Safety Management Plan:
o Objectives
o Scope
o Performance
o Effectiveness
• Reports results of the annual evaluation to the following groups:
o EC Committee
o Patient Safety Council
o Governing Council
o Medical Executive Committee
o Care Excellence Committee
o Appropriate department managers

The EC Committee does the following:

• Reviews and approves the annual evaluation report.
• Documents its discussions, actions, and recommendations in its minutes.

REFERENCES
Joint Commission Standard EC.01.01.01, EP 4. The hospital has a written plan for managing the
following: The environmental safety of patients and everyone else who enters the hospital’s facilities.

Joint Commission Standard EC.01.01.01, EP 5. The hospital has a written plan for managing the
following: The security of everyone who enters the hospital’s facilities.

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File Name: EC_Environment of Care Plan

Joint Commission Standard EC.01.01.01, EP 6. The hospital has a written plan for managing the
following: Hazardous materials and waste.

Joint Commission Standard EC.01.01.01, EP 7. The hospital has a written plan for managing the
following: Fire safety.

Joint Commission Standard EC.01.01.01, EP 8. The hospital has a written plan for managing the
following: Medical equipment.

Joint Commission Standard EC.01.01.01, EP 9. The hospital has a written plan for managing the
following: Utility systems.

ATTACHMENTS
Fire Safety Management Plan
Hazardous Materials and Waste Management Plan
Medical Equipment Management Plan
Safety Management Plan
Security Management Plan
Smoke-Free Policy
Utility Systems Management Plan

APPROVAL
NAME AND CREDENTIALS NAME AND CREDENTIALS
[Name and Credentials] [Name and Credentials]
TITLE TITLE
[Title] [Title]
SIGNATURE DATE
[MM/DD/YYYY]

SIGNATURE DATE
[MM/DD/YYYY]

*Text shaded yellow is content that goes above and beyond Joint Commission standards and, therefore, is not specifically required.
However, the information is included to assist in developing best-practice policies and procedures.

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File Name: MM_Medication Control Policy

Medication Control Policy

[Logo] TITLE IDENTIFICATION NUMBER

Medication Control Policy [Number]
ORGANIZATION(S) LEVEL CATEGORY POSTING DATE
[Organization name] ☐ System ☐ Clinical [MM/DD/YYYY]
☐ Organization ☐ Management EFFECTIVE DATE
[MM/DD/YYYY]
☐ Division ☐ Regulatory
☐ Department
REVIEW CYCLE ☐ 1 year ☐ 3 years REPLACES
LAST REVIEW DATE: [MM/DD/YYYY] TITLE: Medication Control Policy
EFFECTIVE DATE(S): [MM/DD/YYYY]

POLICY STATEMENT
The hospital prescribes, dispenses, administers, and monitors medications in a safe and secure
manner.

PURPOSE
To establish a process that maintains medication safety in all phases of medication management—
storage, handling, wasting, security, disposition, and return to storage—to minimize risk of harm from
medication errors and comply with relevant laws, regulations, and standards.

SCOPE
Applies to all staff whose job involves participating in any aspect of the medication management
process.

DEFINITIONS
Immediately administered medication – A medication that an authorized staff member prepares or
obtains, takes directly to a patient, and administers to the patient without any break in the process. *

Medication – Any prescription medications, sample medications, herbal remedies, vitamins,

nutraceuticals, vaccines, or over-the-counter drugs; diagnostic and contrast agents used on or
administered to persons to diagnose, treat, or prevent disease or other abnormal conditions;
radioactive medications, respiratory therapy treatments, parenteral nutrition, blood derivatives, and
intravenous solutions (plain, with electrolytes and/or drugs); and any product designated by the Food
and Drug Administration as a drug. This definition of medication does not include enteral nutrition
solutions (which are considered food products), oxygen, and other medical gases.

RESPONSIBILITIES
Unsupervised access to medications is the responsibility of only those personnel authorized to do so
by virtue of their license and/or job description.

Ordering medications is the responsibility of only those personnel authorized to prescribe.

Dispensing of medications is the responsibility of only those personnel authorized to do so by the

nature of their license (for example, physician, pharmacist).

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File Name: MM_Medication Control Policy

Administration of medications is the responsibility of only those personnel authorized to do so by the

nature of their license/certification and scope of practice.

Demonstrating competency prior to administering medications is the responsibility of the authorized

licensed/certified staff.

Review and assessment of medication orders, in relation to the patient’s medication profile, are the
responsibilities of the pharmacist.

PROCEDURES
All procedures are performed by authorized licensed/certified staff, unless otherwise indicated.

Storing Medications
1. Ensure that all medications are stored in one of the following ways:
• In a locked container, cabinet, or refrigerator
• Under constant surveillance
2. Label medications with patient’s name, medical record number, and room number.
3. Store food and/or specimens in a separate refrigerator.
4. Prohibit combining partial components of containers, even if labels are the same.
5. Prohibit returning excess medication to the stock/bulk container.
6. Protect all light-sensitive medications from direct light.
7. Conduct medication storage inspections on each unit every month, and report findings to the
unit manager.

Discarding Medications
Licensed/certified staff members do the following:
1. Return all discontinued, expired, damaged, and/or contaminated medications to the
pharmacy.
For pre-drawn syringes:
• Label, date, and discard pre-drawn syringes.

The pharmacist does the following:

1. Discards unused or partially used medications according to established policies and
procedures.

Handling Medications
1. Maintain control of medications at all times.
2. Keep medication in the unit-dose package until administration.
3. Adhere to the procedures described in the Controlled Substance Management Policy, as
applicable.

Returning Medication to Stock/Return Bin

For medications in single-dose containers:
• Return unopened containers to the return bin at the MedStation.
• Select “Print Slip” option on the MedStation screen.
• Wrap slip around the returned item.
• Place item and slip into the return bin.
For medications in multiple-dose containers:
• Open MedStation drawer.
• Withdraw required dose from container.

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File Name: MM_Medication Control Policy

• Return container to the MedStation drawer.

• Close the MedStation drawer.
For controlled substances:
• Perform return processes with another authorized licensed staff member to act as a
witness.
For oversized items that do not fit in return bin:
• Select “Print Slip” option on the MedStation screen.
• Write on the slip the location of the locked cabinet or drawer in which you will store the
item.
• Place slip in the return bin.
• Close the MedStation drawer.
• Take the second return slip that is generated.
• Wrap the oversized item in the second return slip.
• Lock item and slip in the location you described on the first slip.
• If the item is a controlled substance, add the item name and quantity to the inventory.

Ordering Medications
Medication orders are managed in accordance with the Medication Orders Policy.

Preparing and Dispensing Medications

The pharmacist or licensed/certified staff do the following:
1. Review all medication orders prior to dispensing, removal from floor stock, or removal from
automated storage/distribution device.
2. Allow exceptions to order review only in urgent situations when the resulting delay would
harm the patient.
3. Review medication orders with regard to the following factors:
• Appropriateness of the drug, dose, frequency, and route of administration
• Therapeutic duplication
• Real or potential allergies or sensitivities
• Real or potential interactions with other medications, food, and laboratory values
• Other contraindications
• Variation from organizational criteria for use
• Other relevant medication-related issues or concerns
4. Clarify all concerns, issues, or questions with the prescriber before dispensing medication.
5. Compound or admix all sterile medications, intravenous admixtures, or other drugs, except in
emergencies or when not feasible (for example, short product stability).
6. Prepare IV admixtures in accordance with IV Solution Preparation Policy.
7. Use filtered needles on IV ampule medications.

Labeling Medications
1. Label all medications not immediately administered with the following information:
• Drug name
• Strength
• Amount
• Expiration date when not used within 24 hours or expiration time if expiration is less
than 24 hours
2. Include the following information on labels of all compounded IV admixtures:
• Date prepared
• Diluent

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File Name: MM_Medication Control Policy

3. Include the following information on labels when preparing medications for multiple patients
or when the person preparing the medication is not the person administering it:
• Patient name
• Patient location
• Directions for use
• Applicable cautionary statements (for example, “requires refrigeration”)
4. Dispense medications in the most ready-to-administer form via tube delivery system.
For medications and solutions in operative, perioperative, or procedural areas, on and
off the sterile field:
• Use labels even if there is only one medication or solution being used.
• Perform labeling at the time medication or solution is transferred from the original
packaging to another container.
• Perform labeling immediately following preparation. There should be no break
between preparation and labeling.
• Include the following information on labels:
o Drug name
o Strength
o Quantity
o Diluent and volume (if not apparent from the container)
o Preparation time and date
o Initials of the individual preparing the medication
o Expiration date and expiration time when expiration is less than 24 hours
• Verify labels verbally and visually by two qualified individuals, when the person
preparing the medication is not the person administering it.
• Label no more than one medication or solution at a time.
• Discard any unlabeled medications or solutions immediately.
• Retain for reference all original containers from medication or solutions in the
perioperative/procedural area.
• Discard original containers only at the conclusion of the procedure.
• Discard all labeled containers on the sterile field at the conclusion of the procedure.
• Review all medications and solutions and their labels at shift change or break relief.
This review is performed by both entering and exiting personnel.

Administering Medications
1. Obtain medication orders from authorized prescriber.
2. Review all medication orders in a timely manner.
3. Clarify the order with the prescriber, if necessary.
4. Refer to the Patient Worksheet before each dose administration.
5. Verify the order against the order, or verbally verify the order with the prescriber, before
administering the dose.
6. Review drug information before administering to become familiar with effects, dose, rate of
administration, and side/adverse effects.
7. Check for any patient allergies, drug interactions, or alert information.
8. Clarify any questions or concerns with the prescriber before administering.
9. Wash hands prior to handling medications and/or equipment.
10. Read labels three times before administering, at these times in the process:
• Before removing from storage area
• Before preparing medication
• Before returning to storage area

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File Name: MM_Medication Control Policy

11. Engage two licensed staff members to independently conduct a double check for narcotic
and sedative continuous IV drips or PCA, insulin, therapeutic IV heparin, and chemotherapy.
12. Identify correct patient by checking two sources of information, according to the Patient
Identification Policy.
13. For IVs: Identify appropriate free-flow protected infusion pump for specific administration
route/rate.
14. Provide education to the patient about the medication’s expected effects, possible
side/adverse effects, and any applicable food/drug interaction.
15. Verify the following:
• Medication is stable, based on visual examination for particulates or discoloration.
• Medication has not expired.
• No contraindications exist for administering the medication.
16. Compare the medication to the order just prior to administration.
17. Confirm the following just prior to administration:
• Right patient
• Right drug
• Right dose
• Right time
• Right route (include injection site, if applicable)
• Right indication
• Right documentation
18. Observe the patient taking the medication.
19. For injections: Scrub diaphragms of locks and/or injection ports with 70% isopropyl alcohol
prior to injection.
20. Dispose of all contaminated needles and syringes in the appropriate sharps/waste container.
21. Evaluate the patient’s response to medications and document as needed.
22. Document all medications that are withheld (not given).

Monitoring
1. Monitor the patient after the first dose of a medication.
2. Monitor the medication effects on the patient, based on the following:
• Patient’s own perceptions
• Relevant lab results
• Clinical response
• Medication profile
• Other relevant modes
For medication error events:
• Notify the physician immediately.
• Submit Incident Report, according to procedures described in the Incident Reporting
Policy.
For adverse drug reactions (ADRs):
• Notify physician immediately of suspected ADR.
• Report and document the ADR, according to procedures described in the Adverse Drug
Reaction Policy.

REFERENCES
Joint Commission Standard MM.03.01.01, EP 4. The hospital follows a written policy addressing the
control of medication between receipt by an individual health care provider and administration of the
medication, including safe storage, handling, wasting, security, disposition, and return to storage.

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File Name: MM_Medication Control Policy

ATTACHMENTS
Adverse Drug Reaction Policy
Controlled Substance Management Policy
Incident Reporting Policy
IV Solution Preparation Policy
Medication Orders Policy
Patient Identification Policy
Waste Management Policy

APPROVAL
NAME AND CREDENTIALS NAME AND CREDENTIALS
[Name and Credentials] [Name and Credentials]
TITLE TITLE
[Title] [Title]
SIGNATURE DATE
[MM/DD/YYYY]

SIGNATURE DATE
[MM/DD/YYYY]

*Text shaded yellow is content that goes above and beyond Joint Commission standards and, therefore, is not specifically required.
However, the information is included to assist in developing best-practice policies and procedures.

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