Security Management Plan：安全管理计划.docx

tri-state memorial hospital page 6 of 6effective date: 2000revised date: 11/06approved by:location to be placed: administrative manualdepartment:housewide environment of care subject:security management plani. purposethe purpose of the security plan is to provide protection for patients, visitors, and tri-state memorial hospital staff. the plan includes processes that are designed to ensure the well being of patients, visitors and staff.scopethe security management program emphasizes controlling access to tri-state memorial hospital facilities, staff, and patients. the program addresses security issues related to staff, volunteers, medical staff, patients, visitors, and the hospitals buildings and grounds. program effectiveness is dependent upon staff training and participation. the hospital staff is required to facilitate the program by following established policies and by intervening to advise non-staff persons of specific security related requirements.ii.fundamentalsa.a strong working relationship with local, county and state agencies leads to a greater feeling of security by patients, visitors, and staff.b.an ongoing assessment of risks and employees recognition of potential risks is key to reducing crime, injury, and other incidents.c.documentation and analysis of events and incidents is used to identify common causes, trends, and patterns which are used to predict and prevent crime, injury, and other incidents.rp housewidesecurity management pland. staff awareness is crucial to effective security management. tri-state memorial hospital staff is trained to recognize and report either potential or actual incidents to ensure a timely response. staff assigned to sensitive areas are trained in specific measures designed for those areas.e.policies and procedures are in place to assist staff when responding to a variety of emergencies or security incidents.f.violence in the workplace is a growing problem in healthcare. training addressing this issue is provided to every employee.iii.goals and objectives:a. conduct periodic security walk-throughs that cover the hospital buildings and grounds to identify and document potential or actual problems. take appropriate and immediate action to prevent crime, injury, or property loss.b. understand and adhere to security policies and procedures that are in place to assist staff with the performance of their normal duties and when responding to security issues.c. provide timely response to emergencies and requests for assistance. report crime, fire, injury, or other incidents. communicate externally with local, state, or federal law enforcement agencies and other civil authorities. provide internal communications as needed.d. control vehicular traffic on hospital grounds, including parking and access to the emergency department.e. limit access to the grounds, buildings, and sensitive areas by enforcement of staff identification policies. after hours access is limited to the emergency department.f. provide training to all new employees about the security management program. training includes: what types of incidents maintenance staff can respond to, how to report incidents and how to obtain assistance in an emergency. “sensitive area” training is provided as appropriate.g. manage a documentation system for security incidents from receipt of report to resolution of incident.h. the identification of key problems, failures and errors which require attention and actions. aggregate and review data to identify incident patterns and trends and report such findings to the safety committee.i. identify performance indicators, collect data, and report the findings to the safety committee.j. conduct an annual plan evaluation of the objectives, scope, performance, and effectiveness and report findings to the board of directors.k. evaluate the potential for workplace violence and develop an effective, remedial plan.iv.organization and responsibility:a.leaderships designation of personnel responsible for developing, implementing and monitoring the security management plan:administration is responsible for security within the organization. in carrying out this responsibility, the board of directors and administration appoints and supports:the director of safety: the person holding this position is authorized to take immediate action in a security incident, to report security issues at the safety committee meeting, and to encourage staff compliance with security policies and procedures. if the director of safety is not available, designees are as follows: administrator, assistant administrator, administrative person on call, medical surgical charge nurse, maintenance staff on call.the safety committee: the committee receives information on security incidents, makes recommendations on security issues, and proposes resolutions for security problems.housekeeping: this department is responsible for locking the facility at night and on weekends.supervisors: each supervisor is responsible for department specific security policies, procedures and practices applicable in their unit.rp housewidesecurity management planv. security management plan procedures:a.addressing security issues concerning patients, visitors, personnel and property:the safety officer is responsible for managing the security program which addresses security issues concerning patients, staff, visitors, and property. the safety committee is responsible for reviewing and acting on security issues. the focus is risk management.if there is a security incident, administration, the safety officer, the effected supervisor and local law enforcement will investigate the incident and make decisions based on their findings. in less serious incidents the safety officer will work with local law enforcement and hospital personnel to correct the situation.b.reporting and investigating all security incidents involving patients, visitors, staff or property:all security issues should be reported and investigated using a quality management memo. this form is completed by the staff member most directly involved, and should be forwarded to their supervisor for additional investigation. the form is then sent to the director of patient care services who routes it to the safety officer. the safety officer is responsible for ensuring that appropriate investigation and follow up is completed for each incident. data is aggregated looking for common causes and patterns or trends. this aggregated data is presented to the safety committee.the safety officer will also communicate security issues throughout the hospital using mailed memos, bulletin board posting, computer e-mail (mox), and verbal communication during meetings.c.providing identification, as appropriate, for all patient visitors and staff:staff and volunteers are issued identification badges that are to be worn while on duty. in addition, staff is issued a disaster card that will insure access to the hospital during an internal/external disaster. inpatients are issued identification bands during the admitting process which are to be worn until discharge. pediatric patients in specific departments are arm-banded as is the parent/guardian.d.controlling access to sensitive areas, as determined by the organization:tri-state memorial hospital has determined the following areas to be security sensitive: pharmacy, emergency department, radiology records, medical records, and rooms that contain narcotic drugs.personnel assigned to work in sensitive areas receive department-level orientation and training that focuses on special precautions or responses that pertain to their area. this education may include: access controls, security system, or security procedures.e.providing vehicular access to urgent care areas:the emergency department and helipad have been designated as urgent care areas. vehicular access to both of these areas is provided through the following physical controls: roadways, parking lots, directional signs, and night time illumination.the emergency department exterior signage is lighted to provide directions to ambulance personnel and patients. the helicopter pad lights are activated by the emergency department prior to flight arrivals.f.security orientation and education program:1. new employees are required to attend a “new employee orientation” which is scheduled by the human resource department upon hire. instruction is provided by the inservice coordinator. this orientation program may be done through presentation, demonstration, computer training, and/or review of specific materials. security issues include violence in the workplace, information on how to report an incident, and information regarding disaster including bomb threat and child abduction.each new employee is tested for understanding of the subject matter. all records of this orientation and testing are kept by the inservice coordinator. the inservice coordinator notifies the appropriate department supervisor when the new employee satisfactorily completes orientation. 2.annually, each employee is required to attend mandatory updates. this program may be done through presentation, demonstration, computer training and/or review of specific materials. the inservice coordinator documents successful completion of the program by each employee. content of this program may be changed based upon findings of performance improvement, changes in regulatory requirement, and recommendations from the safety committee. educational topics of mandatory updates for employees include but are not limited to: disaster, violence in the workplace, reporting an incident, fire/code red, code blue, right-to-know, infection control, electrical safety, patient confidentiality, performance improvement, child abduction, etc.the appropriate department supervisor is notified of satisfactory program completion by his/her employee.3.the department supervisor is responsible for educating his/her employees on area-specific security hazards in the department. this training is documented on the meeting attendance record kept by each employee or on the unit-specific orientation checklist. when a new piece of equipment or a new procedure is added to a department, the supervisor is responsible for training his/her employees on proper procedure.4.safety committee meeting minutes are distributed to each member for review and to ensure that employees are educated and kept informed of the actions of the safety committee.5.as special needs arise, each department has a budget allocation for continuing education presented off-site. this allows the staff to remain abreast of changes and new technology.g.performance standards: the safety officer is responsible for establishing and developing performance indicators which objectively measure the security management program. the goal is to improve the organizational performance of security management by identifying opportunities to improve. the results of performance indicators are reported to the safety committee. based on the results, the safety officer can retire, revise or continue the performance indicator.h.emergency s