FINAL August 2016

Chapter: Western State Hospital Safety & Health

Policy: Workplace Safety Plan/Accident Prevention Program
Authorizing Sources: WAC 296-800-140
Effective Date: Revised Date: August 22, 2016 ·

Approved by:
Chief Exe6JJ{1ve Officer Date

TABLE OF CONTENTS
1.0 PURPOSE .......................................................................................................................... 2
2.0 AUTHORITY ..................................................................................................................................... 2
3.0 SCOPE ............................................................................................................................... 2
4.0 MANAGEMENT COMMITMENT ..........................·.............................................................. 3
5.0 SAFETY AND HEALTH RESPONSIBILITIES .................................................................... 4
6.0 EMPLOYEE PARTICIPATION ............................................................................................ 6
7.0 HAZARD RECOGNITION ................................................................................................... 8
8.0 HAZARD PREVENTION AND CONTROL ....................................................................... 15
9.0 EMERGENCY PLANNING ............................................................................................... 17
10.0 SAFETY & HEALTH TRAINING ..................................................................................... 19
11.0 WORKPLACE VIOLENCE PREVENTION ...................................................................... 21
12.0 WORKPLACE SAFETY/ACCIDENT PREVENTION PLANNING OBJECTIVES ............ 28
13.0 WORKPLACE SAFETY/ACCIDENT PREVENTION PERF. IMPROVEMENT ............... 28
14.0 WORKPLACE SAFETY /ACCIDENT PREVENT ANNUAL EVALUATION ..................... 28
APPENDIX A: WORKPLACE SAFETY PLAN ANNUAL UPDATE ......................................... 29

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1.0 PURPOSE:
To provide a workplace safety plan for all state hospitals that incorporates federal and state
laws including Occupational Safety and Health Administration (OSHA)/Washington State
Department of Occupational Safety and Health (DOSH), as well as Washington State law for
the management of the environmental safety ofpatients, staff and others through proactive
identification of safety risks and the planning and implementation ofprocesses to minimize
the likelihood of accidents and injuries. Also incorporated are standards of compliance of The
Joint Commission and Centers for Medicare/Medicaid accreditation and certification of
hospitals.

2.0 AUTHORITY:
Western state Hospital is operated by the State of Washington under the auspices ofthe
Department of Social and Health Services, (DSHS), and the Behavioral Health and Service
Integration Administration (BHSIA) in accordance with state and federal law as applicable.

The CEO has delegated authority to the Safety Manager, Infection Control/Employee
Health Manager, Security Manager and Industrial Hygienist to stop any action that places
the lives of employees, patients, contractors and visitors in immediate danger.

3.0 SCOPE:
• Workplace Safety Plan: Applicable to all WSH staff, including contract and support
services employees, (i.e. Consolidated Maintenance Operations, Central Institutional
Business Services, etc.), interns, students and volunteers and includes prevention of risk
related to the environment and provision ofpatient care.
• Accident Prevention Program (APP): Applicable to all WSH staff including support
services employees, (i.e. Consolidated Maintenance Operations, Central Institutional
Business Services, etc.) and encompasses any accidents, threats or acts of violence that
may result in emotional or physical injury or otherwise places one's safety and
productivity at risk. This includes suppmting employees who are victims of domestic
violence when requested, and assisting employees to access the Employee Assistance
Program for counseling and refe1rnl.
• Western State Hospital incorporates the Accident Prevention Program (APP) of the
Consolidated Maintenance Operations (CMO) and Centralized Institutional Business
Services (CIBS) organizations into its business plan and strategic goals. CMO and
CIBS employees utilize their own APP which aligns with WSH guidelines for
employee safe work practices. CMO and CIBS employees will work in concert with
WSH staff to create a safe and healthful work environment by adhering to both CMO
& CIBS guidelines and WSH policies and programs. The ongoing interaction
between agencies involves much more than just accident prevention. It involves
employee, client and resident interaction. In order to clarify this relationship, CMO
and CIBS employees and WSH staff cooperate utilizing the written Service Level
Agreement (SLA) between CMO/CIBS and ADSA (WSH's parent Administration).
The intent of the SLA is to describe the mutually agreed upon responsibilities,
standards, and services obligation between agencies. WSH will retain a copy of the
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 CMO and CIBS APP to ensure it meets WSH criteria. WSH Safety staff will
collaborate with CMO and CIBS safety personnel to create an ongoing and effective
safe and healthful working environment

4.0 MANAGEMENT COMMITMENT:

DSHS and Western State Hospital places a high value on the safety of its employees and
is committed to providing a safe and healthy environment for all employees, patients and
others entering the hospital's facilities. This policy has been developed for Safety
Management and Injury Prevention and involves management, supervisors, and
employees in identifying and eliminating hazards that may develop during work
processes.

All hospital staff is responsible for preserving a safe environment regardless of duty of
assignment, level supervision or command. The Western State Hospital Safety Manager,
Safety Committee Co-Chairs and members of the safety committee are responsible for
this plan. The CEO is responsible for ensuring the existence and the effectiveness of a
comprehensive Workplace Safety Plan/Accident Prevention Plan.

Employees are required to comply with all hospital safety rules and are encouraged to
actively participate in identifying ways to make our hospital a safer place to work.

All Co-Located Support Operations area required to follow WSH's Accident Prevention
Program. In addition, these areas are required to have their own Accident Prevention
Program tailored specifically to their area.

Management is committed to allocating resources necessary to implement all processes

encompassed within this plan:
• Maintaining safety committees composed of management and elected employees;
• Identification and corrective action(s) to eliminate or mitigate hazards;
• Planning for foreseeable emergencies;
• Providing initial and ongoing training for employees and supervisors;
• Implementing a disciplinary policy to ensure that hospital safety policies are
followed.

It is Managements' asse1iion that no task is so impmiant that an employee must violate a

safety rule or take a risk of injury or illness in order to "get the job done".

Safety is a team effort - Let us all work together to keep this a safe and healthy
workplace.

We Believe
• All incidents, injuries and illnesses have the potential to negatively impact quality
of life and can be reduced through mitgation strategies
• Every day, every task can be completed in a safe manner.
• Everyone is responsible and accountable for their safety and the safety of the
patients we serve and others entering WSH facilities.
• The quality of patient care services fosters a safe environment for staff.
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 • Accident prevention is a partnership between staff, management and the
Collective Bargaining Units.

5.0 SAFETY AND HEALTH RESPONSIBILITIES:

5.1 Executive Leadership Responsibilities:

• Ensure that the hospital maintains a safety committee that has both employee
elected and employer-selected members in accordance WAC 296-800-13020.
• Ensure that the hospital safety committee(s) meet monthly and provide all
required documentation.
• Ensure that the safety committees cmTy out their responsibilities as described in
this program.
• Ensure that sufficient employee time, supervisor support, and funds are budgeted
for Personal Protective Equipment (PPE)_equipment and training to implement the
safety program.
• Ensure that incidents are fully investigated and appropriate con-ective action
implemented to mitigate risk and prevent reoccun-ence.
• Ensure a record of injuries and illnesses is maintained and posted as described in
this program.
• Ensure an annual review of the Workplace Safety Plan/Accident Prevention
Program, including Workplace Violence Prevention, is conducted to ensure
compliance with State/Federal law and hospital needs, Centers for Medicare and
Medicaid (CMS) ce1iification and The Joint Commission accreditation of
standards of perfmmance and develop Performance Improvement Activities, as
indicated.
• Provide guidance and oversight to hospital personnel to ensure compliance with
this program. This includes facility management, approval and purchase of
equipment, authorization and payment for training, participation in workplace
inspections, and evaluation of facility program needs.
• Recruit and retain qualified staff to assure effective treatment and maintenance of
a therapeutic milieu.
• Collect and review data and implement quality improvement measures.
• Maintain a communication plan to promote a Culture of Safety.

5.2 Management/Supervisor Responsibilities:

All managers and supervisors are responsible for establishing and documenting
appropriate site-specific policies and procedures, to ensure safe practices for their
areas of operations.
• Managers and supervisors must maintain appropriate safety management
procedural knowledge regmding practices, policies, procedures and
emergency management plans and set good example for employees by
following safety rules and attending required training.
• Ensure each employee receives an initial, documented, site-specific Safety
orientation/training that includes inherent hazards and safe practices before
beginning work.
• Ensure each employee is competent to perform their duties safely and receives
adequate/required training including prevention and intervention techniques,
safe operation of equipment or tasks before stmiing work.
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 • Ensure that a hazard assessment is conducted on each job class and that each
employee receives proper training in the use of the required personal
protective equipment (PPE) before starting work.

• Ensure staff accounts for the safety and location of patients and monitor
environmental factors that affect patient and staff safety ensuring that clinical,
environmental and security needs are met. Ensure staff completed ward checks
while respecting patient privacy and dignity (i.e. knocking on door before
opening). This process may reflect clinical, environmental, and security
differences among units. Staff assigned to ward check continuously circulate
through the ward and intervene with patients as needed. They are not assigned
any other duties during that time.

• Ensure that supervision is sufficient to identify unsafe work practices and that
employees are provided additional training or disciplinary action is conducted
as needed. F01mal co1Tective action is documented according to Human
Resources Policy.
• Ensure all employee injuries· are investigated and all required documentation
is properly completed and submitted to the WSH Safety Office.
• Work with the hospital Safety Manager/Officer and DSHS Enterprise Risk
Management Office (ERMO) to identify and evaluate changes to work
practices or equipment that improves employee safety.

5.3 Employee Responsibilities:

All employees are required to follow established safety policies and procedures
· and encourage co-workers by their words and example to use safe work practices
including but not limited to:
• Following Washington State Safety and Health Core Rules (WAC 296-800) as
described in this program/plan, and referenced in hospital policies, protocols
and training.
• Reporting all injuries and near miss incidents to your supervisor promptly
regardless of how serious.
• Reporting unsafe conditions or actions to your supervisor or safety committee
representative promptly.
• Using personal protective equipment (PPE) as required
• Ensuring that PPE is maintained and in good working condition prior to use
and any malfunctions or need for service or replacement are promptly
rep01ied to your supervisor.
• Not removing or interfering with any PPE or equipment safety device or
safeguard provided for employee protection.
• Making suggestions to your supervisor, safety committee representative or
management about changes you believe will improve employee safety.
• Hold themselves and their colleagues to be attentive to their environment and
to maintain a safe and respectful environment.

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6.0 EMPLOYEE PARTICIPATION
6.1 Safety Committees

Western State Hospital maintains 6 safety committees to help employees and

management work together to identify safety problems, develop solutions, review
incident reports and evaluate the effectiveness of the Workplace Safety Plan/Accident
Prevention Program. These committees consist of management-designated
representatives and employee-elected representatives in an amount equal or less than
employee-elected representatives, from the facility. Resource members include the
Safety Manager, Facilities Coordinator, Security Director, SAFE Team Director,
Infection Control Nurse or Employee Health representative, and a member from
Quality Management. Guests are invited as needed. The safety committee structure
at Western State Hospital includes four patient-care area sub-committees and one
support area sub-committee that report to the Central Safety Committee.

Each Committee will ensure recommendations or concerns are reviewed and status of
the recommendation is documented in the Safety Committee minutes or written
feedback is provided to the initiator within 60 days of the Safety Committee review.

A committee member will be designated to keep minutes for each Safety Committee.
Copies will be posted on the WSH intranet under Departments Tab; Committees;
Safety Committees and on the designated bulletin board for each safety sub­
committee. (See below for locations). After being posted for one month, a copy of
the minutes will be filed for one year. The minutes fmm contains the basic monthly
meeting agenda items.

Location of
Safety Sub-Committee Physical Safety Bulletin Board
Building 28, pt Floor
Between East Campus Nursing Adm. and
PTRCEast East Campus Pharmacy
Building 29, pt Floor Outside of CFS
CFS Nursing Adm.
Building 9, 3rd Floor Outside of Central
PTRC Central Campus Nursing Adm.
Building 21, 2 11d Floor, S-2 Outside of South
PTRC South & HMH Hall Nursinf! Adm.
Building 8, pt Floor,
Safety Area Next to Safety Office

All committees meet on a monthly basis. See table below for date, time and
location for each safety committee meeting.
Safety Date & Time Time Location
Committee
East Nursing Adm.
PTRC East Sub- 3rd Tuesday ofthe Month 1:00 p.m. Conference Room
Committee
Hamilton
CFS Sub-Committee 3rd Thursday ofthe Month 1:00 p.m. Conference Room
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 Webster
PTRC Central Sub- 3 rd Wednesday ofthe Month 9:30a.m. Conference Room
Committee
S-2Nursing
rd
PTRC South & HMH 3 Tuesday ofthe Month 9:30 a.111. Conference Room
Sub-Committee
Building 8
Support Services Sub- l" Monday ofthe Month 1:00 p.m. Webster
Committee Conference
Fitzsimmons
Central Safetv l" Thursday ofthe Month 10:30 a.m. Conference Room

• Membership of the safety sub-committee includes a minimum of 2 management

representatives and a minimum of 6 labor representatives from each patient care
or support area. Each safety sub-committee elects one Management co-chair and
one Labor co- chair. This safety sub-committee structure allows for increased
representation and input at the ward/support level and allows specific safety
issues from each area to be discussed and acted on. Membership is re-appointed
or replaced annually.
•. Responsibilities/duties of each safety sub-committee member includes:
o Encouraging and supporting co-workers to use safe work practices on the job
and encourage co-workers to report hazards.
o Perfmming and/or reviewing monthly self-inspections of the area they
represent. Results and actions taken as a result of the self-inspections will be
discussed at the monthly sub-committee meetings.
o Communicating with the employees they represent on safety issues including
results from safety sub-committee meetings.
o Encouraging safe work practices among co-workers.
o Reviewing repmis of personal injury, 03-133, for their areas and make
recommendations for corrective action as required.
o Reviewing safety data related to assigned area and provide input to the sub­
committee.
o Actively participate in all scheduled sub-committee meetings, Present safety
concerns of co-workers to sub-committee for discussion and consideration.
o Maintain the safety bulletin board for the area they represent.

• The WSH Central Safety Committee is comprised of the co-chairs of each of the sub­
committees, SEIU 1199 representatives and the SAFE Team Director. This
committee is co-chaired by the Chief Operating Officer, and a WFSE Local 793
representative. Resource members include the Safety Manager, Infection
Control/Employee Health representative, Facilities Coordinator, Quality and
Enterprise Solutions representative and DSHS-Enterprise Risk Management Office
Safety Consultant. Guests are invited as needed.

• The responsibilities/duties of the central safety committee members include:

o Be available to all staff in their assigned area of representation to answer
questions or discuss safety concerns.
o Present concerns of the sub-committees they represent at the Central Safety
Committee.
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 o Present an overview of the findings from the self-inspections as they related to
the entire hospital
o Provide an overview of findings from review of injury repmis.
o Paiiicipate in a review of hospital-wide safety data and make
recommendations
o Repmi Safety hazards to the committee and make recommendations to avoid
future occurrences.
o Actively participate in all activities of the central safety committee.

All safety committee members are required to attend their monthly safety meetings
held on the above referenced date/time and location. This meeting is to help identify
safety problems, develop solutions, review incident reports, provide training and
evaluate the effectiveness of our safety program.

6.2 Safety Bulletin Board:

Western State Hospital has five physical bulletin boards and one electronic bulletin
board that are specifically devoted to safety. The main bulletin board is located on the
WSH intranet under Departments; Committees; Safety Committee where all
employees have access. The locations of the 5 physical bulletin boards are referenced in
the above table.
Required postings:
• Notice to Employees -If a job injury occurs (F242-191-000);
• Job Safety and Health Protection (F416-081-909);
• Your rights and a Non-Agricultural Worker (F700-074-000);
• OSHA 300A Summary of Work Related Injuries and Illnesses (required from
February 1 through April 30 of each year);
• Safety meeting minutes.

7.0 HAZARD RECOGNITION

7.1 Injury Record Keeping and Review
Employees are required to report any injury or work related illness to their immediate
supervisor regardless of how serious. Minor injuries such as cuts and scrapes shall be
repmied as well. The employee must use an Injury and Illness Incident Rep01i (DSHS
0 3-133 rev. April, 2014) to report all injuries.

The supervisor:
• Investigates an injury or illness using procedures in the "Accident Investigation"
section below;
• Completes the "Supervisors Review oflnjury and Illness Incident Repmi" (DSHS
03-133) form with the employee;
• Forwards the report to the Safety Office.

The Safety Manager/Officer:

• Reviews the incident form to ensure all peiiinent information has been collected;
• Provides additional comments or investigation results, if indicated, will be
included on the form;

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 • Forwards all paperwork to Enterprise Risk Management Office (ERMO) claims
department.

ERMO (Claims Unit):

• Inputs and tracks all reports of injury through the Risk Master system;
• Determines from the Employee Report, Iajury Investigation Rep01i, and any L&I
claim f01m associated with the accident, whether it must be recorded on the
OSHA Injury and Illness Log and Summary according to the instructions for that
form;
• Enters a recordable injury or illness within six days after the hospital becomes
aware ofit;
• If the injury is not recorded on the OSHA log, it is tracked through the Risk
Master System (non-OSHA recordable injuries and near misses);
• Provides each month before the scheduled safety committee meeting, any new
injury/claim rep01is and investigations to the safety committee for review. The
safety committee reviews the incident reports for trends and may decide to
conduct a separate investigation of any incident.

The Safety Manager/Officer is responsible for posting a completed copy of the OSHA
. Summary for the previous year on the safety bulletin board each February 1 until
April 30. The Summary must be signed by the highest ranking official at the facility.
The Summary is kept on file for at least five years. Any employee can view an OSHA
log upon request at any time during the year.

7.2 Incident Reporting and Investigation Procedure

Near Miss
Whenever there is an incident that did not but could have resulted in serious injury to
an employee (a near-miss), the near-miss is reviewed by the supervisor and additional
investigator(s) depending on the seriousness of the injury that could have occun-ed.
The "Injury and Illness Incident Report (DSHS 03-133), or WSH's Administrative
Report ofIncident form) is used to rep01i and investigate the near-miss. The f01m is
clearly marked to indicate that it was a near-miss and that no actual injury occmTed.
The report will be used to document the near miss and con-ect the hazards to reduce
and/or eliminate the possibility of an injury.

Employee Injury
When an employee is involved in an on-the-job injury, they must repo1i it to their
supervisor immediately and follow the procedures for reporting injuries. When the
supervisor becomes aware of an employee injury, the supervisor completes~

• Injury and Illness Incident Repmi (DSHS 03-133) with the employee to insure all
required information is complete. The injury is investigated by the supervisor and
additional investigator(s) depending on the seriousness of the injury that occuned.
In conducting an investigation, it is imp01iant to:
a) Gather all necessary information.
b) Record the sequence of events.
c) List all causative factors as they occur in the sequence of events.
d) Interview and collect statements from witnesses as indicated.
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 e) Closely review the employee's statement and description of the incident and
identify any discrepancies between employee's statement and actual findings.
f) Make determination based on the findings:
(1) Unsafe Act
(2) Unsafe Conditions
(3) Unsafe Acts/Conditions

• The Employee Report of Possible Client Assault (DSHS 03-391) is completed for
all incidents resulting from a potential client assault. Attach to the Injury and
Illness Incident Report.
• WSH Form 1-100 "Administrative Report on Incident" (AROI). Administrative
Repmis are also completed when any incident of unusual nature occurs involving
patients, visitors, employees, equipment, prope1iy, etc.
• A Post Exposure Packet is completed in all cases resulting in an exposure incident
or blood bome pathogen exposure. This is defined as an eye, mouth, other
mucous membrane, non-intact skin, or contacts with blood or other potentially
infectious materials that results from the performance of an employee's duties.
• Labor and Industry (L&I) Form 242-130-1111 is completed by the employee if
receiving medical or emergency treatment for a work-related incident/injury or
exposure. This form is to be initiated at the physician's office or emergency
room. The physician completes the form with the employee and mails a copy to
Labor & Industries for processing.

Hospitalization, Fatalities, Amputations, and Losses of an eye

If any employee is in-patient hospitalized as a result of a work-related incident, or, an
employee dies while working, or is not expected to survive, or, there is a work-related
incident that results in either an amputation or the loss of an eye that does not require
in-patient hospitalization, the facility designee must contact DOSH at Labor &
Industries (L&I) following the reporting requirements of WAC 296-800-320.

For work related incidents that result in an in-patient hospitalization or fatality, the
hospital CEO, or designee must contact the Department of Labor and Industries
within 8 hours after becoming aware of the incident.

For work related incidents that result in either an amputation or the loss of an eye that
does not require in-patient hospitalization, the CEO, or designee must contact the
Depaiiment of Labor and Industries within 24 hours after becoming aware of the
incident.

The hospital CEO, or designee must talk with a repre$entative of L&I and repmi:
• The employer name, date, location and time of the incident;
• The number of employees involved and the extent of injuries or illness;
• A brief description of what happened and;
• The name and phone number of a contact person.

In the event of employee work-related in-patient hospitalization, fatality, amputation or

loss of an eye that does not require in-patient hospitalization:

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 It DO NOT DISTURB the scene except to aid in rescue or make the scene safe.
Refer to WAC 296.a.800-320.
• Block off and secure area. If in a room, close and lock the room and post a guard,
if in a common area, mark off with tape or ribbon and post a guard. Do not clean
up bodily fluids or pick up other items.
• Keep unnecessary persons out of the area before and after securing it.
• Record the names of persons who have entered the area during and after the
incident.
• Record the names of persons who have witnessed the incident.
• Keep records of any items leaving the area before investigators anive, i.e.
clothing, bloody items and weapons.
• Do not move equipment involved (i.e. personal protective equipment (PPE), tools,
machinery or other equipment), unless it is necessary to remove the victim or
prevent further injures, refer to W AC296-800-32010.

These points are particularly important for an unwitnessed incident; they may be able
to tell investigators what transpired.

Whenever there is an employee accident that results in death or serious injuries that
have immediate symptoms, a preliminary investigation is conducted by the immediate
supervisor of the deceased or injured employee, a person designated by ERMO,
and/or any other persons whose expertise can help with the investigation. The
investigator(s) takes written statements from witnesses, photograph~ the incident
scene and equipment involved. The investigator(s) must_also document as soon as
possible after the incident, the condition of equipment and any anything else in the
work area that may be relevant. The investigator(s) makes a written report of their
:findings. The report includes a sequence of events leading up to the incident,
conclusions about the incident and any recommendations to prevent a similar incident
in the future.

7.3 Patient and Visitor Injuries

All patient injuries are repo1ted to the Quality Management Depmtment through Administrative
Report ofIncident System.

7.4 Hazardous Materials and Waste Spills and Exposures

Processes for reporting and investigating hazardous materials and waste spills and exposures·
m-e described in the Hazardous Materials Management Plan.

7.5 Fire/Safety Management Deficiencies and Failures

Processes for reporting and investigating fires as described in the Fire/Safety Management Plan.

7.6 Product Safety Recalls

All equipment hazard notices and recalls m-e coordinated through the Safety Office and
forwm-ded to identified depmtments for review and action as indicated.

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 7.7 Utility System Failure or User Errors
Failures or user errors related to utility systems are repmied Consolidated Maintenance
Operations as described in the Utility Management Plan.

7.8 General Hazards

Every employee has the right and responsibility to identify hazards and to report them for
coffective action. This must be done by immediately notifying the immediate supervisor and/or
the supervisor ofthe area where the hazard has been identified. The following procedures
apply when repmiing identified hazards:

• Notify supervisor immediately.

• Supervisor must ensure that c01Tective measures are taken (i.e. Work order
entered and follow-up on completion, immediate coffection of the hazard, etc.)
• If no action is taken, notify the Safety Manager by telephone on WSH' s Support
Our Safety (SOS) toll free number (1-888-346-8824) and/or complete an Internal
Hazard Repmiing Form. Complete this form in as much detail as possible.
Repmis may be anonymous; however, providing a name and telephone number
will assist in obtaining additional information that may be necessary to rectify the
hazard.
• Hazard repmis are evaluated by the Safety Manager to determine causative
factors and implement co11'ective actions.
• All repmis and action(s) taken are reviewed by Executive Leadership and the
Safety Committee during regular monthly meetings. Actions are captured in
Safety Committee Minutes and the Safety Action Items/Recommendations­
Results posted on WSH's electronic Safety Committee Bulletin Board.

7.9 Interim Life Safety Measures (ILSM)

Potential hazards related to construction, renovation or maintenance activity are
assessed through the Environment of Care Committee in conjunction with
Consolidated Maintenance Operations, and the Facilities Coordinator Office to
identify potential new or altered risks related to utilities or building systems, fire
safety or interim life safety, general safety issues, emergency preparedness or
response, and security. These hazards are reviewed and monitored by the COO,
Safety Manager, Facilities Coordinator, and repmied to the Environment of Care and
Safety Committees.

Projects that could significantly impact life and/or fire safety result in the
development of an interim life safety plan, which includes specific training materials
and information, the implementation of expanded fire drills, d~ily/weekly
inspections/documentation and compliance of all contractors with ILSM during the
construction period. The Safety Manager coordinates the planning, implementation
and monitoring of all interim life safety measures.

Interim Life Safety Measures (ISLM) are a series of operational activities that must
be implemented to temporarily reduce the hazards posed by:
1) Construction activities (in or adjacent to all construction areas)
2) Temporary Life Safety Code deficiencies including but not limited to the
following:

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 a) Fire, smoke or sprinkler systems temporarily out of service
b) Exit(s) blocked
c) Access for emergency response team is blocked
d) Fire walls/doors are breached
e) Fire doors/windows are missing
f) Other

Interim Life Safety Measures (as identified during planning phase)

1. Ensure free and unobstructed exits. Staff must receive additional training
when alternative exits are designated. Buildings or areas under construction
must maintain escape routes for construction workers at all times. Staff or
designees must inspect means of exiting from construction areas daily.
2. Ensure free and unobstructed access to emergency services for fire, police and
other emergency forces. Fire hydrants, fire lanes, etc. must be readily
available for immediate fire department use.
3. Ensure fire alatm, detection and suppression systems are in good working
order. Provide a temporary but equivalent system when any fire system
becomes impaired. Inspect and test temporary systems monthly. Provide a fire
watch whenever fire alarm or sprinkler system will be out of service more
than 4 hours.
4. Ensure temporary construction partitions are smoke-tight and built of
noncombustible or limited combustible materials that will not contribute to the
development or spread of fire.
5. Provide additional firefighting equipment and train staff in its use.
6. Prohibit smoking throughout buildings as well as in and adjacent to
construction areas.
7. Develop and enforce storage, housekeeping and debris removal to reduce the
building's :flammable and combustible fire load to the lowest feasible level.
8. Conduct a minimum of two fire drills per shift per quarter.
9. Increase hazard surveillance of buildings, grounds and equipment, with
special attention given to excavations, construction areas, construction storage
and field offices.
10. Train staff to compensate for impaired structural or compartmental fire safety
features. ·
11. Conduct organization-wide safety education programs to promote awareness
ofLSC deficiencies, construction hazards and ILSMs. During periods of
temporary Life Safety Code deficiencies, Attachment A - Interim Life Safety
Measures (ILSM) Evaluation Sheet will be the tool used to dete1mine if
ILSMs are required.

7.11 Statement of Conditions

The Facilities Coordinator has the primary responsibility for the Statement of
Conditions and the document is maintained in the Facilities Coordinator Office. The
Facilities Coordinator maintains building floor plans and coordinates the
identification and resolution of facility deficiencies and provides oversight for the
initiation and completion of Plans for Improvement (PFI). The Facilities Coordinator
is responsible for identifying any c01Tections that require special funding or
scheduling and ensuring that a PFI is develop, when indicated.

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 7.11 Safety Inspection Procedures
Western State Hospital is committed to aggressively identifying hazm;dous conditions
and practices which are likely to result in injury or illness to employee and takes
prompt action to eliminate any identified hazards. In addition to reviewing injury
l'ecords and investigating accidents for their causes, management, members of the
Environment of Care Comp1ittee, the safety committee and others regularly check the
workplace for hazards as described below:

Environmental Safety Inspections:

Each month, before the regularly scheduled safety committee meetings, nursing staff
conduct environmental safety inspections to ensure that all patient care areas are
inspected for hazards. The Safety Sub-Committees review these inspections at their
monthly meetings to ensure hazards are being corrected and to make any additional
recommendations necessary. Copies of all monthly inspections are sent to the Safety
Office for review and monitoring.

The Environment of Care Committee sponsors an additional continuous self­

inspection program. Members of the Environment of Care Committee and the
Management Team at a minimum inspect all patient and non-patient areas of the
hospital bi-annually to evaluate staff knowledge and skill, observe current practice,
and evaluate environmental conditions. These inspections are in addition to the
documented monthly environmental safety inspections and the hourly environmental
checks completed by nursing staff in all patient care areas. The results of the area
inspections and any action taken are reported to the Environment of Care and Safety
Committees.

A qualified fire inspector conducts an annual wall to wall fire inspection of WSH, to
include all tenant buildings

Periodic Change Process: A team is formed by Executive Leadership when any

significant changes to the hospital are being considered to identify safety issues that
may arise because of these changes. Examples of when this is necessary could
include new equipment, significant changes to processes (i.e. Non-smoking campus,
or anti-ligature changes) or a change to the building structure. This team is made up
of affected staff, and safety representatives and will examine the changed conditions
and make recommendations to eliminate or control any hazards that were or may be
created as a result of the change.

Proactive Risk Assessment

The Facilities Coordinator in coordination with hospital leadership, Safety &
Security, Department Managers, Consolidated Maintenance Operations and
Environment of Care Committee members conduct comprehensive risk assessments
to proactively evaluate risks associated with buildings, grounds, equipment,
occupants, and internal physical systems that have the potential to impact the safety
of pati~nts, staff and visitors coming to the hospital's facilities. Results of the risk
assessment process are used to create new or revise existing safety policies and
procedures, hazard surveillance elements in the affected area, safety orientation and
education programs or safety performance improvement standards. Risks are
prioritized to assure appropriate controls are implemented to achieve the lowest
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