The safety management plan describes how the organization will provide a physical environment free of hazards and manage staff activities to reduce injuries. The plan provides processes for

a. Maintaining and supervising all grounds and equipment;

b. Conducting risk assessment that proactively evaluates the impact of buildings, grounds, equipment, occupants, and internal physical systems on patient and public safety;

c. Examining safety issues by appropriate representatives from administration, clinical services, and support services;

d. Reporting and investigating all incidents of property damage, occupational illness, and patient, personnel, or visitor injury; and

e. Ongoing hazard surveillance, including response to product safety recalls.

In addition, the plan establishes

f. A qualified individual(s) to oversee development, implementation, and monitoring of safety management;

g. An individual(s) to intervene whenever conditions pose an immediate threat to life or health or threaten damage to equipment or buildings;

h. An orientation and education program that addresses

1. General safety processes,

2. Area-specific safety,

3. Specific job related hazards, and

4. Provision of safety related information through new employee orientation and continuing education;

i. Ongoing monitoring of performance regarding actual or potential risk related to one or more of the following:

Staff knowledge and skills;

Level of staff participation;

Monitoring and inspection activities;

Emergency and incident reporting; or

Inspection, preventative maintenance, and testing of equipment;

j. Safety policies and procedures are distributed, practiced, enforced, and reviewed as frequently as necessary, but at least every three years; and

k. How an annual evaluation of the safety management plan’s objectives, scope, performance, and effectiveness will occur.