Performance Standards: Evaluation and Improvement


All aspects of the Institute's cohesive interdisciplinary program for Managing the Environment of Care are involved in an ongoing process of evaluation and improvement wherein:

  • performance goals and standards are set for the coming year.
    • by the Environment of Care Committee
      • usually at beginning-of-the-year meetings 
  • data is collected and actual performance is evaluated at least annually. (Much of this evaluation is actually done on a continuous
    basis.)
  • improvements are made.
  • goals may change in response to varying conditions
  • reports are provided to appropriate authorities.




 

 



 

Emergency Preparedness

  • Training will be conducted for all employees regardless of funding source
    • at new employee orientation -
    • at annual mandatory refresher courses -
      • attendance improved over previous year with introduction of multi-media presentations.
  • Drills will be conducted twice each year -
    • Participation will be general 
    • Evacuation will be quick, safe and effective 

All done successfully in 2001: There were several events which tested the Institute's response to actual emergencies. The most traumatic of which being the terrorist incidents of September 11. Response plans proved effective. Staff performed admirably. Although the attack on the WTC did not directly impact NYSPI, staff moved rapidly to implement security measures to protect this government institution from possible attack. Internal communications were tested, and all staff were kept up-to-date as to developments. More importantly, staff reacted quickly and effectively to deal with the need to provide emergency and ongoing psychiatric support to victims and others affected by the trauma.   

Additionally, scheduled drills were performed and evaluated as required. 

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Medical Equipment Management

  • Criteria will be established/maintained for inclusion of new items in program
  • Staff will be trained in proper operation before first independent use of new equipment
  • Testing and surveillance of equipment operation will be ongoing
  • Reporting of malfunctions and repair needs will be prompt
  • Repairs will be prompt and effective
  • A system for reporting product recalls will be in place and utilized
  • The Clinical Director and others will report regularly to the Safety Committee

All aspects of the program were performed properly. There were no adverse clinical outcomes or staff injuries due to medical equipment malfunction or misuse.

Maintenance of equipment was carried-out on a scheduled basis by a contracted service provider. 

Staff were appropriately trained in the safe and effective use of all equipment.

All done successfully in 2001

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Hazardous Materials & Waste

  • Training will be conducted for all employees regardless of funding source
    • at new employee orientation -
    • at annual mandatory refresher courses -
  • Access to Material Data Sheets will be improved
    • Web-based computer system started
  • Proper equipment, supplies and materials will be available and properly used
  • Accidents and incidents will be reported and responded to promptly and effectively
    • Number of accidents will be kept low
    • Impact will be minimal
  • Staff with appropriate expertise will monitor and report on the program effectively
    • Lab Safety Sub-committee 

There were no serious incidents or injuries related to hazardous materials.

The Laboratory Safety Sub-Committee remained very pro-active during the year.

Staff education programs were well-attended.

Improvements in the program included increased participation with the CPMC Environmental Health and Safety Office

All done successfully in 2001

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Safety Management

  • Training will be conducted for all employees regardless of funding source
    • at new employee orientation -
    • at annual mandatory refresher courses -
    • Fire drills will be conducted on schedule for all shifts
  • Proper equipment, supplies and materials will be available and properly used
    • Smoke / fire / sprinkler systems will be monitored and maintained
    • Fire extinguishers will be inspected monthly
  • Accidents and incidents will be reported and responded to promptly and effectively
    • Additional training will be provided as appropriate
  • Staff with appropriate expertise will monitor and report on the program effectively
    • Trends will be reviewed
    • Interim Life Safety Measures program will be enforced
    • "No Smoking" policy will be enforced

     

     

    All done successfully in 2001

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Security Management

  • Training will be conducted for all employees regardless of funding source
    • at new employee orientation -
    • at annual mandatory refresher courses -
  • Equipment, supplies and materials will be available and properly used
  • Locks and intrusion alert systems will be maintained in proper working order
  • Safety & Security officers will enforce photo ID badge policy consistently
  • Plans for security of new PI building put into action
  • The Chief safety & Security Officer will report regularly to the EOC Committee.

All done successfully in 2001

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Therapeutic Environment

All Institute staff strive to provide all patients with appropriate meals, recreational opportunities, access to telephones, reasonable privacy, and appropriate clothing and personal materials. Visiting hours are maintained appropriate to each patient's needs and condition.

 

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Utility Systems

  • Training will be conducted for all employees regardless of funding source
    • at new employee orientation -
    • at annual mandatory refresher courses -
  • All utility systems will be tested and maintained in proper order
    • Work performed by outside contractors will be observed and reviewed by facility Engineering staff
      • Problems will be reviewed and corrected promptly.
  • Emergencies / system failures will be reported and dealt with promptly and effectively

There were no adverse outcomes or serious injuries due to utility failures. Utility malfunctions (internal and external) were responded to promptly and effectively. 

All done successfully in 2001

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    Emergency Preparedness

    Medical Equipment

    Hazardous Materials

    Safety Management

    Security Management

    Therapeutic Environment

    Utility Systems


This page last updated - 04/10/07
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