MHHS
ENVIRONMENT OF CARE/ENGINEERING POLICY AND PROCEDURE MANUAL
TITLE: Security Management Plan
CATEGORY: Safety and Security
INDEX NUMBER: SEC 401
ORIGINAL DATE: June 2004
LAST REVIEW DATE: June 2004
SUPERSEDES:
1. PURPOSE
1.1 Security Management at a Memorial Hermann Hospital facility involves the coordinated efforts of the Environment of Care, Safety and Security Services Department, Administration and all other departments of the hospital. Together, they strive to provide a safe and secure environment for all patients, visitors, and staff. This objective is attained, through teamwork, by all levels of staff acting as the eyes and ears of the hospital.
2. INTENT
2.1 It is the intent of a Memorial Hermann Hospital System facility to prepare, implement and continuously evaluate a Safety Management Plan to ensure the safety, security and quality of service to patients, visitors and staff as well as to protect the facility and associated property.
3. SCOPE
3.1 The Security Program is designed to manage the security risks the environment of a Memorial Hermann Hospital System facility presents to patients, staff, and visitors. The program is designed to assure identification of general and high security risks and to develop effective response procedures.
4. FUNDAMENTALS
4.1 A visible security presence in the hospital helps reduce crime and increase feelings of security by patients, visitors, and staff.
4.2 Assessment of risks to identify potential problems is key to reducing crime, injury, and other incidents.
4.3 Analysis of security incidents provides information to predict and prevent crime, injury, and other incidents.
4.4 Training hospital staff is critical to their performance. Staff are trained to recognize and report either potential or actual incidents to ensure a timely response. Staff in sensitive areas are trained about the protective measures designed for those areas and their responsibilities to assist in protection of patients, visitors, staff and property.
4.5 Violence in the workplace is a growing problem in healthcare. It is necessary to develop a program to address workplace violence.
5. OBJECTIVES
5.1 The hospital buildings and property are patrolled on a scheduled basis, to identify and document potential or actual problems.
5.2 Appropriate and timely action is taken to prevent crime, injury, or property loss.
5.3 Security policies and procedures are established and maintained to direct staff performance when responding to security incidents. Security policies are reviewed at least every three years.
5.4 Response is provided for emergencies and requests for assistance in a timely fashion. Crime, fire, injury, or other incidents are reported and documented. Communication is maintained externally with local, state, or federal law enforcement and other civil authorities. Internal communications are provided as needed.
5.5 Vehicle movement on hospital grounds is controlled, including control of parking and access to the Emergency Department.
5.6 Timely response to reports of violent activity or requests for assistance is provided, in restraining violent or aggressive patients or visitors.
5.7 Access to the grounds, buildings, and sensitive areas is limited by enforcement of staff and visitor identification policies and by participating in the design of processes to minimize unauthorized access.
5.8 Timely response to requests for escort, keys and door openings, or other routine requests for assistance is provided.
5.9 All new employees are trained about the Security Program, including what types of incidents Security Department staff can respond to, how to report incidents and obtain assistance in an emergency and training for staff in designated sensitive areas.
5.10 The documentation system for security incidents is managed and used to provide appropriate reports to leadership and the Environment of Care® (EC) Committee.
5.11 Security department activity; including investigations, routine patrol activity, special and routine requests for assistance, and other activities are appropriately documented.
5.12 Identification of problems, failures, trends and user errors that require follow-up. These are summarized and reported to the EC Committee quarterly.
5.13 Performance improvement opportunities are documented and forwarded to appropriate I individuals.
5.14 An annual evaluation of the scope, objectives, performance, and effectiveness of the program is conducted and documented.
5.15 The potential for workplace violence is evaluated as part of risk assessment, and programs are developed to manage it.
6. ORGANIZATION AND RESPONSIBILITY
6.1 The Administrative Team/Quality Committee and/or Governing Body receive regular reports on the activities of the Security Program from the EC Committee. The group reviews, reports and, as appropriate, communicates concerns about identified issues and regulatory compliance back to EC leadership as appropriate. They provide support to facilitate the ongoing activities of the Security Program.
6.2 The Administrative Team receives regular reports on the activities of the Security Program. The CEO or designee reviews reports and, as appropriate, communicates concerns about key issues and regulatory compliance to the Chair of the EC Committee or other appropriate personnel. The Local and System Administration collaborates with Security Management to establish operating and capital budgets the Security Program.
6.3 The Director/Manager of Security works under the general direction of the <<Title>>. Security Management in collaboration with other department heads, and the EC Committee, manages all aspects of the Security Program. In addition, they advises the EC Committee regarding security issues that may necessitate changes to policies, orientation or education, or purchase of equipment.
6.4 Department heads orient new personnel to the department and, as appropriate, to job and task specific security procedures. Department heads who manage within security sensitive areas are responsible for training their personnel in any special security procedures or precautions. Where necessary, the Security team assists department heads in developing department security programs or policies.
6.5 Employees and contractors are responsible for learning and following hospital and departmental procedures for security. Contractors attend orientations and are badged through Construction Safety and/or the local Security team.
7. PROCESSES OF THE SECURITY MANAGEMENT PLAN
The organization identifies and manages its security risks (EC.2.10)
7.1 Security Management Plan (EC.2.10.1)
7.1.1 A Memorial Hermann Hospital facility has developed and maintains a written management plan describing the processes it implements to effectively manage emergencies affecting the facility, patients, staff, and to respond to emergencies in the community that cause an influx of patients. This plan is evaluated annually, and changed as necessary, based on changes in conditions, regulations and standards, and identified needs
7.2 Management of the Security Processes (EC.2.10.2)
7.2.1 The Facility has identified the person or persons, as designated by leadership, to coordinate the development, implementation, and monitoring of the security management activities.
7.3 Risk Assessment (EC.2.10.3)
7.3.1 The facility conducts proactive risk assessments to evaluate the potential for adverse impact on the security of patients, staff, and other people coming to the organization’s facilities. Among the elements that are evaluated is the potential for workplace violence. The Risk Assessment is used to evaluate current programs, and help identify new programs and activities to better protect the patients, staff, and the organization.
7.4 Risk Assessment to Implement Procedures (EC.2.10.4)
7.4.1 The facility uses the information from the risk assessment and other sources to select, develop and implement procedures, activities, and access controls to reduce the probability of serious security risks.
7.5 I. D. Program (EC.2.10.5)
7.5.1 Human Resources and/or Security collaborate to coordinate the identification and badging program.
7.5.2 Hospital administration maintains policies for identification. All personnel are required to display an identification badge on their upper body while on duty. Identification badges are to be displayed picture side out. Personnel who fail to display identification badges may be subject to disciplinary action by their department head. Identification badges are removed from personnel upon termination.
7.5.3 Visitors to patients are not normally expected to have identification. Visitor to some specific units are requested to have identification, or to be recognized by staff. The Security Officers assist in enforcement of visitor identification policies.
7.5.4 Where required, patient identification is provided at the nursing unit where patients are first admitted. If a patient wristband is damaged it is replaced by the nursing staff. Patient identification is not removed upon discharge. Patients are instructed to remove the identification band at home.
7.5.5 The Purchasing Department provides vendor identification. Identification (Visitor) badges are controlled and stored in a secure area.
7.6 Sensitive Areas (EC.2.10.6)
7.6.1 The Director of Security works with leadership to identify security sensitive areas.
7.6.2 The following areas are currently designated as sensitive areas:
7.6.2.1 Psychiatry <<if present>>
7.6.2.2 Business Office (e. g., cashier)
7.6.2.3 Emergency Department
7.6.2.4 Human Resources
7.6.2.5 Newborn Nursery <<if present>>
7.6.2.6 Labor & Delivery <<if present>>
7.6.2.7 Pharmacy
7.6.2.8 Information Systems
7.6.2.9 <<Identify other areas where appropriate>>
7.6.3 Personnel are reminded during their annual in-service about those areas of the facility that have been designated as sensitive. Personnel assigned to work in sensitive areas receive department level continuing education on an annual basis that focuses on special precautions or responses that pertain to their area.
7.7 Emergency Response Plans (EC.2.10.6)
7.7.1 A Memorial Hermann Hospital facility has designed and implements security procedures that address actions taken in the event of a security incident. These include responses for normal activities (such as door opening, and escorts), urgent activities (such as requests for assistance and stand-by, reports of theft, and other crime), and emergency responses (such as immediate patient or staff danger, fire alarms, disasters, and similar activities). General policies for these types of events provide guidance for Security staff, and other hospital staff, and as necessary provide processes to inform leadership, and as needed implement hospital wide emergency activity (such as implementing the emergency management plans). In addition, the Security Departments, and other staff are trained and respond to specific emergency management plan codes, as defined in those plans.
7.8 Child or Infant Abduction Prevention and Response (EC.2.10.8)
7.8.1 The facility has designed and implements security procedures that address the precautions for preventing, and the plans for handling of an infant or pediatric abduction as applicable. The nursery and other selected areas are provided with access control, and with alarm systems to assist staff in becoming aware of a possible potential for the abduction of an infant, or child. Staff receives ongoing training and drills to maintain their awareness. Parents and other designated visitors are also informed of the precautions and their role in those precautions.
7.8.2 Each facility (as appropriate) has procedures in place to respond to and address the Security of its infants.
7.8.3 The plan is tested at least annually and the responses documented, evaluated, critiqued, as appropriate. Corrective activity, additional training, or program improvements are made as applicable.
7.9 Release of Information (EC.2.10.9)
7.9.1 A Memorial Hermann Hospital System Facility has designed and implemented security procedures that address handling of security situations requiring the release of information to persons outside the hospital. Information about patients is limited by regulation, and normal requests for such information are referred to the admitting department. Requests about high profile patients, including those involved in domestic violence, or those that have requested anonymity are handled by the Security department. Administration and Corporate Communication have been designated as the spokespersons for the facility, and all requests for tours or other media related activity are referred to them, and they provide direction as appropriate.
7.10 Vehicular Access to Emergency Care Areas (EC.2.10.10)
7.10.1 The facility has designed and implemented security procedures to control vehicular access to emergency care areas. The Main Entrance, Emergency Department ramp, and Out-Patient Entrance <<Identify others>> are designated as such areas.
7.10.2 Signs are posted to prohibit parking, or standing vehicles in these areas. Security staff patrol these areas for compliance. If needed, arrangements have been made with a towing company to move the vehicle to alternate areas. During emergency plan implementations (disasters) the areas are staffed to prevent people from parking or leaving vehicles where they would impede traffic flow.
The organization monitors and improves conditions in the Environment of Care® (EC.9.10- EC.9.30)
7.11 Reporting of EC Issues (EC.9.10.1)
7.11.1 Security Management makes quarterly reports of Security incidents involving patients, staff, or others coming to the organization’s facilities or property, to the EC Committee. The reports summarize findings of incident reports and other information of security information.
7.12 Collection, Analysis, and Dissemination of Information (EC.9.10.2)
7.12.1 The Safety Officer and designated EC Committee member coordinates the collection and analysis of information about each of the EC management programs. The information is used to evaluate the effectiveness of he programs and to improve performance. The information collected includes deficiencies in the environment, staff knowledge and performance deficiencies, actions taken to address identified issues, and evidence of successful improvement activities.
7.13 Performance Monitoring (EC.9.10.3)
7.13.1 The Chair of the EC Committee coordinates the performance measurement and improvement process for each of the seven functions associated with management of the EC. Security manages the Security Systems program performance measurement process.
7.13.2 Security and/or the Safety officer is responsible for preparing quarterly reports of performance for the EC Committee. The reports include (in summary form) ongoing measurement of performance and hazard notices acted on during the quarter including the results of any Root Cause Analysis of Sentinel Events that are Security related.
7.13.3 Security establishes performance indicators to objectively measure the effectiveness of the Security program. They determine appropriate data sources, data collection methods, data collection intervals, analysis techniques and report formats for the performance improvement standards. Human, equipment, and management performance may be evaluated to identify opportunities to improve the Security program.
7.13.4 The performance measurement process is part of the evaluation of the effectiveness of the Security program. A performance indicator has been established to measure at least one important aspect of the Security program which is outlined by each facilities’ EC Committee.
7.14 Annual Review of Management Plans (EC.9.10.4)
7.14.1 The Safety Officer and EC Committee members are responsible EC programs perform an annual review of each management plan. The review evaluates the content of the plan to determine if changes in organization structure, scope of services, or other changes create a need to update the plan.