YOUR MEDICAL CENTER ADMINISTRATIVE POLICY MANUAL Page1of 4

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Model Policy and Procedure

YOUR MEDICAL CENTER ADMINISTRATIVE POLICY MANUAL Page1of 4

Security Management Plan

PURPOSE:

Your Medical Center is committed to an Environment of Care® (EC) management program that is designed to manage the physical security of patients, staff (including the potential for violence to staff and patients in the workplace), and individuals coming to Your Medical Center’s buildings, as well as providing for the security of the established environment, equipment, supplies, and information. The Security Management Program exists as an interactive process involving staff members at all levels in its implementation and is comprehensive in its scope.

POLICY:

The Security Management Plan is implemented to ensure that Your Medical Center provides patients, staff, and visitors an environment free from recognized safety and health hazards; promotes staff activities that reduce the risk of injuries and illnesses; and fosters an accident and injury prevention culture. This written Plan describes the processes implemented to effectively manage the physical and personal security of patients, staff and others coming to Your Medical Center facilities. (EC.01.01.01 EP 4)

The Security Management Program exists under the authority of the Your Medical Center Board of Trustees and is empowered by the chief executive officer. The Security Management Program is code- and information-driven and makes every reasonable effort to comply with federal, state, local, and other pertinent regulatory authorities. The Program includes the processes of design, education, implementation, analysis and improvement. The Program utilizes a risk assessment process to evaluate the potential adverse impact of the external environment and the services provided on the security of patients, staff and other people coming to Your Medical Center’s facilities.

RESPONSIBILITY:

The administration and senior leadership of Your Medical Center is responsible for Security Management Program leadership, ensuring Program effectiveness and continuous improvement.
The Environment of Care® (EC) Committee is responsible for analyzing identified issues and concerns and for developing recommendations for resolution.

The Manager, Safety Security is designated and authorized by the President/CEO to coordinate the development, implementation, and monitoring of Security Management Program activities. Specific duties include data collection and analysis, risk assessment, development of policies and procedures, provision of education programs, and Program evaluation and improvement.

Management personnel, including department directors, managers, and supervisors are responsible for overseeing security management in their areas of coverage. It is expected that they set a good example and maintain a focus on security in those they supervise by assuring that appropriate area-specific policies and procedures are developed, implemented and enforced. They also ensure that monitoring, education and other pertinent programmatic elements are in place and are relevant to operations. They accept responsibility for the actions of staff, the performance of equipment and machines, and safe operations within their areas.

Associates and other staff are responsible for cooperating with all aspects of the Security Management Program, including compliance with all applicable rules and regulations, and performance of duties in a safe manner. All applicable staff is required to display appropriate identification. Associates and other staff must report actual or potential security risks (suspicious persons, vandalism, and theft) to their supervisor or Security. Associates and other staff attend appropriate education classes as required.

PROCEDURES:

Risk Assessment:

Your Medical Center conducts proactive risk assessments that evaluate the potential adverse impact of the external environment and the services provided on the physical and personal security of patients, staff, and other people coming to the hospital’s facilities (see Administrative Policy – Safety and Security Risk Assessment).

The issues and conditions (collectively identified as “risks”) identified through the Risk Assessment process are used to select and implement procedures and controls to minimize or eliminate identified security risks and to achieve the lowest possible potential for adverse impact on the physical and personal security of patients, staff, and other people coming to Your Medical Center, as well as the Hospital’s physical plant. (EC.02.01.01 EP3)

Identification:

Your Medical Center has identified means to identify, as appropriate, patients, staff, and other people entering the hospital’s facilities.

Human Resources utilizes a digital camera to generate photo identification badges for all applicable staff members. All staff will wear photo identification badges in a conspicuous manner and in accordance with hospital policy, while on duty. Patients will wear identification wristbands in accordance with hospital policy. Transient (visit duration of one day or less) vendor representatives are provided identification at their point of entry (Materials Management; Maintenance; Pharmacy) and are subject to re-application upon return visits. Vendor representatives providing long-term services are allocated permanent photo identification on a case-by-case basis. Newborn infants and their family members are provided with identification specific to the Maternal Newborn Suite and associated areas. (EC.02.01.01 EP 7)

Security-sensitive Areas – Access / Egress Control:

Your Medical Center administrative, risk management and security leadership jointly assess the appropriateness of declaring an area “Security- Sensitive” and provide for the control of access to and egress from those designated areas. This designation is based on: the potential for violence or use of weapons; especially vulnerable populations such as the elderly, infants, and children; the availability of drugs, money, and unsecured personal property; identification and access for visitors/employees in all areas of the Hospital. Your Medical Center staff in security-sensitive areas and security leadership collaboratively develop and implement an access control plan and identify an appropriate security response for each area. Access to sensitive areas of the hospital will be controlled primarily through the use of identification badges, card access systems, combination locks, with the prior approval of the department manager or with escort of a security officer. Other measures include mechanical and electrical locking devices, increased security awareness, alarms, and initial and annual employee education relative to access control and incident response.

The following locations have been identified as areas of high security risk and are provided protection as indicated above. Any combination of access/egress control measures may be used in these locations:

December 2009

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Model Policy and Procedure

YOUR MEDICAL CENTER ADMINISTRATIVE POLICY MANUAL Page1of 4

Emergency Department
Maternal Newborn Suite
Pediatrics
Psychiatry
Pharmacy
Helipad
Ambulance Entrance - ED
Operating Suite & PACU
Critical Care Unit
Health Information Management
Computer Room
Cashier
Construction Areas
President’s Office

December 2009

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Model Policy and Procedure

YOUR MEDICAL CENTER ADMINISTRATIVE POLICY MANUAL Page1of 4

The following locations have been identified as being at moderate risk relative to security and are provided with increased surveillance:

Main Entrance & Lobby
Emergency Department Entrance
Department of Medicine Entrances
Outpatient Care Center

See also Administrative Policy 500-308 Limited Access Policy – Security-Sensitive Areas (EC.02.01.01 EP 8)

Security Incidents

Your Medical Center administrative, risk management and security leadership identifies and has implemented security procedures to address actions taken in the event of a security incident. These procedures include incident response, reporting, and investigative follow-up.

Your Medical Center associates are responsible for familiarity security-related policies and procedures and for reporting hazards and incidents. Employees are required to report hazards and security incidents. Reportable incidents include disturbances; patient, visitor, employee lost/stolen property; suspicious people/items; threats; physical hazards; and unauthorized smoking on the campus. Your Medical Center security officers investigate these reports and also report security discrepancies identified during security rounds using the security incident reporting mechanism. (EC.02.01.01 EP 9; EC.04.01.01 EP 6)

Infant / Pediatric Abduction Events:

Your Medical Center establishes and has implemented, through the Environment of Care Committee, emergency security procedures that address the handling of abduction events.

Announcement of a Code “Pink” alerts Your Medical Center staff to the potential of an abduction event for which a specific response is initiated (see Administrative Policy 200.102 Security of Infants). All other unaccounted for patients are reported to Security, who will initiate a search for the patient. (EC.02.01.01 EP 9)

VIP / Media Events:

Your Medical Center establishes and has implemented, through the Environment of Care Committee, emergency security procedures and a process for responding to incidents and/or events involving VIP’s and/or the media. These procedures and process support Your Medical Center’s mission, goals and objectives.

When required by an emergency, security staff responds to the incident as indicated by the applicable Security response procedure. This Plan supports and authorizes additional security measures for special circumstances such as infant and/or pediatric abduction events, civil disturbances, domestic violence situations, gang-related activities, and response to threats. Additional security personnel will be obtained through re-assignment of available staff.

The Manager of Safety & Security, in collaboration with the Director of Facilities and the Public Relations and Marketing Office, facilitates management of situations involving VIPs and the media. Policy and Procedures that describe special protection and precautions that may be required due to the celebrity or political status of a patient, as well as details of other emergency procedures can be found in the Administrative Policy Manual as well as the Security and Public Relations / Marketing Policies and Procedures Manuals.

Vehicular Access to Emergency Care Areas:

Maintenance of appropriate access to emergency care areas at Your Medical Center is accomplished by controlling parking and vehicle standing areas, and prohibiting parking in fire lanes. Your Medical Center security staff patrol parking lots and hospital roadways and enforce these parking restrictions to ensure emergency vehicle access. Specific considerations of this function can be found in Administrative Policy 500.302 Use of Parking Facility.

Measurement and Improvement Activities:

As a function of the Environment of Care® (EC) Committee reporting calendar the following processes and activities are conducted:

Coordination of the ongoing, hospital-wide collection of information regarding deficiencies and opportunities for improvement in the Environment of Care®;
Coordination of the ongoing collection and dissemination of other sources of information, such as published hazard notices or recall reports;
Coordination of the preparation of summaries of deficiencies, problems, failures, and user errors related to managing the Environment of Care®, including a summary of incidents involving patients;
Coordination of the preparation of summaries on findings, recommendations, actions taken, and results of performance improvement (PI) activities;
Security incident reporting;
Development of security policies and procedures
Monitoring performance relative to actual or potential risk(s) in the Security Management Plan.
Annual evaluation of the objectives, scope, performance, and effectiveness of the Security Management Plan, at a minimum;
Communication to the Patient Care Assessment Committee, as appropriate.

References: TJC Hospital Accreditation StandardsCategory:

(EC.01.01.01, EP 4 and EC.02.01.01)

December 2009