TITLE: ENVIRONMENT OF CARE COMMITTEE Date November 4, 2015
FOCUS DISCUSSION ACTION/FOLLOWUP/EVALUATION

ATTENDANCE:
Mark Vizenor, Ellen Ryan, Karen Renaud, Cindy Teichroew, Leann McMullen, Kim Carlson, Diane Bankers, Kris Bombard, Heather Sanftner, Brent Thompson
GOVERNING BOARD RESPONSE:
Documentation reflects the Governing Board indicates a concurrence to the action of the Safety Committee with no additions or information required for the meeting of August 18, 2015

MINUTES:
The Minutes of August 18, 2015 meeting were accepted as written.

GENERAL SAFETY:

Employee incidents for the 3rd quarter of 2015 were reviewed. There were 3 reported.

There were 7 inpatient falls reported for the third quarter, 2 inpatient, 2 ED and 3 Clinic with no serious injuries.

PERFORMANCE IMPROVEMENT PLAN:
NPSG Clinical Alarm Assessments have all been returned with the exception of Pine City Urgency Services and Ambulance. Ellen presented an evaluation of the Clinic Alarms Assessment. By January 1, 2016 policies and procedures will need to be established along with educating staff about the purpose and proper operation of the alarm systems of which they are responsible for. A subcommittee has been formed and will in meet in November to discuss next steps.

INFECTION PREVENTION & CONTROL:
Flu shot vaccination of employees is at 83%. December 1st is the goal date to have everyone vaccinated. SWANK education will be required for those employees that completed the declination form for the flu vaccine.
There was two construction permits issued during the third quarter, one for Hospital Sleep study and 1 Hinckley Clinic X-ray.
Discussion on changing Sharp’s vendor – looking at various vendors and exploring a reusable option.
HAZARDOUS MATERIALS AND WASTE
Nothing to report at this time.

HAZARD SURVEILLANCE:

The semiannual hazardous safety inspection has been completed by TLC . Facility Operations is working a completing the deficiencies

SECURITY:

Workplace Violence committee is meeting regularly and working on incident response plans for each site. Hospitals must have preparedness and incident response plans in place by mid-January, 2016.

EMERGENCY PREPAREDNESS:

Discussion on the Emergency Sheltering Tabletop Exercise for Kanabec County – November 18th. Ellen reviewed what the general public along with healthcare facilities should consider if an emergency shelter event occurred.

Ellen reviewed the Health Alert Network Procedure. Discussion on distribution lists of Contacts.

There is a statewide emergency preparedness drill scheduled for March 29, 2016 that we will be participating in.

EDUCATION:
2015 OLE training updates are as follows for employees:
• Safety Storm Alpha 73%
• Safety Storm Gamma 69%
• Safety Storm Beta 63%
• Legal Compliance 78.4%
• HIPAA 73%
• Employee Handbook 80%

EQUIPMENT MANAGEMENT

TLC has reviewed the Preventative maintenance report (see attached)
 58 Pieces of equipment added
 10 pieces have been retired
 100% of Class I preventable maintenance completed
 98% of Class II has been completed
 0 patient incidents reported
 3 User errors
 2 Misuse errors

Recall notices have been uploaded to the Public recall folder and have been forwarded to the appropriate managers.

FIRE SAFETY:
All fire drills have been completed for 3rd quarter of 2015

UTILITY MANAGEMENT
Nothing to report at this time.

OTHER:
Lab is still waiting for COLA inspection.

Discussion on PAPR and PPE Inventory. Materials Management is putting together a spreadsheet of inventory. Some additional hoods and PAPR suits will be ordered.

NEXT MEETING:
Next regular scheduled meeting will be Wednesday, February 3rd at 9am in Small Conference Room.