• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

EC.01.01.01 The hospital plans activities to minimize risks in the environment of care.

  • Hospital leaders identify an individual(s) to manage risks, coordinate risk reduction activities in the physical environment.

  • The hospital has a written plan for managing the following; safety, security, hazardous materials, fire safety, medical equipment and utility systems.

EC.02.01.01 The hospital manages safety and security risks.

  • The hospital identifies safety and security risks associated with the environment of care that could affect patients, staff and other people coming in the hospital's facilities.

  • The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

  • The hospital has written procedures to follow in the event of a security incident, including an infant or pediatric abduction.

  • The hospital responds to product notices and recalls.

EC.02.01.03 The hospital prohibits smoking except in specific circumstances.

  • The hospital develops a written policy prohibiting smoking in all buildings. Exceptions for patients in specific circumstances are defined.

  • The hospital takes action to maintain compliance with its smoking policy.

EC.02.06.01 The hospital establishes and maintains a safe, functional environment.

  • Note: The environment is constructed, arranged and maintained to foster patient safety, provide facilities for diagnosis and tratment, and provide for special services appropriate to the needs of the community.

  • Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided. (M)

  • Lighting, air, ventilation, temperature, clean, free of offensive odor, emergency access to all locked and occupied spaces, furnishings and equipment safe and in good repair.

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

  • The hospital establishes a process(es) for continually monitoring, internally, reporting and investigating the following.

  • Injuries, occupational illnesses, damage to property, security incidents, hazardous materials, fire safety management and medical equipment.

EC.04.01.03 The hospital analyzes identified environment of care issues.

  • Representatives from clinical, administrative and support services participate in the analysis of environment of care data.

  • The hospital uses the results of data analysis to identify opportunities to resolve environmental safety issues.

EC.04.01.05 The hospital improves its environment of care.

  • The hospital takes action on the identified opportunities to resolve environmental safety issues. (M)

  • The hospital reports performance improvements to those responsible for analyzing environment of care issues.

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