Example from 1997 JCAHO Accreditation Manual
Occupational Safety and Health Administration Example for LD.1.1.1
The leaders of two hospitals reviewed their committee structures in an effort to streamline the amount of resources required to manage their hospitals’ activities. The smaller hospital decided to reconfigure three committees into one to manage the Surveillance, Prevention and Control of Infection and Management of the Environment of Care functions.
A new Safety and Health Committee was made accountable for overseeing the activities of the former Infection Control Committee, the Employee Health Committee, and the Safety Committee. This reconfigured committee met an OSHA recommendation for a safety and health committee. The committee members included:
• the infection control practitioner;
• the facilities manager;
• a maintenance representative;
• a security officer;
• an employee representative;
• a nursing representative;
• an administration representative; and
• a medical staff representative.
The larger hospital also merged the responsibilities of multiple committees into one Safety and Health Committee. Its leaders believed that multidisciplinary groups were more effective and worked best if representatives from all categories of staff in the hospital, including leaders and staff, were included. The committee members included:
• an infectious disease physician;
• the infection control team’s lead nurse;
• the director of facilities management and engineering;
• the chief of security;
• the industrial hygienist;
• the certified safety professional;
• the team leader of the hospital’s disaster and emergency preparedness group;
• the director of employee health;
• the environmental response team leader;
• the fire safety manager;
• the chief of security;
• an elected employee representative from each of the hospital’s three service worker unions; and
• staff representatives from other clinical departments, such as nursing, radiology, dietary, social services, and outpatient services.
Input from other major groups working in the hospital was on an "ad hoc" basis. Staff representatives from laundry, central sterile processing, housekeeping, materials management, the inpatient operating suite and outpatient surgery services, pathology and clinical laboratory services, and the pharmacy were also designated to attend meetings when discussions concerning their responsibilities were held.
Source: Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL; 1996.
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