October 29, 2018

The ASC Safety Officer Role – Who, what, why, and how?

By: Fawn Esser Lipp, MBA, BSN, RN, CNOR, CASC, Executive Director, The Surgery Center LLC

The safety officer plays an important role in helping a healthcare facility maintain a safe environment for patients, staff, and visitors. The person in this role should complement the safety plan in helping to reduce risk. Responsibilities of the safety officer include assisting in staff safety education, monitoring the environment, and reporting. These duties should be done by someone who is trusted by physicians and staff and who can lead by example. Whether you are a manager taking on the safety officer role or you’re delegating the responsibilities to a staff member, here are some helpful tips:

  1. Create checklists.

Checklists keep you on track and assist in monitoring compliance with policies. Your checklists should mimic your accreditation standards and Life Safety Codes. Checklists can be designed to reflect specific areas, such as OR, PACU, storage, etc. Organize checklists into categories including, but not limited to, environment of care, Occupational Safety and Health Administration (OSHA), fire safety, and emergency drills. Allow space for comments. Don’t forget about an orientation checklist, which should consist of the dates and topics discussed upon hire, such as personal protective equipment (PPE), bloodborne pathogens, fire, and sharps safety.

Checklists can be organized into daily, monthly, and/or annual lists, depending on individual requirements, and they should be kept in an accessible binder. Label binders accordingly and include relative information such as policies or plans. This allows another staff member to easily perform the task or inspection if needed.

  1. Know your resources.

You have them. Use them! Review your governing body guidelines. If you are accredited by the Joint Commission or Accreditation Association for Ambulatory Healthcare (AAAHC), be sure to implement their standards. Put a shortcut to their handbook on your computer for easy access. Check websites often for specific information and updates from the Centers for Medicare & Medicaid Services (CMS), OSHA, and the Department of Health and Human Services. If your facility uses lasers, review the ANSI Z136.1 Safe Use of Lasers standard. Other third-party websites like pbcompliance.com and safetyskills.com provide safety awareness materials and courses, potentially with a cost.

  1. Divide and conquer.

ASCs often run lean, so you may need to have staff share in the role. Divvy up the different duties between departments or appropriate staff. Utilize staff members who can be responsible for a specific piece of safety, such as OSHA compliance. This piece alone includes maintaining safety data sheets for compliance, spill kit locations, sharps safety, PPE, eyewash station management, and managing bloodborne pathogen exposure. Train the staff member and provide the resources needed to execute the tasks. Ensure that responsibility for carrying out each action step is explicitly stated, not implied. Don’t be afraid to delegate, but make sure you delegate to the right person. Sharing in the responsibility can help with staff engagement as well.

  1. Report to the Quality Assurance team and Board.

Report on all the activities being monitored, and review any trends in detail. You may find there’s a need to perform a quality or performance improvement study or develop a policy. Staff incidents and patient safety occurrences should also be shared. Remember, the purpose of reporting is to create improvements, not point fingers.

  1. Feel confident about the security of your facility.

Verify that security cameras are in place and working. Install panic buttons at your reception and nurse desks. Make sure that access points (entry and exit) are controlled, including those for all clinical areas, stairwells, and loading docks. Check the lighting in isolated areas and parking lots to be sure it’s working.

Although the requirements seem complex, the safety officer role can easily be tailored to meet the facility’s needs. Delegating, using resources and checklists, and communicating can help maintain a safe environment. A commitment to a culture of safety can start with your safety officer.

Do you have a safety officer in your surgery center? Are the responsibilities of this role assigned to someone in a different position? How do you train for this role? We’d love to hear your story!

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