Immaculate Clinic Safety Plan

Immaculate Conception Medical Clinic
Poblacion President Quirino, Sultan Kudarat Region 12 (SOCCSKSARGEN) 9804

Email: immaculateconceptionmc17@yahoo.com Cell #: 0917-1639-494
Policy No: ICMC 18-30 Date Issued: September 01, 2018

Performance Area:
SAFE PRACTICE AND ENVIRONMENT
Policy Title: Management Plan which includes policies, procedure and
programs, risk assessment, hazards surveillance among others which
address safety, security, disposal and control of hazardous
materials/biologic wastes, emergency and disaster preparedness, safety and
utility system.
INTRODUCTION
An overall management plan includes standard procedures, which is essential to

achieve a safer and protective environment not only for the staff but more importantly
for the PATIENTS. Safety, Disaster and Emergency Preparedness is important to avert
damages in times of disaster, safety and security threats. It also focuses on developing
plans to handle properly he issues and concerns on hazardous waste, fire, safety,
radiation safety and utility systems.
I. SAFETY MANAGEMENT
A. BACKGROUND / RATIONALE:
Safety management plan is formulated to provide a safe, functional and efficient

environment of care for the patients, visitors and employees of ICMC. A well-defined
plans and strategies are created to identify and manage inherent risk associated in
health care operations.
B. POLICY
1. To provide a safe and secured environment for the patients, visitors and
employees of ICMC.
2. To monitor the physical environment of the facility for actual and potential
hazards.
3. To address and correct the concerns regarding the hazards discovered through
monitoring and surveillance activities.
C. RESPONSIBLE INDIVIDUAL / PERSONNEL
ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

To institute continues Safety Management Functions, the hospital management has

assigned individuals to administer and maintain the Safety Management Plan for the
entire hospital. The ICMC Safety Committee is composed of individuals coming from
various committees in the hospital.
II. HOSPITAL EMERGENCY AND DISASTER PREPAREDNESS PLAN
DEFINITION OF TERMS:
1. Triage- classification of patients according to type and seriousness of injury in order

to provide the most orderly, timely and efficient use of medical resources while
providing maximal care in time of disaster.
2. Internal Disaster- disaster occurring within the facility such as fire, explosion, etc.
3. External Disaster- a disaster that occurs outside the hospital, somewhere in the
community, where there is a disproportionate number of hospital staff to care for
the incoming emergency room patients or victims.
4. Basic Life Support- a level of pre-hospital care which includes patient stabilization
and airway clearance, control of hemorrhage, critical wound care, fracture
stabilization and other techniques and procedures.
5. ON-CALL STAFF- the hospital personnel who are responsible for attendance at the
hospital when their presence is required.
6. Stabilize- to provide such medical treatment of an emergency medical condition
that is necessary to assure within reasonable probability, that no material
deterioration of the condition is likely to result from or occur during the transfer of
the individual from a facility or that the woman has delivered the child and the
placenta.
The program shall address the four phases of emergency management during
disaster which includes mitigation, preparedness, response and recovery.
The hospital shall adopt the Hospital Preparedness Plan in accordance with the
existing guidelines, policies which include, among others, the following:
1. On-Site Triage and Emergency Team that renders adequate first aid.
2. System for the transport, treatment and dispositions of patients.
3. Coordination with the other hospitals shall be involved in handling casualties,
emphasis on proper distribution of cases to prevent over burdening the
capabilities of any single hospital.
Prepared by; Marjorie M. Quilos., RN

Head Nurse
Reviewed by: Galileo A. Dogoldogol

Owner/Administrative Officer

Noted by; Luzviminda B. Madronero, MD

Medical Director
DISASTER TRAINING/ DRILL
All health care staff undergo Disaster Preparedness Trainings such as:
1. Basic Life Support (Cardio-Pulmonary-Resuscitation)

2. First-Aid Training
3. Disaster Preparedness
 Transfer and Ambulation
 Evacuation of Victims
4. Earthquake Drill
5. Fire Drill
EMERGENCY AND DISASTER MANAGEMENT
Hospitals play a great role during emergencies and disasters. People automatically
seek assistance to hospitals during these cases. The duty of providing care to the
patients or victims becomes the primary responsibility of medical staff. Thus, they must
be well-trained and equipped to handle emergency case, etc.
HOSPITAL FUNCTIONS:
1. Observe all requirements, protocols, standard: (hospital emergency plans, HEICS,

Code Alert Systems, Triaging, etc.) needed to respond to emergencies and
disasters.
2. Enhances facilities to respond of the victims during emergencies.
3. Ensure the staff capability in Health Emergency Management.
4. Networks with other private hospitals in the area to optimize resource and
coordinate transferring of victims to the appropriate facility.
5. Reports all health emergencies on the Operation Center.
6. Documents all incidents responded.

DEFINED PLANS AND STRATEGIES
The ICMC defines set goals, strategies, activities and risk analysis of the hospitals
toward an effective, efficient and immediate response in any event of emergency or
disaster.
The Hospital Disaster and Emergency Preparedness Response and Recovery Plan
contain goals, strategies and activities that the hospital will consider in building hospital
capacity in responding to emergencies and disaster.
The response plans includes strategies and activities utilizing resources for
effective and efficient response during emergencies and disasters. It also includes
policies, protocols, guidelines and procedures pertaining to various emergency
management systems.
GENERAL OBJECTIVES:
To sustain the ICMC Health Emergency Preparedness Response and Recovery Plan,
thus reducing morbidity and mortality rate.
SPECIFIC OBJECTIVES:
1. To develop policy for response to both internal external disasters that may affect
the hospitals staff; patients and the community, as well.
2. To strengthen skills, knowledge, capability necessary to accomplish, mitigation,
preparedness, response and recovery in the management of disaster victims.
3. To institutionalize the Health Emergency Management in the hospital.
4. To establish networking with other line agencies for an effective and efficient
delivery of immediate needs of disaster victims.
5. To improve the general status of emergency response in the hospital taking into
consideration availability of drugs and medical supplies.
6. To report to the authorized agencies.
7. To document and report all responded disasters and emergencies.

EMERGENCY AND DISASTER MANAGEMENT PLANNING
1. Observe all requirements, protocols, standards: (hospital emergency plans,

HEICS, Code Alert System, Triaging, etc) needed to respond to emergencies
and disasters.
2. Enhances facilities to respond of the victims during emergencies.
3. Ensures the staff capability in Health Emergency Management.
4. Networks with other private hospitals in the area to optimize resource and
coordinate transferring of victims to the appropriate facility.
5. Reports all heath emergencies on the Operation Center.
6. Documents all incidents responded.
DEFINED PLANS AND STRATEGIES
The ICMC defines set goals, strategies, activities and risk analysis of the hospitals
toward an effective, efficient and immediate response in any event of emergency or
disaster.
The Hospitals Disaster and Emergency Preparedness Response and Recovery Plan
contain goals, strategies and activities that the hospital will consider in building hospital
capacity in responding to emergencies and disasters.
The response plans includes strategies and activities utilizing resources for
effective and efficient response during emergencies and disasters. It also includes
policies, protocols, guidelines and procedures pertaining to various emergency
management systems.
GENERAL OBJECTIVES:
To sustain the ICMC Health Emergency Preparedness Response and Recovery Plan,
thus reducing morbidity and mortality rate.
SPECIFIC OBJECTIVES:
1. To develop policy for response to both internal external disasters that may affect
the hospitals staff; patients and the community, as well.
2. To strengthen skills, knowledge, capability necessary to accomplish, mitigation,
preparedness, response and recovery in the management of disaster victims.
3. To institutionalized the Health Emergency Management in the hospital.
4. To establish networking with other line agencies for an effective and efficient
delivery of immediate needs of disaster victims.
5. To improve the general status of emergencies response in the hospital taking into
consideration availability of drugs and medical supplies.
6. To report to the authorized agencies.

7. To document and report all responded disasters and emergencies
EMERGENCY AND DISASTER MANAGEMENT PLANNING
The plan was develop in accordance with the requirements set by Department of
Health pursuant to the pertaining laws institutionalizing the Hospitals Disaster and
Emergency Preparedness and Recovery Plan in all hospitals levels. The hospital
management develops a hospital emergency and disaster plan to ensure that the
hospital is ready to respond during emergencies.
GENERAL CONSIDERATIONS
LINES OF AUTHORITY
The following persons in order listed, will be In-Chrage:
1. Medical Director
2. Administrative Officer
3. Resident on Duty
4. Head Nurse
5. Nurse on Duty
6. Medical Technologist
7. Technical Staff/ Administrative Staff
FUNCTIONS
1. Develop the structural framework of the plan.

2. Solicit participation/ commitment of another key player’s organization.
3. Conceptualize the Plan.
4. Dissemination/ orient hospital staff and others with the plan.
5. Test/ Implement Plan.
6. Monitor/ evaluate/ update the plan from time to time.
DUTIES AND RESPONSIBILITIES OF INDIVIDUALS/DEPARTMENTS

In a major disaster will do the following functions:
I. Medical Director/ Administrator
1. Check with local authorities to verify the disaster and obtain additional
information (In case of Major Disaster).
2. Authorize announcement of disaster to hospital personnel.
3. Ask for help from the local police and volunteer organizations as deemed
necessary.
4. Stay in the area of administrative officer to be available to assist as
requested by different departments.
II. Medical Response Team (Physicians, Nursing Service Staff)
1. Will attempt to find adequate numbers of nursing personnel. (This can also
be assigned to the Communications Coordinator, upon the order of the
hospital Administrator.)
2. The nursing service staffs are responsible in checking of all the equipments,
medicines, and supplies in the emergency room.
3. Set-up facilities and support system to ensure efficient and effective
management of medical emergency measures to minimize lost of life and
suffering and refer all cases, which are beyond the hospital capability to
handle.
4. Responsible in triage of patients/ victims so as to classify the victims
according to the degree of injury or damage.
III. Maintenance and Housekeeping
1. Maintain full operation of all facilities.

2. Be responsible for setting up extra beds in the hospital if needed, as well as
transporting storeroom supplies and bringing in extra supplies from other
areas.
3. Be willing to help with the movement of victims from ambulance to ER, or to
other facilities, or vice versa.
4. Be available to help clean the receiving area, and clean rooms between
cases in trwatment areas.
5. Ensure that all hallways are clear or free from any obstructions.
IV. Medical Records
1. Supplies] extra foam.

2. Responsible for maintaining casualty lists and assist with paper works as
neded.
3. Responsible for releasing of information to the press or other concerned

agencies after the families of victims have been notified.
V. Laboratory
1. Have arrangements made to obtain blood, equipment and supplies from

other institutions.
2. Call personnel from nearby hospitals or clinics as necessary.
3. Performs all laboratory exams as needed.
VI. Materials Management- Purchasing:
1. Ensure that all needed supplies and medicines are available.

2. Have the stock card in the pharmacy and central supply updated.
VII. Plan Development and Maintenance:
1. This plan will be updated every 5 years or as changes in the hospital set-up
occur.

Head Nurse


Medical Director
STRUCTURAL FRAMEWORK

MEDICAL DIRECTOR
ADMINISTRATOR
ADMINISTRATIVE ANCILLIARY SERVICES MEDICAL SERVICES NURSING SERVICES

SERVICES
MEDICAL RESIDENT ON DUTY HEAD NURSE
TECHNICAL STAFF TECHNOLOGIST
PLANS:
1. A Communications system shall be set for recalling of additional staff when

needed.
2. Visitors control center should also be installed to accommodate the patient’s
families.
3. Supplies and equipments should always be ready with complete medicines and
supplies.
4. Valuables and linens should always be in placed especially in treatment areas.
5. Medical Recording of casualties or patients must be properly accomplished and
flied for purposes of investigations by the police, insurances of patients.
6. Patients pronounced as DOA will be transported immediately to the funeral
facility. In case where delay of transportation to the funeral facility occurs, the
cadaver should be stored in an area outside the ER.
PROCEDURES:

1. A technical staff will be assigned as in charge of communications to handle and

coordinate communications such as recalling of additional staff when there is
increased patient load or casualties.
2. Nursing coordinator will be assigned to inform the In0charge of communications to
coordinate when the concerned agencies/ institutions/ patients relatives whenever
transport to higher facility is needed e.g Contact Ambulance.
3. The person In-Charge of communications must be also be responsible in
coordinating with concerned agencies or authorities in cases of the following.
a. Bureau of Fire Protection, in cases of fires
b. The police, in cases of vehicular Accident or other incidents needing police
attentions.
4. Visitors should not be allowed to enter ER Visitors Center is installed to attend to

the patients families or relatives.
5. Drug and Medicines, Supplies and Equipments should always be ready and
complete.
6. Linens and other valuables are always checked by the Central Supply In-Charge.
7. Medical Records forms must always be available to facilitate completion of medical
information.

Head Nurse


Medical Director

MANAGEMENT PLAN FOR SAFETY
FIRE PREVENTION AND LIFE SAFETY MANAGEMENT PLAN
INTRODUCTION:
The fire Prevention and life safety management program is designed to support
ICMC core values by designing, constructing, maintaining the facility in a manner that
minimizes the possibility of a fire emergency requiring the evacuation of patients,
watchers, visitors and employees.
GOALS AND OBJECTIVES:

The goal of the Fire Prevention and Life Safety Management Program to design
processes to protect patients, visitors, watchers, and employees in the event of fire.
The objectives of this Hospitals Fire Prevention and Life Safety Management plan
include the following:
1. To assure that t hospital facilities are designed, constructed, maintained and
operated to minimize the possibility of a fire emergency requiring evacuation and
are in compliance with applicable standards of Fire Department.
2. To provide adequate education/information through conducting trainings and drills
on the elements of the Fire Prevention and Life Safety Management Program
including isolation of fire, transfer and evacuation of occupants from the ICMC and
office buildings.
3. To test and maintain the fire sprinklers systems, fire extinguishers and detection
system every three months and institute life safety measures and maintenance
report during system failures.
4. To maintain documentation of events and fire incidents with the fire Committee.
5. The Medical Director as the Incident Commander is ultimately responsible for the
fire prevention and life management program at ICMC.
6. The Head Nurse as the Safety Prevention and Life Safety Program, maintaining and
managing all structural elements and compliance with the Fire Prevention and Life
Safety Program.
7. Each department is responsible for orienting new staff members to the department
and job specific fire safety procedures.
8. All employees of this hospital are responsible for learning the hospital-wide and
departmental fire safety plans.
ELEMENTS OF THE FIRE SAFETY MANAGEMENT PLAN
The fire safety management program is described in this management plan. The
plan describes the processes implement by the hospital to effectively manage fire safety.
FIRE RISK MANAGEMENT:

1. It is the responsibility of the Medical Director, Safety Officer and the Administrative
Officer to proactively manage the fire safety management program to protects the
patients, employees, visitors and hospital property by providing appropriate fire
protection equipment, employee training and interim life safety measures.
2. Employees shall be oriented with the general fire safety instruction for their
departments including location of fire extinguishers, oxygen tanks, and evacuation
routes
3. The hospital is equipped with fire sprinklers systems and general-purpose portable
fire extinguishers. The fire extinguishers are located throughout the hospital. It is
the responsibility of each employee to know the location and how to use these fire
extinguishers.
THE FIRE EMERGENCY PRE PLAN (RACE)
S- SOUND ALARM
A- ADVICE FIRE DEPARTMENT
F- FIGHT FIRE
E- EVACUATE PATIENTS AND OTHER OCCUPANTS
T- TELL OTHERS ABOUT FIRE
Y- YOU GO OUT, NEVER COME BACK
HOW TO USE FIRE EXTINGUISHER

P- PULL THE PIN
A- AIM THE NOZZLE
S- SQUEEZE THE LEVER
S- SWEEP THE NOZZLE SIDE BY SIDE
a. Rescue anyone in immediate danger

b. Alarm
 Know the location of the nearest fire alarm
 Know he emergency umber to dial
c. Confine – close all doors and windows
d. Extinguish
 Know the location of fire extinguishers and how to use them
 Know the location of fire extinguisher and hoe to use them
 Know the location of the exits.
 Know proper evacuation procedures and routes
 Hospital Fire Evacuation Plans are kept in accessible locations in each
department or unit of the hospitals.
 All employee are not permitted to smoke in the facility.

Head Nurse


Medical Director


Immaculate Clinic Safety Plan

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Immaculate Conception Medical Clinic

Poblacion President Quirino, Sultan Kudarat Region 12 (SOCCSKSARGEN) 9804

Policy No: ICMC 18-30 Date Issued: September 01, 2018

An overall management plan includes standard procedures, which is essential to

Safety management plan is formulated to provide a safe, functional and efficient

C. RESPONSIBLE INDIVIDUAL / PERSONNEL

ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

To institute continues Safety Management Functions, the hospital management has

II. HOSPITAL EMERGENCY AND DISASTER PREPAREDNESS PLAN

1. Triage- classification of patients according to type and seriousness of injury in order

Prepared by; Marjorie M. Quilos., RN

Reviewed by: Galileo A. Dogoldogol

ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

Noted by; Luzviminda B. Madronero, MD

DISASTER TRAINING/ DRILL

1. Basic Life Support (Cardio-Pulmonary-Resuscitation)

EMERGENCY AND DISASTER MANAGEMENT

1. Observe all requirements, protocols, standard: (hospital emergency plans, HEICS,

ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

DEFINED PLANS AND STRATEGIES

ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

EMERGENCY AND DISASTER MANAGEMENT PLANNING

1. Observe all requirements, protocols, standards: (hospital emergency plans,

DEFINED PLANS AND STRATEGIES

6. To report to the authorized agencies.

EMERGENCY AND DISASTER MANAGEMENT PLANNING

The following persons in order listed, will be In-Chrage:

1. Develop the structural framework of the plan.

DUTIES AND RESPONSIBILITIES OF INDIVIDUALS/DEPARTMENTS

In a major disaster will do the following functions:

I. Medical Director/ Administrator

II. Medical Response Team (Physicians, Nursing Service Staff)

III. Maintenance and Housekeeping

1. Maintain full operation of all facilities.

IV. Medical Records

1. Supplies] extra foam.

3. Responsible for releasing of information to the press or other concerned

1. Have arrangements made to obtain blood, equipment and supplies from

VI. Materials Management- Purchasing:

1. Ensure that all needed supplies and medicines are available.

VII. Plan Development and Maintenance:

Prepared by; Marjorie M. Quilos., RN

Reviewed by: Galileo A. Dogoldogol

Noted by; Luzviminda B. Madronero, MD

ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

ADMINISTRATIVE ANCILLIARY SERVICES MEDICAL SERVICES NURSING SERVICES

1. A Communications system shall be set for recalling of additional staff when

ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

1. A technical staff will be assigned as in charge of communications to handle and

4. Visitors should not be allowed to enter ER Visitors Center is installed to attend to

Prepared by; Marjorie M. Quilos., RN

Reviewed by: Galileo A. Dogoldogol

Noted by; Luzviminda B. Madronero, MD

ICMC MANUAL OF POLICIES AND PROCEDURES 2018 EDITION

MANAGEMENT PLAN FOR SAFETY

FIRE PREVENTION AND LIFE SAFETY MANAGEMENT PLAN

GOALS AND OBJECTIVES:

ELEMENTS OF THE FIRE SAFETY MANAGEMENT PLAN

FIRE RISK MANAGEMENT:

THE FIRE EMERGENCY PRE PLAN (RACE)

Y- YOU GO OUT, NEVER COME BACK

HOW TO USE FIRE EXTINGUISHER