Current through all regulations passed and filed through September 16, 2024
(A) Policy statement
The university of Toledo shall have a safety and health
management plan in order to manage safety risks.
(B) Purpose of policy
To meet the mandates set forth by local, state and federal
governments and relevant regulatory agencies including but not limited to the
joint commission, environmental protection association "EPA," centers for
disease control and prevention "CDC," occupational safety and health
administration "OSHA," national fire protection association "NFPA," department
of transportation "DOT," and department of homeland security "DHS." To provide
for the safety, health and well-being of patients, staff and the public by
creating an environment of care free of hazards.
(C) General overview
The safety management plan describes how the organization will
provide physical environment free of hazards and manage staff, faculty,
student, patient, visitor and volunteer activities to reduce the risk of
injuries. The university identifies these risks and plans and implements
processes to minimize the likelihood of those risks causing incidents.
(D) Development of plan
(1) Develop and maintain a written management
plan describing the processes it implements to effectively manage the
environmental safety of staff, faculty, students, patients, visitors and
volunteers coming to the university facilities.
(2) Buildings on the campus are constructed
in accordance with all applicable fire and building codes, so as to ensure
compliance with all requirements regarding fire egress and exits, construction
materials, corridor width and electrical safety.
(E) Roles and responsibilities
(1) The environmental health and safety
department is to identify a person(s) to intervene whenever conditions
immediately threaten life or health or threaten damage to equipment or
buildings: the president of the university of Toledo and/or her designee have
appointed the chairmen of the university of Toledo safety and health
committees, or his/her designees, to fulfill this responsibility.
(2) Conduct proactive risk assessments that
evaluate the potential adverse impact of buildings, grounds, equipment,
occupants and internal physical systems on the safety and health of staff,
faculty, students, patients, visitors and volunteers coming into the
institution's facilities.
(3)
Identify risks and select and implement procedures and controls to achieve the
lowest potential for adverse impact on the safety and health of staff, faculty,
students, patients, visitors and volunteers coming to the hospital's
facilities.
(4) Through proactive
risk assessments the environmental health and radiation safety department
identifies risks to individuals and structures on campus and make
recommendations to lower or eliminate these risks on campus.
(5) Establish safety procedures, plans and
programs that are distributed, practiced, enforced and reviewed on a regular
basis.
(6) Ensure that all grounds
and equipment are maintained appropriately:
Environmental safety rounds, facilities maintenance routine
preventive maintenance in accordance with manufacturers' warranty
recommendations, and department-specific inspections of equipment accomplish
this goal, in addition to the grounds department's daily scrutiny of any
problems with university grounds; adherence to institutional safety procedures
that address the use of equipment also assure compliance with this
requirement.
(7) Executive
leadership supports the safety and health program by assuring the formation and
development of the university safety and health committees.
(8) Administration also supports the safety
and health program by appointing an employee who will act as the director of
environmental health and radiation safety.
(9) The director of environmental health and
radiation safety is authorized to take immediate action when a condition exists
that poses an immediate threat to life, safety and/or property. All such action
is to be reported by the director to his/her supervisor as soon as possible
following the incident.
(10)
Conduct safety and health programs including:
(a) Safety and health management;
(b) Fire prevention/life safety;
(c) Emergency management;
(d) Hazardous materials and
environment.
(11) The
director of environmental health and radiation safety is responsible to:
(a) Report safety and health activities to
the public safety officer, the board of trustees or governing body, and makes
reports, as applicable, to department managers. The director further reports to
the university safety and health committees the results of ongoing monitoring,
actions taken or actions proposed, and follow-up recommendations.
(b) Participates in incident/accident
investigation and reporting; facilitates the development of hospital-wide
safety and health policies and procedures, and ensures that these policies and
procedures are reviewed as needed but at least every three year.
(c) Participates in the organization,
development and implementation of an ongoing safety education orientation
program, and is responsible for assessing the effectiveness of that
program.
(d) Collect and evaluate
information on safety issues, concerns and problems, and communicates this
information as needed to the appropriate department chairman, directors,
managers, or supervisors.
(e)
Receive and evaluate summaries and reports of activities related to safety,
fire prevention/life safety, medical equipment, utility systems,
security/campus police, emergency management and hazardous materials.
(f) Ensure that policies are in place for
maintaining all grounds and equipment, for conducting risk assessments on
various elements, such as grounds, equipment, buildings and internal physical
systems, and their impact on patient and public safety (this is done through
analysis of campus police reports and occurrence reports through the OSHA three
hundred illness and injury log); for seeing that all incidents of property
damage, occupational illness and patient, personnel or visitor injury are
reported and investigated (these issues are handled by a three-pronged approach
between risk management, campus police and environmental health and radiation
safety, by which the appropriate department handles crimes against persons:
campus police; illness in the workplace: safety and health; and personnel and
visitor injury: risk management and safety and health, via the occurrence
reporting system, and the OSHA three hundred illness and injury log
system).
(F)
University of Toledo safety and health committees
(1) There currently are two safety and health
committees at the university of Toledo, one for the health science campus and
one for all of the other university campuses.
(2) A multi-disciplinary team comprised of
representatives from administration, laboratory research, departmental
directors, managers and supervisors from a variety of institutional and
academic departments.
(3) The
university safety and health committee meets regularly to review, discuss and
vote as needed on issues that impact the safety, health and well-being of
patients, staff, faculty, visitors, volunteers and students.
(G) Conduct a process of hazard
surveillance (called environmental safety rounds at the university) on a
regular basis, with various in-house expert staff evaluating the areas toured
for safety problems.
(H)
Responsibilities of department/lab managers/directors
(1) The ultimate responsibility for the
development and maintenance of current department standard operating procedures
related to safety and health shall lie with individual department/lab
managers/directors with the assistance of the director of environmental health
and radiation safety and other environmental health and radiation safety
department personnel as needed/appropriate.
(2) Assure that new employees are properly
educated and have attended new employee safety orientation. The safety
orientation and education program will address:
(a) General safety processes;
(b) Area-specific safety;
(c) Specific job-related hazards;
(d) Provide documented
continuing education on departmental/lab-specific safety policies and
procedures annually;
(e) Stimulate and encourage employee interest and
participation in the safety and health program at the university;
(f)
Assist in any way possible with the investigation of any injuries that occur
within their department/lab;
(g) Continually work
to ensure that unsafe conditions are identified and eliminated;
(h)
Assist in monitoring safety recommendations pertaining to the specific
department.
(I) Employee, faculty, student, and volunteer
responsibilities
(1) To cooperate in making a
safe environment by attending safety education training as necessary and to
obey all posted safety information.
(2) Required within established time periods,
reporting and documenting all incidents or injury and near-injury, and
reporting unsafe conditions immediately to their immediate supervisor, the
environmental health and radiation safety department (419-530-3600), or to
campus police (419-530-2600).
(J)
Joint
commission annual reporting and evaluation
(1) The scope, objectives, performance and
effectiveness of the safety and health management plan will be evaluated in an
annual report to administration and shared with the board of
trustees.
(2) Evaluation will
include all areas of safety management.
(3) Performance monitors will be identified
that will assist in the overall management of safety. These monitors will be
tracked and trended in order to determine the overall effectiveness of the
safety program.
