VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

# 

# [SAFETY MANAGEMENT PROGRAM]{.underline}

1\. [PURPOSE]{.underline}: To establish a VAAAHS Safety Management
Program that provides protection to VAAAHS patients, visitors, and staff
and complies with Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) Standards, OSHA Standards, and other regulatory
organizations dealing with safety.

2\. [POLICY]{.underline}: The VA Ann Arbor Healthcare System (VAAAHS)
will ensure a safe environment of care for patients, employees, and
visitors through the establishment and maintenance of an effective
environment of care program that includes life safety, equipment and
utilities management, hazardous waste management, emergency
preparedness, and security management. This program will be based on
monitoring and evaluation of organizational experience, applicable laws
and regulations, and accepted practice.

3\. [RESPONSIBILITIES]{.underline}:

a\. The VAAAHS Director is responsible for the overall safety management
program, and approves all minutes and recommendations of the Safety and
Occupational Health Committee. The Director will be the approving
official for all policies and procedures related to the Safety Program.

b\. The Environmental Safety Staff are responsible for:

\(1\) The development, implementation, and monitoring of the Safety,
Occupational Health, Fire Protection, and Radiation Safety Programs.

\(2\) Implementation and maintenance of an ongoing hospital-wide system
to collect and evaluate information for use by the Safety & Occupational
Health Committee about hazards, safety practices, and safety management
issues.

\(3\) Review of all Department safety plans and all VAAAHS safety
policies and procedures and the submission of a summary report to the
Safety and Occupational Health Committee (S&OH).

\(4\) Investigating all incidents that involve property damage,
occupational illness, and patient, personnel, or visitor injury.

c\. Department Heads are responsible for:

\(1\) Development and implementation of an effective department safety
program and participating in and supporting the Safety Management
Program of the VAAAHS, including ensuring reporting and review of all
employee accidents.

2\.

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(2\) Ensuring employees receive annual mandated training in general
safety, fire or life safety, hazardous material safety, emergency
preparedness, infection control, and security. Special
department-specific training will also be provided as needed.

\(3\) Preparing departmental safety policies and procedures that are
distributed, practiced, and enforced.

\(4\) Using safety-related information in the orientation of new
employees and continuing education.

\(5\) Reporting all security incidents involving patients, visitors,
personnel or property.

\(6\) Educating and monitoring of personnel who manage, or regularly
come in contact with, hazardous materials and wastes.

\(7\) Identifying, evaluating, and preparing an inventory of hazardous
materials and wastes used or generated in each department.

\(8\) Reporting all hazardous materials waste spills, and exposures or
other incidents that involve patients, visitors, personnel, or property.

\(9\) Assessing and minimizing the clinical and physical risks
associated with medical equipment through inspection, testing, and
maintenance of equipment and education of users.

\(10\) Reporting and investigating equipment problems, failures, or user
errors that may have an adverse effect on patient safety or the quality
of care.

\(11\) Developing department specific policies that detail employee
actions to be taken when equipment fails (i.e., department actions taken
when a defibrillator fails).

\(12\) Reporting all utility systems management problems, failures or
users errors that are or may be a threat to the patient care environment
(i.e., a 110V plug forcibly inserted into a 208V outset).

\(13\) Reporting all fire protection deficiencies, failures, and user
errors.

\(14\) Employee Education. Attachments dealing with safety, life safety,
security, hazardous materials and wastes, medical equipment, and
utilities will be reviewed with each employee within 30 days of hire.
Area processes for reporting include deficiencies in any area, specific
area hazards (radiation, toxic materials, flammable storage, medical
equipment usage, etc.), specific equipment assembly and operation,
location and proper use of emergency transport equipment, and operation
procedures for emergency shut-off controls, will be covered by section
specific supervisors.

3\.

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(15\) Reviewing JCAHO Environment of Care standards and ensuring
personnel are knowledgeable of all elements in the EC section.

d\. Facility Management Department, in addition to the responsibilities
outlined in paragraph 3c., is responsible for:

\(1\) The design and implementation of a medical equipment management
program that assesses and controls the clinical and physical risks of
fixed and portable equipment used for the diagnosis, treatment,
monitoring, and care of the patients, and other fixed and portable
electrically-powered equipment, according to VAAAHS policy.

\(2\) The design and implementation of a utilities management program
that assures the operational reliability, assessment of special risks
involved, and response to failures of any utility system that supports
the patient care environment.

\(3\) Ensuring, with the Safety Manager, adherence to the Life Safety
Code (NFPA) and all aspects of the Environment of Care Standards
(JCAHO), as set forth by VHA.

\(4\) Design and construct facility projects/renovations in compliance
with VHA Construction guidelines, NFPA Life Safety Code, A.D.A.
guidelines for handicap accessibility, and any other applicable design
guidelines used by Department of Veterans Affairs.

e\. All employees are responsible for the prevention of accidents and
injuries; reporting all incidents that involve property damage or
occupational illness, or injury to patients, personnel or visitors;
reporting all unsafe conditions to their supervisor; and attending
annual safety training.

f\. Chief, VA Police is responsible for the development, implementation,
and monitoring of policies and procedures for the identification of
staff, visitors, and personnel; the maintenance of a security program
which includes a Behavioral Emergency Management Plan in concert with
workplace violence identification & prevention, and the Emergency
Preparedness Plan.

g\. Radiation Safety Officer is responsible for advising the VAAAHS
Safety and Occupational Health Committee of significantly identified
radiation safety issues, corrective actions taken, and managing the
VAAAHS Radiation Safety Program.

h\. Safety Manager is responsible for monitoring all aspects of the
Safety Management Program including fire drills, compliance with the
National Fire Safety Code, portable equipment checks, and liaison with
Facility Management Department to ensure compliance with the Life Safety
Code during construction and renovations.

i\. Associate Director is responsible for a monitoring program involving
product safety recalls. Textile Team Leader has the responsibility of
overseeing the purchase of flame retardant materials used within the
facility and TOPC.

4\.

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

j\. Human Resources Team Leader is responsible for ensuring the use of
safety-related information in the orientation of new employees and
supervision of the Workers' Compensation Program for the facility.

k\. Supervisors are responsible for supporting the safety, fire
protection, and industrial hygiene programs by the application of
approved standards, regulations, practices, and work

methods. Routine discharge of their responsibility includes instruction
and training subordinates in compliance of safe working methods and
practices.

l Industrial Hygienist is responsible for offering technical advice in
connection with the industrial hygiene program. The Industrial Hygienist
is also responsible for developing specific program elements and
corrective action to otherwise stimulate and guide an industrial hygiene
program. The Industrial Hygienist ensures monitoring for compliance with
the hazardous materials and wastes program requirements, medical
surveillance, respirator, and ergonomics.

4\. [PROCEDURES]{.underline}:

a\. The Safety Manager and Specialist for the VAAAHS are granted the
authority to immediately intervene or stop work, operations, projects,
or acts which may result in injury, impairment, sickness, or immediately
endanger the life of patients, employees, or visitors, or threaten
damage to equipment or buildings. The Radiation Safety Officer and
Industrial Hygienist have the same authority in their respective areas
of responsibility.

b\. The Safety Manager will establish a risk assessment program that
proactively evaluates the impact on patients and public safety of
buildings, grounds, equipment, occupants, and internal physical systems.

c\. The Safety Specialist will ensure ongoing fire drills are conducted
and documented.

d\. The Safety Manager will assure an annual inspection is done of
Community Residential Care Homes and Contract Nursing Homes as required
by VHA standards.

e\. The Industrial Hygienist will ensure an effective hazard
surveillance program is conducted throughout VAAAHS.

f\. A Safety and Occupational Health Committee is established to
evaluate and complete annual evaluation of the objectives, scope,
performance, and effectiveness of the documented Safety Management
Program.

5\. [REFERENCES]{.underline}:

Accreditation Manual for Hospitals, Joint Commission on Accreditation of
Healthcare Organizations Environment of Care.

OSHA Standards 29 CFR 1910, 1926, and 1960

5\.

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

NFPA 101, Life Safety Code

5\.

6\. [RESCISSIONS]{.underline}: Policy Memorandum 00-6, dated May 1, 2000

7\. [EXPIRATION]{.underline}: September 2006

8\. [FOLLOW-UP RESPONSIBILITY]{.underline}: Safety Manager (50S)

James W. Roseborough

JAMES W. ROSEBOROUGH

Director

Distribution F + 15 for 30, 10 for 50S

VA Ann Arbor Healthcare System Attachment A

Policy Memorandum S-3

September 30, 2003

  ------------------- --------------- --------- --------- --------- --------- --------- --------- --------- --------- --------- --------- --------- ---------
                      **SAFETY,                                                                                                                     
                      OCCUPATIONAL                                                                                                                  
                      HEALTH & FIRE                                                                                                                 
                      PROTECTION                                                                                                                    
                      COMMITTEE**                                                                                                                   

                      **ANNUAL AGENDA                                                                                                               
                      ITEMS**                                                                                                                       

  **TOPIC**           **FREQUENCY**   **JAN**   **FEB**   **MAR**   **APR**   **MAY**   **JUN**   **JUL**   **AUG**   **SEP**   **OCT**   **NOV**   **DEC**

                                                                                                                                                     

  INFECTION CONTROL   MONTHLY         X         X         X         X         X         X         X         X         X         X         X         X

                                                                                                                                                     

  INTERIM LIFE SAFETY MONTHLY         X         X         X         X         X         X         X         X         X         X         X         X

                                                                                                                                                     

  ACCIDENT REVIEW     MONTHLY         X         X         X         X         X         X         X         X         X         X         X         X
  BOARD                                                                                                                                             

                                                                                                                                                     

  Q.A. - INCIDENT     BI-MONTHLY                X                   X                   X                   X                   X                   X
  REPORT                                                                                                                                            

                                                                                                                                                     

  SECURITY INCIDENTS  BI-MONTHLY      X                   X                   X                   X                   X                   X         

                                                                                                                                                     

  HAZ. SURV. -        QUARTERLY                           X                             X                             X                             X
  (Environ. of Care)                                                                                                                                

                                                                                                                                                     

  EQUIPMENT           QUARTERLY                 X                             X                             X                             X\*        
  MANAGEMENT                                                                                                                                        

                                                                                                                                                     

  UTILITIES           QUARTERLY       X                             X                             X                             X\*                  
  MANAGEMENT                                                                                                                                        

                                                                                                                                                     

  LIGHT               QUARTERLY                 X                             X                             X                             X          
  DUTY/OWCP/MEDICAL                                                                                                                                 
  RPT.                                                                                                                                              

                                                                                                                                                     

  ACCIDENT REPORT     QUARTERLY       X                             X                             X                             X                    
  ANALYSIS                                                                                                                                          

                                                                                                                                                     

  RADIATION SAFETY    QUARTERLY                           X \*                X                             X                             X          

                                                                                                                                                     

  EMERGENCY           SEMI-ANNUAL                                                       X\*                                                         X
  PREPAREDNESS                                                                                                                                      

                                                                                                                                                     

  SVC. SPECIFIC       ANNUALLY                                                                                                  X                    
  SAFETY TRAINING                                                                                                                                   

                                                                                                                                                     

  SAFETY PROGRAM      ANNUALLY                  X                                                                                                    
  REVIEW                                                                                                                                            

                                                                                                                                                     

  LIFE SAFETY         ANNUALLY                            X                                                                                          
  MANAGEMENT                                                                                                                                        

                                                                                                                                                     

  HAZ. MAT.           ANNUALLY                                      X                                                                                
  MANAGEMENT                                                                                                                                        

                                                                                                                                                     
  ------------------- --------------- --------- --------- --------- --------- --------- --------- --------- --------- --------- --------- --------- ---------

VA Ann Arbor Healthcare System Attachment B

Policy Memorandum S-3

September 30, 2003

[LIFE SAFETY MANAGEMENT PROGRAM]{.underline}

1\. [PURPOSE]{.underline}: The Life Safety Management Program is
designed to ensure a fire safe environment for healthcare delivery
through appropriate building design and construction, system inspection
and testing, education and training and enforcement of safety policies.

2\. [POLICY]{.underline}: Construction at VAAAHS will remain in
compliance with NFPA 101, Life Safety Code. All fire warning suppression
and control equipment will be maintained as a priority to ensure systems
will function properly when required. All personnel will receive
training regarding Life Safety issues to ensure compliance with the
procedures delineated in this policy.

3\. [PROCEDURES]{.underline}:

a\. [Life Safety Code Compliance]{.underline}.

All facilities in which patient care is delivered will be constructed
and maintained in accordance with the 1999 Edition of the Life Safety
Code. These facilities include VAAAHS, Extended Care Center, (ECC), all
community-based outpatient clinics, and contract community nursing homes
as residential board and care facilities.

The VAAAHS has been granted a Fire Safety Evaluation System (FSES)
equivalency with the Life Safety Code by the Joint Commission on Health
Care Organization in May 1990. The equivalency recognizes that
alternative methods of compliance may be developed to meet the intent of
the code where explicit code compliance may be physically difficult or
economically impractical. Approved FSES equivalency obviates the need to
correct such issues as dead end corridor situations and excessive travel
distance to exits by construction of stair towers.

b\. Facility Occupancies. The facilities will be classified as the
following occupancies:

Building #1W ‑ Health Care Occupancy (Chapter 19)

Building #1E - Health Care Occupancy (Chapter 18)

Building #1E, Auditorium ‑ Assembly Occupancy (Chapter 13)

Nursing Home Building #28 ‑ Health Care Occupancy (Chapter 19)

Toledo VA Outpatient Clinic ‑ Business Occupancy (Chapter 39)

Contract Nursing Homes ‑ Health Care Occupancy (Chapter 18, 19)

Board & Care Facilities ‑ Residential Board and Care Occupancy (Chapter
32. 33)

Research Building #31 -- Industrial Occupancy (Chapter 40)

Research Building #22 - Industrial Occupancy (Chapter 40)

> Attachment B1

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

All differing occupancies within the VAAAHS complex will be separated by
construction with a minimum two-hour fire rating.

c\. [Unit Concept of Fire Containment]{.underline}.

The concept of containment of fire and the products of combustion
through compartmentalization (units of defense) will be supported by
facility construction and educational efforts. The order of the units of
defense are: rooms, smoke compartments, floor assemblies, building
construction, and exits.

This concept will be presented at employee safety training programs by
the facility Safety staff.

d\. [Interior Finish]{.underline}.

Interior finish of walls and ceilings throughout the VAAAHS and ECC will
be Class A. However, in individual rooms having a capacity of no more
than four persons, walls and ceilings may have a Class A or B finish.
Interior floor finish in corridors and exits will be Class I.

For the TOPC interior finish on walls, enclosed corridors furnishing
access thereto, or ways of travel there from will be Class A or Class B.
In office areas, interior finish may be Class B Interior floor finish in
corridors and exits will be Class I or Class II

e\. [Handicapped Accessibility]{.underline}.

The VAAAHS entrances and common use areas will be accessible to
physically disabled individuals. An appropriate number of handicapped
parking spaces will be provided near the main entrances. All new
construction will provide accessibility in accordance with UFAS (Uniform
Federal Accessibility Standards) requirements.

f\. [Grounds Safety]{.underline}.

The facility grounds will be regularly maintained and inspected as
described in Facilities Management 99-51-14, Inspection, Maintenance,
Supervision of Grounds and Lawn Equipment. Additionally, the hazard
surveillance team will inspect the grounds on a semi‑annual basis.
During construction and renovation, adequate barriers will be installed
to restrict access to authorized personnel only. Construction will not
restrict access to fire fighting equipment. Any substantial construction
site staging will be coordinated with the Ann Arbor Fire Department
(AAFD) to assure adequate access to hydrants, standpipes, and entrances.
The ambulance entrance will be clearly marked with appropriate signage,
and policed regularly to minimize traffic congestion.

g\. [Fire Protection and Prevention]{.underline}.

\(l\) Fire Warning/Safety Systems. Facilities are equipped with
electrically supervised, manually operated fire alarm systems. VAAAHS
and ECC fire alarm systemss automatically transmit to Simplex Alarm
Company, who immediately notifies the Ann Arbor Fire Department. TOPC
system will transmit to Guardian Alarm, who will notify the Toledo Fire
Department.

Attachment B2

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(2\) The entire main hospital building and ECC are protected with
automatic wet pipe sprinkler systems. The TOPC has sprinkler protection
for hazardous areas only. Additionally, cooking facilities are protected
with dry chemical extinguishing systems.

\(3\) Portable fire extinguishers are provided throughout the VAAAHS,
and will be placed no more than 75 feet apart.

\(4\) All components of the fire warning and safety system will be
inspected and tested in accordance with Facilities Management Policy
USOM-FP-1, Inspection and Testing of Fire Protection Equipment System.

\(5\) Flame resistant curtains, furnishings and other building materials
will be utilized to control the combustible load of the building.
Records will be kept that verify the class and flame spread ratings of
these materials. (Policy Memorandum S-3, Attachment Q)

\(6\) Emergency Preparedness Plan (Policy Memo S-5) describes fire
response plan and fire drill requirements.

h\. [Fire Fighting Equipment]{.underline}.

\(l\) [Fire Extinguishers]{.underline}.

\(a\) Fire extinguishers are located in all fire extinguisher closets,
on walls in special fire hazard areas, and throughout all buildings in
accordance with the standards. Extinguishers are usually the quickest,
easiest, and first equipment to be used in fighting a fire.

\(b\) Extinguishers are classified for use based on the three classes of
fire:

[l]{.underline} Class \"A\" fires are defined as fires in ordinary
combustible material where the quenching and cooling effect of
quantities of water is of first importance. Examples are fires involving
wood, paper, textiles, fabric, rubbish, etc. Extinguishers provided for
this use are type \"A\" or \"ABC\" multi‑purpose dry chemical.

[2]{.underline} Class \"B\" fires are defined as fires of flammable
liquids, etc., where the blanketing or smothering effect of the
extinguishing agent is of first importance. Examples are

fires involving gasoline, oils, alcohol, and other flammable liquids.
Extinguishers provided for this use are type \"BC\" carbon dioxide or
type \"ABC\" multi‑purpose dry‑chemical.

[3]{.underline} Class \"C\" fires are defined as fires involving
electrical equipment, where the use

of a non‑conductive extinguishing agent is of first importance. Examples
are fires involving electric appliances, motors, or wiring.
Extinguishers provided for this use are type \"BC\" carbon dioxide.

\(c\) Fire extinguishers will not be removed from places provided for
them, except in case of fire or drill, or for authorized maintenance and
repair.

Attachment B3

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(d\) Any time extinguishers are discharged or seals are broken, the
Safety Specialist must be immediately notified in order to insure they
are inspected and/or recharged.

\(e\) Fire Extinguisher Operation.

[1]{.underline} Pull safety or locking pin.

[2]{.underline} Grasp bottom and grip handle and then aim nozzle at base
of fire.

[3]{.underline} Squeeze the grip handle and direct the agent in a
sweeping motion across the base and front of the fire.

\(2\) [Using material at hand]{.underline}. In many cases, a fire can be
handled faster and more effectively by quick action with a blanket,
mattress pad, or container of water. Immediate use of material at hand
may be the best action, provided it will do the job.

\(3\) A fire requires three properties for it to be sustained:

\(a\) Combustible ‑‑ something that will burn.

\(b\) Air ‑‑ oxygen sustains the flame.

\(c\) Ignition ‑‑ something to ignite the combustible.

Remove, displace, or eliminate any of the three and the fire can be
stopped.

i\. [Fire Prevention]{.underline}.

\(l\) [Responsibility]{.underline}. Every employee is responsible for
the prompt reporting and elimination of all fire hazards observed. Each
employee is responsible for knowing where the fire alarm boxes and
initial fire fighting equipment are located within their work areas, as
well as exits from work areas. Fires do not generally develop except
when known precautions are

Attachment B4

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

neglected or potentially dangerous conditions are allowed to exist. Good
housekeeping and common sense are two of the best fire preventive
measures.

\(2\) [General Housekeeping]{.underline}. Constant supervision is
essential if satisfactory conditions are to be maintained. This can be
assured only through continual inspection of individual work place. Good
housekeeping serves a two‑fold purpose by reducing the possibility of
fire starting and facilitating the control of a fire should one start.

\(a\) All shops, store rooms, supply closets, and other storage areas
will be kept free from any accumulation of trash, rubbish, or
unnecessary combustible materials.

\(b\) All rubbish will be kept in flameproof containers with fitted
covers, where available, and accumulations should be removed daily.

\(c\) Oil and grease soaked cloths and rags should be disposed of as
soon as possible; if retained, they are to be kept in self-closing
covered metal containers away from other combustible items.

\(3\) [Flammable Liquids]{.underline}. Flammable liquids will be handled
with extreme care. Alcohol, gasoline, and other flammable liquids will
be stored in approved rooms, cabinets, and containers and will be
properly marked. Flammable liquids will be transported only in approved
containers. Flammable liquids will not be placed in standard
refrigerators. Standard refrigerators will be labeled to indicate that
such storage is hazardous. Sealed containers of volatile materials may
be stored in refrigerators designated and certified as being explosion
proof. Smoking is prohibited in both storage and use areas.

\(4\) [Flammable Liquids Use]{.underline}. Use of flammable liquids will
be limited to that required for maintenance, demonstration, laboratory
work, and medical use as prescribed by a physician, and used in a
well-vented area. Under no circumstances will such liquids be used in
the operating room area or in an area where oxygen and/or nitrous oxide
is being used or stored. The aggregate capacity of flammable liquids
outside of storage cabinets in any one department will not exceed ten
gallons or a two‑day working supply, whichever is fewer gallons. All
quantities of flammable liquids in one department unit in excess of ten
gallons will be stored in an approved room or cabinet.

\(5\) [Flammable Liquid Disposal]{.underline}.

\(a\) Any unused portion of a container remaining after seven days will
be disposed of through the hazardous material disposal program, as
described in Policy Memorandum 00‑3, Hazardous Materials Management
Plan.

\(b\) The Industrial Hygienist should be contacted at extension 5417
during regular duty hours for information on disposal.

Attachment B5

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(6\) [Fire Doors]{.underline}. Fire doors are located at the entrances
to all stairwells. These doors protect the vertical exits from fire,
smoke, and toxic gases. It is mandatory that fire doors be kept closed
and latched at all times. Door wedges or other devices must never be
used to prop or hold fire doors open.

\(7\) [Smoke Barrier Doors]{.underline}. Smoke barrier doors are located
across corridors throughout the facility. Closing these doors provides
areas of refuge from fire, smoke and toxic gases. These doors are held
open by automatic magnetic door holders and must be closed manually if
doors fail to close automatically upon activation of the fire alarm
system.

\(8\) [Use of Oxygen]{.underline}. Personnel administering oxygen must
be properly instructed in the dangers involved and the precautions to be
taken whenever oxygen is in use. The following regulations will be
adhered to:

\(a\) Rooms where oxygen is in use will be properly posted against use
of any ignition source such as matches, lighters, and smoking materials
as well as readily combustible materials. Conspicuous signs warning that
oxygen is being administered will be displayed at the room door.

\(b\) Oil, grease, or readily flammable or dust-retaining materials must
never come in contact with oxygen cylinders, valves, regulators, gauges,
or fittings.

\(c\) All using personnel should secure oxygen as well as other types of
gas cylinders on the cylinder stands. These stands are designed to
prevent the cylinders from being accidentally overturned while in use
during transport.

\(d\) All oxygen control valves will be labeled with signage identifying
rooms covered by each control valve. See Safe Use of Oxygen, Attachment
P.

j\. [Decorations, Stage Curtains, and Drapes]{.underline}. Every
precaution must be exercised to limit the use of decorative materials
that create hazards and fires.

\(l\) [Flameproof Decorative Materials]{.underline}. Only flameproof
materials are to be permitted wherever decorations are to in the medical
center. The Safety Specialist will approve construction and placement of
all such materials.

\(2\) [Christmas Trees, etc]{.underline}. Trees will be artificial or of
a fire retardant material. (A tree will not in any way interfere with
any means of egress.) Flammable material or lighted candles will not be
used for decoration on trees. Live decorations are prohibited.

\(3\) [Candles]{.underline}. Lighted candles are strictly prohibited
except when used in religious ceremonies in the Chapel.

Attachment B6

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(4\) [Electric Lights]{.underline}. For the safety of all concerned,
strings of electric lights will only be used as listed below.

\(a\) [Exterior Lights]{.underline}. Exterior electric lighting is
permitted providing it is exterior grade, U.L. listed, and approved for
use each year by the Safety Specialist.

\(b\) [Interior Lights]{.underline}. Interior lighting is permitted on
one centrally located Christmas tree in the medical center, provided the
lights are of the miniature or cool ray type, U.L. listed, and approved
for use each year by the Safety Specialist. The lights will be on only
while a competent person is in attendance.

\(5\) [Windows, Doors]{.underline}. Decorating windows, doors, or walls
with stickers, artificial snow, etc. is prohibited.

\(6\) [Authority]{.underline}. The Safety Manager and Specialist will be
delegated responsibility for the inspection of decorative materials,
including Christmas trees, to ensure they meet the requirements of this
policy and that no hazardous conditions exist.

k\. [Fire Equipment Testing ‑ Facilities Management]{.underline}.

\(l\) [Sprinkler Inspections]{.underline}. All water type sprinkler
systems will be tested and checked on a regular basis. Water flow tests
will be conducted semiannually by the plumbing shop, and the control
valves of each sprinkler system will be examined monthly and labeled.
Records of inspections will be kept by the plumbing shop, with copies
sent to safety staff (50S) upon request.

\(2\) [Fire Alarm Testing]{.underline}. The fire alarm system will be
checked and maintained on a regular basis. Weekly tests will be
conducted from a different location and all devices will be tested
annually. These tests will be conducted on Tuesdays between 7:00 a.m.
and 9:00 a.m. or at the call of the Maintenance & Repair (M&R)
Supervisor.

\(3\) [Fire Extinguisher Testing]{.underline}. All fire extinguishers
and fire fighting equipment will be checked on a monthly basis. Fire
extinguishers will be maintained on a yearly basis. Carbon dioxide and
dry chemical extinguishers will be weighted to insure proper charge. All
will be hydrostatically tested as directed by NFPA. Records will be kept
on all inspections. Any damaged or discharged fire extinguishers will be
reported to the Safety Specialist at ext. 5418.

\(4\) [Water Supply for Fire Protection]{.underline}. Adequacy of water
supply and distribution for fire demand will be reviewed at least
annually and whenever there is a likelihood of change in pertinent
conditions. Water supply, including sources available to the VAAAHS and
its storage capacity will be sufficient to meet necessary fire
protection requirements. These requirements are to be considered in
addition to normal operating demand.

Attachment B7

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(5\) All fire protection equipment inspections are conducted by the
Safety Manager or Specialist in coordination with the plumbing and
electric shops. Any problems should be reported to the M&R Shop at
extension 5503, or the Safety Manager at extension 5418.

\(6\) Further information may be found in Facilities Management
USOM-FP-1, Fire Alarm Systems.

l\. [Smoking Policy]{.underline}. The facility's no smoking policy is
outlined in Attachment T.

m\. [Reporting to the Safety & Occupational Health
Committee]{.underline}. An annual summary report of the Fire Prevention
Plan will be prepared by the Safety Manager and forwarded to the Safety
& Occupational Health Committee for review and action as indicated by
the schedule in Attachment B.

4\. [RESPONSIBILITIES]{.underline}: The Safety & Occupational Health
Committee will annually review the Life Safety Management Summary report
and all corrective actions will be monitored until abated as agenda
items.

Attachment C

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[EQUIPMENT MANAGEMENT]{.underline}

1\. [PURPOSE]{.underline}: The purpose of this Attachment is to define
the Equipment Management Program at VAAAHS and the TOPC. This program
will assess and control the clinical and physical risks of fixed and
portable equipment used for the diagnosis, treatment, monitoring, and
care of patient or other fixed and portable electrically powered
equipment.

2\. [POLICY]{.underline}:

a\. [Criteria for Inclusion of Equipment and Equipment
Inventory]{.underline}.

\(l\) All equipment, regardless of ownership, will be evaluated against
the following criteria for inclusion in the equipment management
program. This review will be documented and will encompass patient
contact, usage, and risk factors attendant with its normal, expected
use. All equipment and systems will receive a rating based on the
following elements:

\(a\) Equipment Function 0‑3 Points

\(b\) Clinical Application/Physical Risks 0‑3 Points

\(c\) Maintenance Requirements 0-2 Points

\(d\) Equipment Incident History 0-2 Points

The ratings will be used as follows:

[POINTS]{.underline} [PRIORITY]{.underline} [ACTION]{.underline}

8‑10 Critical Preventive maintenance completed at 95% level within
assigned time.

5-7 Required Preventive maintenance should be completed at 80% level
within assigned time.

2‑4 Low Risk Normally not included in Equipment Management Inventory.

Periodic maintenance is normally done during repairs.

These thresholds will be adjusted if review of failures and department
history so justifies.

\(2\) All equipment that has been evaluated and included in the
Equipment Management Program will be identified in the AEMS/MERS
inventory. This inventory will be current and accurate.

Attachment C1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

b\. [Maintenance]{.underline}.

\(1\) All the equipment will have a written testing procedure and a
written user training program designed to manage clinical and physical
risks.

\(2\) All equipment, regardless of ownership, will be tested prior to
initial use and at least annually thereafter. Rental equipment necessary
for patient treatment that is brought in during non-administrative hours
will be inspected on the first working day after its arrival. The test
results are documented.

c\. [Training]{.underline}. All equipment will have pre‑use orientation
and annual continuing education for those who use and/or maintain the
equipment.

d\. [Problem Resolutions]{.underline}.

\(l\) The Equipment Management Program will identify and document
equipment failures and user errors that have or may have an adverse
effect on patient safety or quality of care. Such problems may also be
identified through the facility\'s Quality Management program and
referred to the appropriate department through the Safety Manager and
Chief, Biomedical Engineering for follow‑up action.

\(2\) Summaries of equipment failures, user errors, and relevant
published reports of equipment hazards will be reviewed by the S&OH
Committee and other staff deemed appropriate by the Chief, Biomedical
Engineering and Safety Manager. The reviews will identify equipment
performance or use problems.

\(3\) When problems are identified, action will be taken to resolve
them. Those actions and their outcomes will be documented and sent to
the S&OH Committee within three weeks.

\(4\) The S&OH Committee will review the problem resolution documents,
evaluate them for effectiveness, and then decide whether further
monitoring is necessary. Further monitoring of corrective actions will
take place at least annually.

3\. [PROCEDURES]{.underline}:

a\. [Inventory and Maintenance]{.underline}.

\(1\) A unique inventory of the equipment that is assigned for
management under this program will be kept current by quarterly
Facilities Management inspections and Purchasing Department annual
reviews of Consolidated Memorandums on Receipt and Turn‑Ins. The
quarterly Periodic Maintenance (PM) inspections constitute the sample
inventory verification.

Attachment C2

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(2\) Facilities Management will evaluate all equipment for inclusion in
the plan and document the results. The criticality field and/or the
JCAHO field in the equipment file (AEMS/MERS) will be utilized to
distinguish those equipment items included in the Equipment Management
Program.

\(3\) Written PM procedures and PM timetables for the equipment will be
defined, followed, and documented.

b\. [Training]{.underline}. All users of and persons who maintain the
equipment will be oriented to the equipment before the first clinical
use and will have continuing education on an annual basis. These
training classes will have written outlines that include the clinical
and physical risks involved with the equipment. Each user department
will document this training. An annual listing of outlines and
individuals receiving training will be sent to the Biomedical Engineer
(51B) no later than January 31 of each year.

c\. [Problem Resolutions]{.underline}.

\(l\) All relevant information about equipment failures or user errors
that have or may have an adverse affect on patient safety or the quality
of care will be reported to the Quality Management staff within 24 hours
of occurrence and to the Chief, Biomedical Engineering and Safety
Manager immediately thereafter. Such occurrences will be documented on
VAF 10‑2633, \"Report of Special Incident Involving a Beneficiary.\"

\(2\) The S&OH Committee or other appropriate staff will analyze the
information to determine the need to change activities or education.

\(3\) If the analysis indicates action should be taken, a memorandum
outlining the actions and a follow‑up date will be sent to the affected
department head for action.

\(4\) The affected department head will see that the actions and their
results are documented and then sent to the S&OH Committee. That
committee, or other qualified staff, will review the outcomes and
recommend further action (e.g., discontinue monitoring, more PM\'s,
further education, etc.).

4\. [RESPONSIBILITIES]{.underline}:

a\. [Safety & Occupational Health Committee]{.underline}.

\(l\) Review and analyze summaries of maintenance, training, and problem
resolution. The Committee will then recommend corrective actions if
necessary.

\(2\) Track problems until resolved.

Attachment C3

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

b\. [Department Heads]{.underline}.

\(l\) Document the orientation and annual training for users of the
equipment.

\(2\) Document and send to the Chief, Biomedical Engineering evidence of
equipment or user errors.

\(3\) Document and report to the Chief, Biomedical Engineering and
Safety Manager those actions and outcomes for problem resolution.

\(4\) Inform Facilities Management of the arrival of all equipment at
this medial center if it has bypassed the Warehouse or Personal Property
Management (e.g., leased, rented, borrowed, loaned, or
staff/patient‑owned equipment).

c\. [Central Supply]{.underline}. Make equipment available for
inspection and notify Facilities Management (manager of the AEMS/MERS
inventory) of all equipment additions or deletions to the equipment
inventory/CMR.

d\. [Facilities Management]{.underline}.

\(l\) Assure maintenance and PM program goals are met.

\(2\) Administer AEMS/MERS equipment inventory, assign a point rating,
and enter it into CRITICALITY field of the Equipment Inventory along
with all other device information.

\(3\) Administer and document the maintenance orientation and continuing
education.

\(4\) Prepare summary report of equipment maintenance for submission to
S&OH Committee.

\(5\) Submit a quarterly summary report and an annual report of the
equipment management program for S&OH Committee review (see Attachment
B).

e\. Utilization Management.

\(l\) Ensure that a VA Form 10‑2633 \"Report of a Special Incident
Involving a Beneficiary\" is completed on any instance of equipment
malfunction or user errors that affect patient care or have the
potential of doing so.

\(2\) Refer such reports within ten days to the Safety Manager (50S).

\(3\) Follow‑up to ensure the problem is reviewed and appropriate action
is taken to reduce the likelihood of recurrence.

Attachment D

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[UTILITIES MANAGEMENT]{.underline}

1\. [PURPOSE]{.underline}: To establish a Utilities Management Program
designed to ensure the safe and reliable operation of utility systems at
VAAAHS, assess special risks, and respond to failures of utility systems
that support the patient care environment.

2\. [POLICY]{.underline}: VAAAHS will maintain the following utility
systems in accordance with NFPA 101 ‑ 2000 Life Safety Code; NFPA 99 ‑
Health Care Facilities, 2002; JCAHO Environment of Care Standard --
2003; Department of Veterans Affairs Manual, MP‑3.

a\. Electrical distribution

b\. Emergency power

c\. Vertical and horizontal transport

d\. Heating, ventilating and air‑conditioning

e\. Plumbing

f\. Boiler and steam

g\. Medical gas

h\. Medical/Surgical vacuum

i Facility communication and data exchange

3\. [PROCEDURES]{.underline}: To ensure compliance, the following
procedures will be accomplished:

a\. The following criteria will monitor the performance of life support,
infection control, environmental support, equipment support, and
communication systems of this facility.

\(l\) Maintenance/inspection and failures of the following systems will
be monitored on a monthly basis as part of the Facilities Management
internal quality assurance program. The noted minimum criteria will be
followed for recording failures of the systems.

\(a\) [Facility Wide]{.underline} - Telephone system ‑ Failure of one
(l) line card

\(b\) [Patient Care Areas]{.underline} ‑ Buildings #1E, 1W and #28

[l]{.underline} Vertical transport ‑ One unit failure

[2]{.underline} Electrical distribution ‑ Entire circuit breaker panel
overload/trip

Attachment D1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[3]{.underline} Public address system ‑ Entire zone failure

[4]{.underline} Paging System ‑ Transmitter failure

[5]{.underline} Steam Distribution ‑ Entire zone failure

[6]{.underline} Air Conditioning - Failure of units larger than 10 tons

[7]{.underline} Medical gas and vacuum ‑ Compressor/pump failure

b\. A consistently reliable emergency power system will be maintained to
provide electricity to the following areas as defined by NFPA 99, Health
Care:

\(l\) Alarm systems

\(a\) Fire

\(b\) Automated data processing

\(c\) Agent cashier

\(d\) Canteen

\(e\) Chaplain\'s office

\(f\) Director's office

\(g\) Medical gas

\(h\) Narcotics vault

\(i\) Operating rooms

\(j\) Pharmacy

\(k\) Telephone equipment room

\(l\) Veterans Department Officers

\(2\) Blood, bone, and tissue storage units

\(a\) Blood bank refrigerators #1 ‑ #3

\(b\) Blood plasma freezer

\(c\) Surgical/Autopsy refrigerator

\(3\) Egress illumination

\(a\) Corridors

\(b\) Stairwells

\(4\) Elevators and Materials Transport

\(a\) Passenger elevators #1 ‑ #4-Building 1W, #1 - #6 Bldg. 1E

\(b\) Freight elevators #5 ‑ #6-Building 1W, #7 - #10 Bldg. 1E.

\(c\) Freight elevator Buildings 3,and 4

\(d\) Dumbwaiters #1 ‑ #2, Building #lW, #1 in Bldg. #1E

\(e\) Passenger elevators #1 ‑ #2, Buildings 28, 29, 30 and 31

Attachment D2

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(5\) Emergency Treatment Room (ETR)

\(6\) Emergency Communication Systems

\(a\) Telephone

\(b\) Two‑way radio (two channel)

\(c\) Hospital Emergency Administrative Radio (H.E.A.R.)

\(d\) Direct in‑dial emergency phone line

\(e\) Public address system

Emergency Disaster Alert pagers

Quick Call emergency System -- Washtenaw County-wide

\(7\) Illumination of exit signs

\(8\) Liquid ring medical air compressors #1 ‑ #2

\(9\) Medical/Surgical vacuum systems

\(a\) Main vacuum pumps #1 ‑ #3, Building #lW & Bldg. #1E

\(b\) Fifth floor, MICU/CCU vacuum pump

\(c\) Buildings #22 and #31

\(10\) Operating rooms

\(11\) Post anesthesia recovery unit -- 5E, Building 1 East

\(12\) Special care units

\(a\) Cardiac Care Recovery Unit ‑ 7E, Building 1 East

\(b\) Medical Intensive Care Unit ‑ 7E, Building 1 East

\(c\) Surgical Intensive Care Unit ‑ 5E, Building 1 East

\(d\) Thoracic Intensive Care Unit ‑ 5E, Building 1 East

c\. A current, accurate and unique inventory of systems equipment as
defined under \"Policy\" will be established and maintained.

d\. A complete set of operational plans for each system will be compiled
and maintained.

\(l\) Plans currently in effect include those described under policies
and Facility Management's Utility Systems Operation Manuals (USOM):

Attachment D3

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(a\) Inspection and Testing of Fire Protection Equipment and Systems.

\(b\) Preventive Maintenance and Inspection of Medical Gas Systems and
Equipment, and Safe Use of Oxygen, Attachment P.

\(c\) Preventive Maintenance and Inspection of Heating, Ventilation, and
Air Conditioning Equipment Systems.

\(d\) Preventive Maintenance and Inspection of Elevators and
Dumb‑waiters.

\(e\) Preventive Maintenance of Inspection of Electrical Distribution
Systems.

\(f\) Preventive Maintenance and Inspection of Essential Electrical
Equipment (emergency generator).

\(2\) Testing and maintenance intervals will be established and
monitored.

\(3\) Documentation supporting the operational reliability of systems
will be maintained.

\(4\) Orientation and annual training will be provided to those
individuals responsible for inspecting and maintaining subject systems.

e\. A complete set of current plans indicating distribution and controls
for partial or complete shutdown of systems will be compiled and
maintained. All emergency shut‑off controls will be labeled accordingly.

f\. Items such as utility problems, failures, user errors, etc., that
pose a threat to patients, visitors, or staff will be communicated to
the Safety & Occupational Health Committee on a quarterly basis.
Procedures used under failure conditions will be developed and reviewed
by the Safety & Occupational Health Committee.

\(1\) System failure procedures currently in effect include those
described under policies and USOMs:

\(a\) Failure of Essential Electrical Systems and Equipment.

\(b\) Failure of Heating, Ventilating, and A/C Systems.

\(c\) Failure of Essential Medical Gas System.

\(d\) Failure of Essential Medical/Surgical Vacuum Equipment and System.

\(2\) Summaries of such incidents will be reviewed by the committee for
evaluation of utility system performance per Attachment B.

Attachment D3

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(3\) Committee will take corrective action on all identified problems
in an expedient manner.

\(4\) Actions taken by the committee will be documented in the committee
minutes.

\(5\) Corrective actions will be evaluated by committee for
effectiveness on an ongoing basis.

4\. [RESPONSIBILITY]{.underline}:

a\. Chairperson, Safety & Occupational Health Committee oversees the
entire Utilities Management Program as an integral part of the
Environment of Care Standards and to execute those duties noted in
Section f. of \"PROCEDURES.\"

b\. Facilities Management Officer ensures completion of items *a.*
through *f.* of \"PROCEDURES,\" and provides Utilities Management
Training upon request.

c\. Department heads notify Facilities Management when utility system
complications occur.

d\. Safety Manager monitors compliance of all the above and identifies
areas as they occur.

Attachment E

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[INDUSTRIAL HYGIENE PROGRAM]{.underline}

1\. [PURPOSE]{.underline}: To establish the scope of the facility\'s
Industrial Hygiene Program and to cross-reference other policy memoranda
related to Industrial Hygiene issues.

2 . [POLICY]{.underline}: This Industrial Hygiene Program involves (l)
the recognition of environmental factors and stresses associated with
work and work operations and understanding their effects on individuals
and their well-being in the work place and community; (2) the
evaluation, through training and experience, and with the aid of
quantitative measurement techniques, of the magnitude of these factors
and stressors in terms of ability to impair health and well-being; and
(3) the prescription of methods to control or reduce such factors and
stressors when necessary in order to alleviate their effects.

3\. [PROCEDURES]{.underline}: An Industrial Hygienist (50IH) is a person
having a college or university degree or degrees in Facilities
Management, chemistry, physics, or medicine‑related biological sciences
who has acquired competence in Industrial Hygiene. Special studies and
training must have been sufficient in all of the above cognate sciences
to be able to (l) recognize environmental factors and stresses
associated with work and work operations and understand their effect on
humans and their well-being: (2) evaluate the magnitude of these
stresses in terms of ability to impair human health and well-being; and
(3) prescribe methods to eliminate, control or reduce such stresses when
necessary to alleviate their effects.

The VAAAHS Industrial Hygiene program provides the following elements
(other related VAAAHS policy memoranda are referenced):

a\. Medical Surveillance

\(l\) Pre‑placement Physical Examination

\(2\) Periodic Health Physical Examination

\(3\) Special Examination

\(4\) Medical Surveillance Procedures for Chemical Hazards

b\. Health and Safety Education

c\. Environmental Surveillance and Control.

\(l\) Hearing Conservation Program (Policy Memorandum S-11)

Attachment E1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(2\) Confined Space ‑ Entry and Work Procedures, Facilities Management
Memorandum (99-51-16)

\(3\) Asbestos Control Program (Policy Memorandum S-9)

\(4\) Hazard Communication Program (Policy Memorandum S-2)

\(5\) Hazardous Waste Management (Policy Memorandum S-2)

\(6\) Environmental Monitoring

\(a\) Class I and II Hood Certification

\(b\) Noise and Hearing Conservation Program (Policy Memorandum S-11)

\(c\) Mercury Control and Reduction Plan (Policy Memorandum S-13 & S-17)

\(d\) Ethylene Oxide (Policy Memorandum S-2)

\(e\) Nitrous Oxide (Policy Memorandum S-2)

\(7\) Non‑Ionizing Radiation

\(8\) Respirator Program (Policy Memorandum S-7)

\(9\) Welding Standards (Policy Memorandum S-3, Attachment R)

\(10\) Personal Protective Equipment (Policy Memorandum S-3, Attachment
L)

\(11\) Hazardous Drug Safety & Health Plan: Preparation, Administration
and Disposal of Cytotoxic Drugs (Policy Memorandum 119‑6)

\(12\) Pesticides (Policy Memorandum S-2)

\(13\) Hazardous Material Spills (Policy Memorandum S-2)

\(14\) Heat Stress (Policy Memorandum S-16)

4\. [RESPONSIBILITIES]{.underline}: The Industrial Hygienist is
responsible for the development, implementation and monitoring of all
procedures outlined in this attachment.

Attachment F

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[ACCIDENT REPORTING, INVESTIGATION & COMMUNICATION]{.underline}

1\. [PURPOSE]{.underline}: To establish guidelines on reporting,
evaluating, and treating occupational accidents and illnesses that may
involve investigating accidents involving VA employees, beneficiaries,
visitors, and/or VA property.

2\. [POLICY]{.underline}: VAAAHS will maintain an active and current
accident reporting and investigation

program involving all aspects of VA employees and beneficiaries, and VA
property and liabilities. All employees will be the primary reporting
source of all accidents or incidents involving all occupations in their
immediate work environments. All supervisors will be secondary reporting
individuals when such incidents involve their immediate work
environments.

3\. [PROCEDURES]{.underline}:

a\. [Definitions]{.underline}.

\(l\) [Accident]{.underline}. Any unintended or unplanned occurrence
that results in injury to personnel, property damage, production
interference, or a combination of these conditions.

\(2\) [Beneficiary]{.underline}. Any person receiving or entitled to
receive treatment or other benefits

from the VA. For the purpose of this policy, visitors to the VAAAHS are
included as beneficiaries.

\(3\) [Beneficiary Fatality]{.underline}. Any accidental death of a
beneficiary that occurs on VA premises or while riding in a VA-operated
motor vehicle.

\(4\) [Beneficiary Reportable Injury]{.underline}. Any accidental injury
to a beneficiary that occurs on VA premises or while riding in a
VA-operated motor vehicle other than a fatality or a first aid case, as
per VA Form 10-2633.

\(5\) [Board of Inquiry]{.underline}. Three or more VAMC personnel
appointed by VAAAHS management, including AFGE Safety Steward, to
investigate a serious accident or occupational illness. Each Board will
prepare a narrative report that identifies causative factors and concise
recommendations to prevent recurrence. The appropriate VA department
involved will provide a member for the Board of Inquiry when requested
to do so by management. The Board will commence its investigation within
five working days following the incident.

\(6\) [Accident Review Board]{.underline}. The Accident Review Board
(ARB) is composed of the Safety Manager, AFGE representative, OWCP
Manager, and Occupational Health nurse. The ARB is established solely as
a fact-finding committee to investigate all traumatic injuries/illnesses
that result in one or more lost workdays. The ARB has no authority to
counsel, invoke/recommend disciplinary actions involving an employee for
sustaining an on-the-job

Attachment F1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

injury or illness on medical treatment issues. The ARB will meet the
second Monday of each month or at the call of the chairperson. The ARB
will submit a copy of its findings, and any recommendations to prevent
recurrence of similar incidents to department head of the employee
involved and the S&OH Committee each month. A summary of the ARB meeting
will be put on the monthly S&OH Committee agenda.

\(7\) [Employee]{.underline}. Any person who receives pay from VA (other
than on contract basis) for departments rendered.

\(8\) [Employee Fatality]{.underline}. Any occupational injury or
occupational illness that results in the death of an employee while in
VA department.

\(9\) Employment Accident. Any unintended or unplanned occurrence that
results in injury to personnel, property damage, production,
interference, or a combination of all these conditions while an employee
is actually on duty. This occurrence can be on or off station.

\(10\) Employee Recordable Occupational Injury or Occupational Illness.
Any occupational injury or occupational illness which results in a
fatality, lost workday case, medical treatment case, or in one or more
of the following consequences:

\(a\) Termination of employment

\(b\) Diagnosis of occupational illness

\(c\) Loss of consciousness

\(d\) Restriction of work or motion

\(11\) [First Aid Treatment Case]{.underline}. One-time treatment and
subsequent observation of minor scratches, cuts, burns, splinters, etc.,
which do not ordinarily require additional medical care, even though
initially provided by a physician or registered professional personnel.

\(12\) [Lost Workdays]{.underline}. Days or partial days employee would
have worked, but did not

due to an occupational injury or illness. Lost Workdays are calculated
beginning with any part of any work shift the employee has missed after
the reported date of injury. Medical documentation from Employee Health
physician or private physician is required before this classification
occurs. Number of lost workdays does not include the day of injury but
does include all days (consecutive or not) on which;

\(a\) the employee would have worked but could not

\(b\) the employee worked at a permanent job less than full time

\(c\) the employee worked at a permanent job but could not perform all
duties assigned

\(d\) the employee could not be assigned to a light duty assignment

Attachment F2

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(13\) [Medical Treatment Case]{.underline}. Any occupational injury or
illness for which treatment is administered by a physician or by
registered professional personnel under the standing orders of a
physician. Medical Treatment Case does not include "Employee Fatality\"
or \"Lost Workday.\" \"First Aid Treatment Case,\" as previously
defined, becomes a medical case if treated more than once for the same
injury by Employee Health staff or with outside personal physician care.

\(14\) [Member of the Public]{.underline}. Any person injured while on
VA premises or as a result of a motor vehicle accident involving a
VA-operated motor vehicle, who is neither an employee nor a beneficiary
under the care or control of the VA. This includes visitors, volunteers,
personnel who work without compensation, employees of other Federal
agencies, and employees of VA contractors. Use VA Form 2162 and/or VA
Form 10‑2633 to record this type of injury.

\(15\) [Motor Vehicle Accident]{.underline}. Any occurrence involving a
Government owned or leased vehicle, or privately-owned vehicle while
operated on official VA business, that results in death, injury, or
property damage of \$250 or more regardless of injury or property
damaged.

\(16\) [Occupational Injury]{.underline}. Any major or minor injury to
an employee such as a cut, fracture, sprain, amputation, etc., resulting
from a work accident or exposure in the work environment.

\(17\) [Occupational Illness]{.underline}. Any abnormal condition or
disorder sustained by an employee other than one resulting from an
occupational injury, caused by exposure to environmental factors
associated with employment. This includes acute and chronic illnesses or
diseases caused by inhalation, absorption, ingestion, or direct contact.
A medical doctor diagnoses this type of illness, and it occurs/develops
after exposure has been diagnosed to have occurred over a period of time
greater than one working day.

\(18\) [Property Damage Accident]{.underline}. Any accident arising from
official VA activities (excluding motor vehicle accidents) which results
in damage of \$250 or more to government property, equipment or
materials, or to privately-owned property, equipment or materials.

\(19\) [Serious Accident]{.underline}. Any employee accident which
results in an employee (either Federal or non-Federal) fatality, in the
hospitalization of three or more employees, or occurrence of a death
which is the result of an employee accident, or which involves property
damage of \$100,000 or more. These types of serious accidents should be
reported to the Safety Manager immediately.

b\. [Emergency First Aid Medical Treatment and Reporting of Accident
Injury or Illness]{.underline}.

\(1\) Emergency first-aid medical treatment is available on a 24‑hour
basis (ext. 5189).

Attachment F3

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(a\) Employees should be directed to the Employee Health clerk in Room
C104 in Bldg.#1E (extension 5132) during administrative hours, and the
ETR, B108-Bldg.#1W (extension 5189) in 1st floor north,
non-administrative hours.

\(b\) Volunteers, outpatients, or members of the public incurring an
injury or illness while on VA premises will be promptly taken or
directed to the AOD or Employee Health Office, room C104.

\(c\) [Life Threatening Injuries]{.underline}. The injured person will
be taken directly to the Emergency Treatment Room if possible without
causing further injury, or a Medical Emergency will be called by dialing
2222 and giving the operator the location and nature of emergency. This
will result in the disposition of persons on the Cardiac Arrest, Medical
Emergency, or S.A.T. Team(s) with appropriate equipment to the location
of the victim(s).

\(d\) A VAAAHS physician will examine the individual, make an initial
diagnosis of the nature and extent of the injury or illness and provide
emergency first-aid treatment if necessary. If the injured individual is
an employee, Employee Health will notify the supervisor concerned of the
nature and extent of the injury or illness in order so the necessary
reports can be prepared. This will include the physician\'s
determination of physical limitations resulting from the injury. Light
duty assignments will be evaluated by the Employee Health physician and
employee\'s supervisor. If the nature of the injury has caused the
employee to be disabled from performing his/her occupation at full
capability, Employee Health will notify immediate supervisor and the
OWCP Claim Manager of a pending Lost Workday case. The Safety Manager
will be notified in order to investigate the nature and cause of this
lost time injury case.

\(2\) Supervisors of areas where accidents occur are responsible for
submitting an Accident Report (VAF 2162) during administrative and
non-administrative hours. During administrative hours the Safety Manager
will be notified of any hazardous accident so that an investigation can
be initiated and corrective action taken to eliminate imminent hazard.
During non‑administrative hours, the ETR will submit an Accident Report
(STUB), via ASISTS on DHCP. The AOD will investigate the accident and
take corrective action to eliminate any imminent hazard. VA Form 2162
will be used for this investigation. Accident reporting can be
accomplished by accessing the ASISTS program on DHCP.

This form will be completed within two workdays of any injury and
forwarded to the Associate Director (50) electronically through the
ASIST Program.

c\. [Recording, Investigating, and Reporting Accidents, Injuries,
Occupational Illnesses, and Fires]{.underline}.

\(l\) The following types of accidents, injuries, occupational
illnesses, and fires will be investigated by the Safety Manager to
determine causative factors and appropriate actions to prevent
recurrence:

Attachment F4

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(a\) Fatalities or accidental injuries to beneficiaries which occur on
VA premises or while riding in VA‑operated vehicles (An intentionally
inflicted injury of a beneficiary is not an accidental injury.)

\(b\) Fatalities or accidental injuries to members of the public which
occur on VA premises or as a result of motor vehicle accidents involving
VA‑operated motor vehicles

\(c\) Fatalities or employee occupational injuries, occupational
illnesses, and

radiation exposure

\(d\) Motor vehicle accidents resulting in injury and/or property damage
of \$100 or more

\(e\) Fire of any kind

\(f\) Property damage accidents that result in damage of \$100 or more

\(g\) Medical device incidents that have or may have caused or
contributed to a serious injury, illness, or death of a VA employee or
member of the public

\(2\) SF‑91, Operator\'s Report of Motor Vehicle Accident, will be
completed at the scene of a motor vehicle accident by the operator of
the VA‑operated motor vehicle. Copies of SF‑91 will be carried in each
motor vehicle owned or controlled by the VA including privately‑owned
vehicles used for VA business.

\(3\) The Safety Manager will maintain OSHA Form 200, Log of Federal
Occupational Injuries and Illnesses.

\(4\) If another Federal agency\'s personnel or equipment is involved in
a VA operational occurrence, it may be necessary to complete other
Federal agency forms.

\(5\) The Safety Manager will

\(a\) Coordinate investigation of accidents

\(b\) Review investigation reports to assure adequacy

\(c\) Arrange for transmittal of investigation reports

\(d\) Provide technical guidance as requested

d\. [Telephone or Fax Reports]{.underline}. VAAAHS management will
report the following types of incidents to VISN 11 by telephone or fax.
For incidents involving beneficiaries on VA premises, refer to VA Form
10-2633.

Attachment F5

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(l\) Accidental fatality to a beneficiary or member of the public that
occurs on VA premises or as a result of a motor vehicle accident
involving a VA‑operated motor vehicle, must be reported immediately to
the Safety Manager on extension 3803 or pager 0010.

\(2\) An occupational injury or occupational illness to an employee is
an injury intentionally inflicted on an employee by another person while
the person is in the course of his/her employment. These instances and
fatal occupational injuries must be reported immediately to the Safety
Manager on extension 3803, and VA Police at extension 7914.

\(3\) Employee radiation overexposures must be reported immediately to
the Radiation Safety Officer on extension 7916.

\(4\) Motor vehicle accident, fire, or property damage accident which
results in over \$2,500 damage must be reported to VISN 11.

\(5\) An employment accident which results in the hospitalization of
three or more employees, or which involves both VA employees and non‑VA
persons and results in a fatality or the hospitalization of three or
more such employees or persons, must be reported immediately to the
Safety Manager on extension 3803. This report will be made within two
hours after the occurrence (or outbreak, in case of fire), if this falls
within regular VA Headquarters business hours. If the incident occurs
during non‑regular hours, the report will be made immediately on
resumption of regular VA Headquarters duty hours. The report will
describe the incident, give name and status of person or persons
involved, and the extent of property damage. Included also will be
details as to the probable cause, responsibility, fire department
response (if appropriate), method of investigation underway or proposed,
and corrective actions being taken.

e\. [Recurrent Cases]{.underline}. If an injury or illness recurs as a
natural consequent and no aggravation has occurred, the injury or
illness will not be reported again nor will the supervisor investigate
it again. VA Ann Arbor Healthcare System

f\. The attending physician will make the determination as to whether an
injury or illness is a recurrence of an occupational injury.

**Employees are required to be seen in Employee Health (C104) in person
to report any work related injury, recurrent or not, and inform the
Employee Health Nurse if they will be off work due to an attending
physician\'s orders.**

g\. [Employees Visiting or On Detail]{.underline}. In cases where a VA
employee is assigned to one facility and incurs a recordable injury
while at another facility, the following rules apply:

Attachment F6

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(1\) If the employee is not under the supervision of the facility at
which the accident occurred (i.e., the employee is visiting this
facility on official business), the injury will be

charged to the facility on whose payroll the injured person appears.
Investigation of the accident and the required copies of the completed
accident report(s) will be furnished to the employee\'s home facility
for processing. Use VA Form 2162 (via ASISTS program on DHCP) and visit
the Employee Health Office in room C104.

\(2\) If the employee of one facility is engaged in work, irrespective
of its duration or type, under the supervision of another VA facility,
the supervising office assumes responsibility for the safety of the
worker and will be charged with the injury. Investigation of the
accident and submission of the necessary reports will be made by the
supervising facility. An additional copy will be prepared and furnished
to the employee\'s home facility. This additional copy will be sent to
the Employee Health Office (11A1) and Safety Manager (50S).

h\. [Availability of Records]{.underline}. Records are available to
employees, in accordance with applicable statutes and regulations, and
any collective bargaining agreements. Records pertinent to occupational
accidents will be made available when requested within 15 work days from
the date of request, in accordance with the Privacy Act and per 29CFR
1910.20 guidelines.

i\. VA [Form 2162 (Report Of Accident]{.underline}).

\(l\) The supervisor of an employee or operation will complete VA Form
2162 (Report of Accident) following an accident or any incident
resulting in injury, property damage, or a combination of both when an
employee, volunteer, outpatient, beneficiary, or member of the general
public is involved. VA Form 2162 will be completed within two workdays
by the designated supervisor via the ASISTS Program on DHCP. Employee
Health Nurse or ETR nurse will start the process for each reported
employee work related injury/illness by completing a STUB report,
located in the ASISTS Program in each ETR RN Employee Health Menu
option. This report is the initial accident record and establishes a
case number, date, time, location, nature, employee name, employee's
supervisor, and contact information of injured employee. Each STUB
report must be completed before releasing an injured employee from care
from Employee Health or ETR.

\(2\) If lost workdays are involved and the employee has not returned to
work before the supervisor sends the forms, the lost workdays section
should remain blank. This will infer that lost work time is involved and
that the information will be updated/edited electronically upon further
communication with employee. Employee Health Nurse will be able to
assist supervisors on this process.

\(3\) A copy of completed Form CA‑l/CA-2 (Federal Employee\'s Notice of
Traumatic Injury and Claim for Combination of Pay/Compensation) must be
given to the injured employee and one copy sent to the OWCP Manager
(24).

Attachment F7

Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

4\. R[ESPONSIBILITY]{.underline}:

a\. It is the responsibility of all supervisors to complete
electronically VA Form 2162 no later than two working days after injury
date. Supervisors must inform employees that each work related
injury/illness must be evaluated, documented, and treated by the
Employee Health Nurse, Medical VA Doctor, or ETR (during off-hours)
before employee leaves his/her work shift on the day of injury/exposure.
CA-1/CA-2 forms must be filled out when injury will involve lost work
time, medical expenses, or exposure to blood borne pathogens. Employee
Health Nurse can assist supervisors in making the decision to fill out
CA-1/CA-2 when either lost work time, medical expenses, or bloodborne
pathogen exposure will occur after the initial treatment and diagnoses
is complete.

b\. It is the responsibility of all employees to report work related
injuries or illnesses to their immediate supervisor and Employee Health
(administrative hours) or ETR (after 4:30 PM and on weekends and
holidays) upon occurrence or identification. Employees must complete
their section of the CA-1/CA-2 electronically as soon as possible.
Supervisors can complete employee section of these forms when the
injured employee is incapacitated. All OWCP claims processing will not
begin until both the employee and supervisor have signed off on
CA-1/CA-2.

c\. It is the responsibility of the Safety Manager to record all
accidents. All cases requiring additional investigation and reporting
will be completed by the Safety Manager via coordination with each
involved supervisor. The Safety Manager is designated the \"OSHA Record
keeper\" for all non‑patient accidents that occur at this facility and
Toledo Outpatient Clinic. Safety Manager will provide training related
to accident reporting when requested.

Attachment G

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[ELECTRICAL AND SPECIAL SAFETY REOUIREMENTS]{.underline}

1\. [PURPOSE]{.underline}: The purpose of this Attachment is to describe
policies and procedures of Electrical and Special Safety issues.

2\. [POLICY]{.underline}: The purpose of this section is to identify
specific safety issues as they relate to any employee, contractor,
beneficiary or property associated with VAAAHS.

3\. [PROCEDURES]{.underline}:

a\. [Electrical Safety Program]{.underline}. This program refers to the
electrical safety of the facility.

\(l\) The National Electrical Code of the National Fire Protection
Association, NFPA 70, and the Safety and Health Regulations for
Construction Part 1926, Title 29 of the Code of Federal Regulations,
Subpart V, adopted by reference in Section 954, paragraphs (a) through
(j), will be used as standard on all matters concerning electrical
safety.

\(2\) All electrical circuits and equipment will be de‑energized before
work is performed on them. The circuits to be worked on will be tested
to verify they are de‑energized. Test equipment, rated for the maximum
voltage available, will be maintained at this facility where VAAAHS
employees perform electrical maintenance. Tests of circuits over 600
volts require the approval of the Facilities Management Department. If
it is not possible to de‑energize the circuit to perform the necessary
work, advanced approval will be obtained from the Facilities Management
Department, who will take personal responsibility to assure the work is
accomplished safely. The requirement for advanced approval from the
Facilities Management Officer may be waived in emergency situations
where life is endangered. No employee will work alone or near exposed
circuits carrying over 600 volts between conductors.

\(3\) Ground Fault Circuit Interrupters will be used in all wet areas.

\(4\) All electrical panels will have a 36‑inch semi‑circle of access.
Blockage or posting of any materials is prohibited. Storage of materials
within a 36‑inch access distance is prohibited in all areas throughout
the medical and research centers.

b\. [Electrical Safety for Patients]{.underline}.

\(l\) The areas of the VAAAHS are divided into three classes of patient
susceptibility to electricity, primarily dependent upon the basis of
contact with electric conductors in the environment, as follows:

\(a\) [Non‑Patient]{.underline}. Administrative areas and areas where
patients have little or no direct contact with electrical and electronic
equipment.

Attachment G1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(b\) [Patient]{.underline}. Areas where patients have or may have
direct contact with non‑invasive therapy and/or electrical or monitoring
equipment.

\(c\) [Patient Suitable for Intra-cardiac Connection]{.underline}. Areas
having patients who are or may be subjected to invasive monitoring or
therapy using direct pathways to the cardiac musculature. This area may
also be termed an \"electrically susceptible patient care area.\"

\(2\) [Special Precautions]{.underline} are required when care of a
patient requires the use of an electrically operated device. Certain
patients are particularly sensitive to electrical hazards because of
debilitating medical conditions, a major loss of skin resistance due to
the use of wet dressings, or because of severe electrolyte imbalance.
Personnel within \"patient\" or \"electrically susceptible patient
areas\" should inspect all pieces of equipment before each use for such
hazards as broken or damaged plugs, frayed cords, abnormal operation,
obvious chassis damage, overheating, or tingling sensations.

If a hazard is suspected or detected, that piece of equipment will not
be used unless it is irreplaceable life support equipment in which case
it will be closely monitored until repaired or replaced. Promptly report
suspect equipment for maintenance and repair to Facilities Management
Department and promptly tag the equipment **Do Not Use**.

\(3\) Electrical Wiring and Appliance. Electrical equipment, appliances
and wiring systems will be installed, maintained and used in accordance
with the National Electrical Code (NFPA 70). Equipment, appliances, and
wiring will be kept in a safe operating condition.

\(a\) Extension cords will not be used in VAAAHS to replace permanent
wiring. Extension cords may be temporarily used in case of emergency
only and will be 16 gauge or heavier.

\(b\) \"Cheater\" adaptors used on 3‑prong electrical plugs to enable
the device to be plugged into a 2‑prong receptacle are prohibited.

\(c\) Portable comfort or space heating devices are prohibited in all
health care areas of VAAAHS. No hot plates, irons, or similar electrical
equipment with heating elements will be placed in use without the
approval of the Chief, Biomedical Engineering.

\(4\) [Patient‑owned Electrical Line & Battery Operated
Devices]{.underline}. Prohibited from all electrically susceptible
patient areas. In other areas of the facility, a VA Form 10‑3213b,
\"Request and Facilities Management Work Order\" will be completed and
forwarded to the Facilities Management Department to initiate a safety
check. When patient‑owned electrical line operated devices are
permitted, they will be inspected before using and must meet the
electrical safety requirements of similar VA‑owned equipment.
Patient‑owned battery operated radios, electronic calculators, cordless
electric razors are permitted at the patient\'s bedside with the unit

Attachment G2

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

head nurse's authorization. Line‑operated charging devices will be
utilized only at the nursing station under Patient Care supervision.

\(5\) [Televisions]{.underline}. Employees and patients will not be
allowed to maintain personally owned television sets in any area of the
VAAAHS.

\(6\) [VA‑owned Line Operated Devices]{.underline}. Televisions, radios,
and electric razors are prohibited in all electrically susceptible
patient care areas, unless inspected and approved by Facilities
Management. This permission is to be requested by memorandum from the
physician in charge of that area. Battery operated radios and cordless
razors are permitted at the patient\'s bedside with a physician\'s
authorization. Authorized television sets will be wall or ceiling
mounted at such a distance that they couldn't be reached by the patient
or by an individual at the patient\'s bedside.

\(7\) [Staff‑owned Electrically Operated Devices]{.underline}.
Prohibited, except for coffee makers and radios. Coffee makers and
radios will be inspected before usage and must meet the electrical
safety requirements of similar VA‑owned equipment. Items inspected will
be labeled as to the condition, the shop completing the inspection, and
the inspector\'s initials. Contact M&R at extension 5503 for this
inspection prior to usage of your equipment on VA property.

\(8\) [Bedside Lamps]{.underline}. In electrically susceptible patient
care areas, bedside lamps will be grounded and permanently affixed at
the patient\'s bedside area.

c\. [Electron Microscope]{.underline}.

\(l\) Shielding provided by the manufacturer will be used whenever an
electron microscope is operated. Operating practices will comply with
manufacturer\'s recommendations.

\(2\) Each electron microscope will be surveyed for radiation leakage
immediately following installation, annually thereafter and after any
modification or maintenance which might result in a potential radiation
hazard. A suitable calibrated survey instrument will be used.

\(3\) Regulations contained in Section 1910.96, Occupational Safety and
Health Standard (29 CFR), relating to film badges, permissible limits,
posting of areas, and instruction of personnel, are applicable.

\(4\) The Radiation Safety Officer (50R) should be contacted for
assistance in conducting radiation surveys of electron microscopes and
can be reached at extension 7916 or on pager 394.

d\. [Food Department and Potable Water Supply]{.underline}. Food Service
and Canteen Service will establish and conduct a health control program
encompassing the purchase, storage, preparation,

Attachment G3

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

handling, and disposal of food (see M‑2, Part III, Dietetic Department
and VCS‑l, Veterans Canteen Department Operating Procedures).

e\. [Infection Control]{.underline}. VAAAHS Policy Memorandum S-4
establishes the facility Exposure Control/Infection Control Program,
under the auspices of the Infection Control Committee, conducted in
accordance with pertinent accreditation requirements. Copies of meeting
minutes will be forwarded to the Associate Director as Chair of the
Safety Committee. The Infection Control Practitioner (111I) can be
reached at extension 5828 or pager 282.

f\. [Radiological]{.underline}. A Radiological Safety Program
encompassing diagnostic x‑ray units such as dental, cyctoscopic, and
special procedures, Nuclear Medicine equipment, and equipment used in
research, is established under the overall supervision of the Radiation
Safety Officer with the consultation, advice, and assistance of the
heads of Radiology and Nuclear Medicine, and the Radiation Safety
Committee. This includes responsibility for the maintenance of
associated documentation. The Radiation Safety Officer can be reached at
extension 7916 or pager 394.

g\. [Sanitation Control]{.underline}. A Sanitation Control Program is
established under the auspices of Facilities Maintenance Department,
which includes an active program of pest control. Waste disposal will be
accomplished in accordance with established area public health practices
and the VA Ann Arbor Healthcare System Policy Memorandum 51-14, Trash
Collection and Removal.

h\. [Prohibited Waste Disposal]{.underline}.

\(1\) Any gasoline, benzene, naphtha, fuel oil, or other flammable or
explosive liquid, solid or gas.

\(2\) Any waters or waste having a pH lower than 6.0 or higher than 9.0
or having any other corrosive property capable of causing damage or
hazard to structure, equipment and personnel of the sewage works.

\(3\) The involved room should not be used until the defect is repaired.

i\. [Hazard Communication and Hazardous Waste Clean‑Up]{.underline}.
Refer to Policy Memorandum S-2, Hazardous Materials Management.

j\. [Hazardous Waste Disposal]{.underline}. Refer to Policy Memorandum
S-2, Hazardous Materials Management.

k\. [Technical Reference Library]{.underline}. The Safety Office will
maintain technical reference materials, including appropriate standards
and code references. This material is available to department Heads,
supervisors, and all employees, at the Safety Office. The Safety Office
is located in Building 3, Room 108.

Attachment G4

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

4\. [RESPONSIBILITIES]{.underline}:

a\. All supervisors are responsible for identifying any special safety
issues in their work environment, to communicate those issues to their
employees, and to forward any questions or concerns to the Safety
Manager.

b\. All employees will be briefed on any special safety issues during
their orientation to their work area. Employees are also responsible for
notifying their supervisors of any detected safety concerns requiring
attention.

Attachment H

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[MANAGEMENT OF THE ENVIRONMENT OF CARE PROGRAM]{.underline}

1\. [PURPOSE]{.underline}: To outline VAAAHS policy and responsibility
for maintaining an effective environment for the provision of quality
care.

2\. [POLICY]{.underline}: To provide a safe, clean, and well‑maintained
facility for veterans, visitors, and staff through a systematic
inspection process.

3\. [PROCEDURE]{.underline}:

a\. Areas in the VAAAHS will be inspected weekly by the Hazard
Surveillance Team (HST) on Thursdays at 10:30 a.m. to assess the level
of cleanliness, safety, repair, and equipment utilization. Inspection
areas for the HST are identified on the inspection schedule attached.

b\. VAAAHS facilities will be inspected weekly each Tuesday commencing
at 2:00 p.m. by the Associate Director and representatives from Central
Supply, Facilities Management, Facilities Maintenance, Infectious
Disease, and Patient Care. The group will convene in the Associate
Director's office to evaluate the previous week\'s HST inspections for
status, completions, and outstanding deficiencies prior to conducting
its inspection. It will also look for opportunities to improve systems
issues. They will review areas randomly - direct patient care areas
semi‑annually and non‑patient areas annually. The site for each week\'s
rounds will be determined at a pre‑meeting. Potential deficiencies are
tracked on a spreadsheet and the Safety Manager maintains corrective
action/completion.

4\. [RESPONSIBILITY]{.underline}:

a\. The HST will consist of the Industrial Hygienist, Safety Manager,
Infection Control Practitioner, and AFGE representative.

b\. The HST will identify deficiencies found during inspection. The
Safety Manager will record these deficiencies using the Facilities
Management electronic work order system for corrective action and
tracking purposes. The Safety Manager will route all non‑Facilities
Management work orders to appropriate responsible departments for
corrective action.

c\. Responsible departments will correct deficiencies within 30 business
days. If departments determine deficiency corrections cannot be
completed by the next scheduled inspection (30 business days), an
explanation will be provided by the department Heads to the Associate
Director through the Safety Manager.

d\. The group will provide follow‑up on outstanding deficiencies
identified by the HST within 30 business days. They will monitor HST
tracking system to ensure all deficiencies are corrected.

Attachment H1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

e\. All VAAAHS employees are responsible for providing a safe, clean,
and well‑maintained facility.

5\. [REFERENCES]{.underline}:

VA Manual M‑l, Part VIII,

VA Manual MP‑3, Part III

VA Manual MP‑2, Subchapter E

JCAHO Standards

Attachment I

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[HEALTH AND SAFETY EDUCATION]{.underline}

1\. [PURPOSE]{.underline}: To provide health, safety, environmental, and
industrial hygiene information for all employees on a consistent,
continuing basis.

2\. [POLICY]{.underline}: VAAAHS will maintain an active and current
Health and Safety Educational Program for all employees. This policy
will be in compliance with all standards as established by JCAHO, NFPA,
OSHA and DVA requirements.

3\. [PROCEDURES]{.underline}:

a\. Safety staff will conduct New Employee Safety and Health Orientation
every other Tuesday as part of the New Employee Orientation Program
conducted by Human Resources. This training will be mandatory for all
new employees, within 30 days of hire.

b\. Safety staff will present a Supervisory Safety and Health Training
session annually.

\(l\) The information provided at this session is to be passed along to
subordinates by their respective supervisors who have attended the
training.

\(2\) It is mandatory for all supervisors to attend.

c\. [Department Specific Training]{.underline}. Department Heads and
supervisors will provide their employees with on‑the‑job instruction
including:

\(l\) Workplace orientation for new employees, volunteers, and others,
including location and use of fire protection equipment, fire plan
procedures and response, and basic job safety and safety practices.

\(2\) On‑the‑job instructions regarding potential hazards involved in
the specific job, safe practices to be followed, accident and fire
prevention, and proper and safe use of equipment utilized before an
employee or volunteer begins work or first uses equipment. Each
supervisor will be provided a copy of this manual to use for training
purposes

\(3\) On‑the‑job refresher instruction annually, based on Supervisory
Safety and Health Orientation attendance by supervisors, with emphasis
on safe work practices.

\(4\) Training should be provided when there are changes in job
techniques and work procedures.

\(5\) Hazardous Materials and Waste Training as outlined in Policy
Memorandum S-2, on an annual basis.

Attachment I1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(6\) Emergency Preparedness Training in conjunction with Policy
Memorandum S-2, on an annual basis.

\(7\) Compted training will be documented in the SynQuest Education
Tracking System by employees as they complete their training or by their
education liaison within the service. It will be available to Safety
Staff (50S), by October 1st, of each fiscal year.

4\. [RESPONSIBILITY]{.underline}:

a\. Safety staff will provide documented training outlined in 3.a and
3.b above.

b\. Supervisors will provide documented training as outlined annually in
3.c and 3.d above.

5\. [REFERENCE]{.underline}:

Policy Memorandum 11E-5, Supervisory/Managerial and Team Leader Training
& Development

Attachment J

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[SAFETY MANAGEMENT PROGRAM COMMUNITY BASED OUTPATIENT
CLINICS]{.underline}

1\. [PURPOSE]{.underline}: To establish a department specific safety
policy for the Community-based Outpatient Clinics (CBOCs).

2\. [POLICY]{.underline}: It is the policy of the VAAAHS Director to
establish and maintain a safety program in concert with all DVA, OSHA,
and other regulatory standards regarding safety. Procedures, as outlined
in Policy Memorandum S-3 "Safety Management Program," will be adhered to
ensure the safety environment for all patients, visitors, and employees.

3\. [PROCEDURES]{.underline}:

a\. The Safety Coordinator will be the Clinic Administrative Officer.
The alternate will be the CBOC Program Manager.

b\. This policy establishes the Safety & Occupational Health Committee
at the Toledo CBOC as a subcommittee of the Ann Arbor Safety &
Occupational Health Committee. The committee will be composed of the
following representatives:

Clinic Administrator Chairperson

Inventory Management Manager Member

Laboratory Supervisory Member

Quality Assurance Coordinator Member

Patient Representative Member

Nursing Coordinator Member Supervisor, Physical Therapy Member

Dental Hygienist Member Medical Administrative Officer Member

AFGE Safety Steward Member

Committee will meet quarterly on the last Monday of the quarter or at
the call of the Chair. Minutes will be forwarded to the Safety &
Occupational Health Committee for review.

c\. Safety & Occupational Health Subcommittee -- Toledo CBOC will be
responsible for:

\(l\) Performing an annual review of all safety policies and procedures,
safety training plans, and monitoring department specific
orientation/continuing education programs dealing with safety issues at
all CBOCs.

\(2\) Promoting an ongoing Hazard Surveillance Program that surveys all
patient care areas at least semi‑annually and all non‑patient care areas
at least annually.

\(3\) Establishing a system for reporting and investigating all
incidents that involve injuries or occupational illness of patients,
personnel, or visitors, as well as fire or property damage.

Attachment J1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(4\) Establishing a program to orient new personnel to the Safety
Management Program, and ensure all personnel participate in continuing
safety education and training on an annual basis.

\(5\) Evaluating the objectives, scope, organization, and effectiveness
of the safety management program on an annual basis.

\(6\) Reviewing summaries of Life Safety Management Program that
evaluate impact on patient care and safety of the buildings, grounds,
occupants, and internal physical systems through quarterly reviews of
equipment management, and utilities management programs, bi‑monthly
security management reviews, and Annual Life Safety Management Review.

\(7\) Monitoring compliance with the Hazardous Materials Management
Program requirements, and evaluating effectiveness of the program
through an annual review and training

\(8\) Reviewing the TOPC's performance during implementations of the
emergency preparedness plan on a semi‑annual basis, as well as
conducting an annual review/training of the emergency preparedness plan
manual.

\(9\) Reviewing summaries of action taken by other organization‑wide
monitoring activities, including Quality Management and Infection
Control.

d\. [Safety Training/Education]{.underline}. The Safety Manager and
Industrial Hygienist will conduct annual training for supervisors.
Attendance and documentation of annual safety, fire, industrial hygiene,
emergency preparedness, and any other related safety training will be
filed in the administrative office. All safety related training issues
will be in accordance with Policy Memorandum S-3, Attachment J, "Health
and Safety Education," in the following manner:

\(l\) All new CBOC employees will attend New Employee Safety and Health
Orientation within 30 days of hire.

\(2\) All supervisors will attend the Annual Supervisory and Health
Orientation Training and disseminate pertinent information to those
under their supervision.

\(3\) Supervisors will orient all employees to location and use of fire
protection equipment, fire alarm procedures/response, and basic job
safety as it relates to each work environment.

\(4\) Supervisors will conduct on‑the‑job training regarding potential
hazards and proper use of equipment on an ongoing basis within 30 days
of hire and/or transfer.

\(5\) Supervisors will provide annual training on hazardous materials
and wastes in accordance with Policy Memorandum 00‑2, "Hazardous
Materials Management Plan."

Attachment J2

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(6\) Supervisors will provide annual emergency preparedness training in
accordance with Policy Memorandum S-5, Appendix A, CBOC Emergency
Preparedness Plan and Attachment K, Policy Memorandum S-3.

\(7\) All training activities will be monitored by the Safety Manager
and the Emergency Preparedness Coordinator. An annual summary report
will be forwarded to the S&OH Committee in October of each year.

e\. [Location of Policies and Material Safety Data Sheets]{.underline}.

\(l\) The clinic secretaries will have a copy of Policy Memorandum S-2,
S-3, S-5 (Appendix A) and 00‑16, located in each management assistant's
workstation.

\(2\) A master file of Material Safety Data Sheets (MSDS) is located in
the Inventory Management Manager\'s Office, Room #7 at Toledo. Work
specific MSDS will be located in each supervisor's office, in a yellow
and black binder.

f\. [Personal Protective Equipment (PPE]{.underline}). TOPC personnel
may warrant usage of Personal Protective Equipment. Attachment L, Policy
Memorandum S-3, "Request for Personal Protective Equipment," will be
used in coordination with each supervisor.

g\. [Smoking Policy]{.underline}. TOPC is a smoke‑free facility. See
Attachment T, "Facility Smoking Policy," for specific instructions.

h\. [Safety Program Review]{.underline}. Review of the overall TOPC
Specific Safety Program, including this and related policies, will occur
annually in October of each year. The review process will be initiated
by the Clinic Administrator and will be concurred upon by the Clinical
Administrator prior to forwarding to the Safety & Occupational Health
Committee for review.

4\. [RESPONSIBILITIES]{.underline}:

a\. The Director is responsible for the overall Safety Management
Program at the CBOCs. Through the Director, the Clinic Administrator
will manage and ensure that all aspects of this safety program are
established, implemented, and practiced routinely. The Clinic
Administrator (Safety Coordinator) will also ensure that an annual
review is conducted and will provide feedback to the Director's Office
on all safety related issues.

b\. CBOC personnel will attend annual scheduled safety training and
perform their specific daily duties in a safe manner.

c\. CBOC supervisors, in addition to those items noted above, are
responsible to attend Annual Supervisory Safety Training, schedule and
conduct safety training for their subordinates, and monitor and evaluate
safe work practices.

Attachment J3

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

d\. A CBOC representative is a member and will attend each monthly
Safety & Occupational Health Committee meeting. An alternate will attend
if primary staff member cannot.

Attachment K

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

[REOUEST FOR PERSONAL PROTECTIVE EOUIPMENT]{.underline}

1\. [PURPOSE]{.underline}: To establish a policy regarding the usage,
distribution, training and purchase of personal protective equipment for
employees.

2\. [POLICY]{.underline}:

a\. Coordination of Personal Property Equipment (PPE) equipment issuance
and purchasing will occur between immediate supervisor of requesting
employee. This is accomplished via review of each service specific
Hazard Assessment Survey for PPE on file in the Safety office.

b\. Steel/plastic toe safety shoes, protective eyewear, hearing
protection, gloves, head protection gear, welding/brazing protective
clothing, and face protection gear, will be issued upon request with
justification from each supervisor. Issuance will occur from supervisor
to employee, via coordination between the Facilities Management Office
and information contained in each service specific Hazard Assessment
Survey for Personal Protective Equipment on file in the Safety office.

c\. Respirator requirements per Policy Memorandum S-7, will also be
requested and justified by each supervisor and forwarded to the
Industrial Hygienist. All other personal protective equipment requests
will be initiated and justified by each supervisor and forwarded to the
SPD. The Safety Office Staff will discuss each personal protective
equipment request with the requesting supervisor prior to issuance. For
accountability and control, initiation of purchasing of all personal
protective equipment, outside of direct patient care areas, will be
consolidated with the Safety Office staff.

3\. [PROCEDURE]{.underline}: All requests for personal protective
equipment must be submitted by the appropriate supervisor through the
department head for necessary action. Analysis of each service specific
Hazard Assessment Survey for Personal Protective Equipment will identify
all exceptional wear needs in PPE. Examples are (wet location s,
hazardous material contaminators, chemical handling, noise levels, head,
foot, face, respirator, eye, protective clothing, and allergic concerns,
etc.) and may warrant additional purchasing of personal protective
equipment on an as-needed basis. This will be determined by the
supervisor with review and concurrence of the Safety Office. All
employees issued PPE will be trained on usage, replacement, comfort of
use, fit-tested (when indicated), cleaning, different types, and
storage.

4\. [RESPONSIBILITIES]{.underline}:

a.  Supervisors are responsible for identifying needed personal
    protective equipment, initiating requests and/or purchases, assuring
    employees use/wear the apparel provided, and are trained on all
    aspects of PPE awareness. Supervisors will monitor all safety
    equipment, ensuring correct usage. Each supervisor will coordinate
    replacement of needed PPE through proper channels. If any
    alterations have occurred, said PPE will be classified as \"unsafe\"
    and will not be permitted to be worn.

Attachment K1

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

b\. It is the responsibility of each supervisor to verify the needs of
his/her employees for the provision of PPE. Educating each employee on
PPE usage at the time of issuance and documenting training, issuance,
and replacement of each PPE issued is required.

c\. The Safety Manager, Radiation Safety Officer, or Industrial
Hygienist will review all requests for personal protective equipment
when notified by any supervisor. Reported or observed alterations to PPE
will be investigated by Safety Office staff under the categories of
unsafe act and unsafe work practice. Disciplinary action will follow.

5\. REFERENCES:

29 CFR 1910 Subpart I ‑ Personal Protective Equipment

29 CFR 1960 Subpart B ‑ Administrative

29 CFR 1960 Subpart C ‑ Standards

29 CFR 1960 Subpart D ‑ Inspection and Abatement

29 CFR 1960 BASIC PROGRAM ELEMENTS FOR FEDERAL EMPLOYEE OCCUPATION

SAFETY AND HEALTH PROGRAMS AND RELATED MATTERS

VA Ann Arbor Healthcare System Attachment K2

Policy Memorandum S-3 September 30, 2003

\[SAMPLE OF REQUEST FOR PERSONAL PROTECTIVE EQUIPMENT\]

(Date)

(Supervisor Initiating Request)

Request for Personal Protective Equipment (PPE)

Safety Office (50S)

THRU (Department Head)

1\. It is requested that (PPE requested) be provided for (name of PPE
user). Currently, (name of PPE user) is assigned to (required duties)
which entails (description of hazards).

2\. If you have questions regarding this request, please contact me at
extension ( ).

(Supervisor Initiating Request)

Attachment L

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[SAFE MEDICAL DEVICES ACT]{.underline}

1\. [PURPOSE]{.underline}: Establish guidelines on medical device
tracking and incident reporting in accordance with the Safe Medical
Devices Act of 1990.

2\. [POLICY]{.underline}: VAAAHS will maintain an accurate tracking
method for medical devices deemed subject to tracking by the Food and
Drug Administration (FDA). This includes permanently implanted devices,
life‑sustaining or life‑supporting devices used outside device user
facilities, and other devices designated by FDA. In addition, VAAAHS
will maintain an active and accurate medical device incident reporting
program to identify and evaluate medical device incidents resulting in
potential or actual injury to VA patients, employees, and members of the
public.

3\. [PROCEDURES]{.underline}:

a\. [Definitions]{.underline}.

\(1\) [Device User Facility]{.underline}. Hospital, ambulatory surgical
facility, nursing home, or an outpatient diagnostic or outpatient
treatment facility that is not a physician\'s office.

\(2\) [Medical Device]{.underline}. Any item that is used for the
diagnosis, treatment, or prevention of a disease, injury, illness or
other condition, and is not a drug.

\(3\) [Serious Illness/Injury]{.underline}. Illness or injury that is
life threatening, results in the permanent impairment of a body function
or permanent damage to the body structure, or necessitates medical or
surgical intervention to preclude permanent impairment of a body
function or permanent damage to a body structure.

\(4\) [Death]{.underline}. That which occurs due to equipment
malfunction or during the use of a medical device.

\(5\) [Reportable Medical Device Related Incident]{.underline}. Device
user facilities are required to report to the manufacturer when a device
has or may have caused or contributed to a serious injury/illness; and
to the manufacturer and the FDA when a device has or may have caused or
contributed to a death.

\(6\) Mem[bers of the Public]{.underline}. Visitors, volunteers, and
personnel who work without compensation, employees of other Federal
agencies and employees of VA contractors.

b\. [Medical Device Tracking]{.underline}.

\(1\) [An accurate tracking method will be provided for the following
medical devices]{.underline}.

Attachment L1

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(a\) [Permanently Implanted Devices]{.underline}. Upon implementation
of a permanently implanted device into a VA patient, the service
performing the implantation procedure (e.g. Surgery Service, Cardiology
Section, etc.) will do the following. Record and maintain information
regarding patient name and social security number, prescribing
physician, attending physician, date of implementation, and
manufacturer, lot, batch, model and serial number of the device
implanted.

\(b\) [Life‑sustaining or Life‑supporting Devices Used Outside Device
User Facilities]{.underline}. Upon delivery of a life‑sustaining or
life‑supporting device for use outside the Ann Arbor Healthcare System
to a VA beneficiary, the following will be completed. User service
delivering the device (e.g. Prosthetics) will record and maintain
information regarding patient name, address, telephone number, and
social security number. Prescribing physician, attending physician,
manufacturer, lot, batch, model and serial number of the device
delivered, date device was delivered, and date device was returned. Will
be documented by surgery service.

\(c\) [Other Devices Designated by the FDA]{.underline}. Upon receipt of
other devices designated by the FDA, a notification letter will be sent
to the manufacturer indicating name and address of the vendor; lot,
batch, model and serial number of the device received; and date device
was received. The device will be inspected according to equipment
management policy (see Attachment D \"Equipment Management\") and
maintained within the AEMS/MERS equipment inventory.

\(d\) Upon notification of medical device recalls, the above records
will be reviewed to determine if any of the recalled products are in use
by any VA beneficiaries or in use at this Ann Arbor Healthcare System.
Procedures for notification, response, and sequestering should be
followed as established in Ann Arbor Healthcare System Policy Memorandum
90‑10 \"Product Recalls and Internally Identified Hazards.\"

\(e\) Upon removal of a permanently implanted device from a VA patient,
the service performing the removal procedure (e.g. Surgery Service,
Cardiology Section, etc.) will record and maintain information regarding
patient name and social security number; operating physician; date of
removal; and manufacturer, model and serial number of the device
removed.

\(f\) Upon disposition of either a life‑sustaining or life‑supporting
device for use outside the Ann Arbor Healthcare System or another device
designated by the FDA, a notification letter will be sent to the
manufacturer indicating lot, batch, model and serial number of the given
device. Disposition may include scraping, selling, removal, or disposing
of, or destroying the device.

c\. [Medical Device Incident Reporting]{.underline}.

\(1\) A \"Report of Special Incident Involving a Beneficiary\" (VA Form
10‑2633) will be initiated in all instances in which there is reason to
believe that a medical device has or may have caused or contributed to a
serious injury, illness, or death of a VA patient. Procedures for
initiation,

Attachment L2

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

reporting, review, and investigation will be timely and should be
followed as established in Medial Center Policy Memorandum 11‑5
\"Patient Incident Reporting" program.

\(2\) An \"Accident Report\" (VA Form 2162 via ASISTS Program) will be
initiated in all instances where there is reason to believe that a
medical device has or may have caused or contributed to a serious
injury, illness, or death of a VA employee or member of the public.
Procedures for initiating, reporting, reviewing, and investigating will
be timely and should be followed the guidelines established in
Attachment G, \"Reporting and Investigation of Occupational Injuries,
Illnesses, Accidents and Fire Incidents.\"

\(3\) Upon investigation by the Chief of Staff\'s office and Biomedical
Engineering (BME), medical device incidents involving patients,
employees and members of the public, the Director or his/her designee
will determine if the occurrence is a reportable medical device related
incident. If designated as reportable, BME will prepare an FDA MedWatch
Form 3500A and submit copies to the following institutions within ten
working days from the date of the incident:

\(a\) Medical Device Manufacturer in the event of a potential or actual
serious injury, illness, or death of a VA patient, employee, or member
of the public.

\(b\) FDA in the event of a potential or actual death of a VA patient,
employee, or member of the public.

\(c\) National Acquisition Center, Customer Service Division, Hines, IL
for incidents involving non‑repairable devices (e.g. catheters,
syringes, tubing, etc.).

\(d\) National Engineering Service Center, Biomedical Equipment and
Technology Division, St. Louis, MO for incidents involving repairable
devices (e.g. ECG machines, infusion pumps, imaging equipment, etc.).

\(4\) A quarterly report will be submitted to the Safety Committee by
BME regarding all medical device incidents that have occurred in the
prior three months from the reporting date. It will be noted as to
whether or not the device was a reportable medical device related
incident and what corrective action and notification procedures were
followed (in any).

\(5\) A semi‑annual report will be submitted to the FDA by BME regarding
a summary of all reportable medical device related incidents that
occurred in the prior six months from the reporting date.

4\. [RESPONSIBILITIES]{.underline}: Any employee who witnesses or has
reason to believe that a medical device has or may have caused or
contributed to a serious injury, illness, or death of a VA patient,
employee, or member of the public, is responsible for initiating an
incident report and notifying the Chief of Staff's (COS) office
regarding medical device incidents involving VA patients, or the Safety
Section for medical device incidents involving VA employees and members
of the public.

Attachment L3

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

a\. The supervisor will ensure that the VA patient, employee, or member
of the public receives proper medical attention; the equipment and
accessories involved are impounded; and will review and sign the
incident report. The report will be submitted to the COS office or the
Safety section within 24 hours of the supervisor being notified.

b\. Department Heads are responsible for establishing a mechanism to
assure the systematic ongoing education of staff in the safe use of
medical devices and the Safe Medical Devices Act of 1990, and to
document such education.

c\. COS office is responsible for maintenance of Patient Incident Review
(PIR) program.

d\. The Safety Section is responsible for the maintenance of a medical
device incident reporting, review, and investigation program for VA
employees and members of the public. The Safety Manager and Chief,
Biomedical Engineering will monitor compliance and effectiveness of this
policy and report to the Safety Committee on an as-needed basis.

e\. Biomedical Engineering is responsible for the investigation of
medical device incidents, maintaining records of medical device
incidents, notifying appropriate agencies in the event of a reportable
medical device related incident, and providing all affected services
with the current listing of medical devices deemed subject to tracking
by the FDA.

f\. The Director or his/her designee is responsible for determining
whether a medical device incident is reportable, and for assuring that
effective processes are in place to identify and pursue opportunities
for improvement.

5\. [REFERENCES]{.underline}:

VAAAHS Policy Memorandum 11‑5 \"Patient Incident Reporting" program

VAAAHS Policy Memorandum 54-5 \"Product Recalls and Internally
Identified Hazards"

VHA Directive 10‑94‑010 \"Medical Device Incident Reporting\"

JCAHO Accreditation Manual for Hospitals

American Society for Hospital Engineering\'s \"Safe Medical Devices Act
of 1990: Current Hospital

Requirements and Recommended Actions\"

Attachment M

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[STORED ENERGY/CONTROL PROGRAM]{.underline}

1\. [PURPOSE]{.underline}: To establish performance requirements for the
control of energy during servicing and/or maintenance of machines and
equipment at the Ann Arbor VAMC.

2\. [POLICY]{.underline}: This policy will be used to ensure that
equipment or machines are stopped, isolated from all potentially
hazardous energy sources. Locked out and/or tagged out before affected
employees perform any servicing or maintenance, where the unexpected
energizing or start-up of the machine/equipment or release of stored
energy could cause injury.

3\. [PROCEDURES]{.underline}: All affected employees are required to
comply with the restrictions and limitations imposed upon them during
the use of lockout and/or tag out. The authorized (affected) employees
are required to perform the lockout/tag out in accordance with this
procedure. Employees upon observing a machine or equipment that is
locked out and/or tagged out for servicing or maintenance, will not
attempt to start, energize or use that machine or equipment.
Disciplinary action will be taken for violation of the above. The
following are authorized (affected) employee occupations:

1\) Electric Shop Foreman 8) AC Equipment Mechanics

2\) Electricians 9) Boiler Plant Foreman

3\) Carpenter Shop Foreman 10) Utility Systems Repairer/Operators

4\) Maintenance & Repair Engineer 11) Plumbing Shop Foreman

5\) Industrial Equipment Mechanics 12) Pipefitters

6\) HVAC Shop Foreman 13) Biomedical Specialists/Engineers

7\) Material Handlers 14) Medical Equipment Repairers/Workers

Only authorized employee is a person who locks out or tags out machines
or equipment in order to perform servicing or maintenance on that
machine or equipment; this could include an \"affected\" employee if
that employee\'s duties include performing servicing or maintenance
covered under this procedure.

**Definitions applicable to Procedure(s):**

[AFFECTED EMPLOYEE]{.underline}: An employee whose job requires him/her
to operate or use a machine or equipment on which servicing or
maintenance is being performed under lockout or tag out, or whose job
requires him/her to work in an area in which such servicing or
maintenance is being performed.

[AUTHORIZED EMPLOYEE]{.underline}: A person who locks and/or implements
a tag out system procedure on machines or equipment to perform the
servicing or maintenance on that machine or equipment. An authorized
employee and an affected employee may be the same person, when the
affected **employee\'s duties include the performing maintenance or
service on a machine or equipment, requires a locked out and/or a tag
out system implementation.**

Attachment M1

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[CAPABLE OF BEING LOCKED OUT]{.underline}: An energy isolating device is
considered capable of being locked out either if it is designed with a
hasp or other attachment or integral part to which, or through which, a
lock can be affixed, or if it has a locking mechanism built into it.
Other energy isolating devices will also be considered capable of being
locked out, if lockout can be achieved without the need to dismantle,
rebuild, or replace the energy-isolating device or alter its energy
control capability.

[ENERGIZED]{.underline}: Connected to an energy source or containing
residual or stored energy.

[ENERGY ISOLATING DEVICE]{.underline}: A mechanical device that
physically prevents the transmission or release of energy including, but
not limited to, the following. Manually operated electrical circuit
breaker; disconnect switch, manually operated switch by which the
conductors of a circuit can be disconnected from all ungrounded supply
conductors, and no pole can be operated independently. Slide gate; a
slip blind; a line valve; a block and any similar device used to block
or isolate energy. Energy Isolating Device does not include a push
button, selector switch, or other control circuit type devices.

[ENERGY SOURCE]{.underline}: Any source of electrical, mechanical,
hydraulic, pneumatic, chemical, thermal, or other energy.

[HOT TAP]{.underline}: A procedure used in the repair, maintenance, and
service activities which involves welding on a piece of equipment
(pipelines, vessels, or tanks) under pressure in order to install
connections or appurtenances. It is commonly used to replace or add
sections of pipeline without the interruption of service for air, gas,
water, steam, and petrochemical distribution systems.

[LOCKOUT]{.underline}: A device that utilizes a positive means such as a
lock, either key or combination type, to hold an energy isolating device
in the safe position and prevent the energizing of a machine or
equipment.

[SERVICING AND/OR MAINTENANCE]{.underline}: Work place activities such
as constructing, installing, setting up, adjusting, inspecting,
modifying, maintaining, and/or servicing machines or equipment. These
activities include lubrication, cleaning, or disengaging of machines or
equipment. Making adjustments or tool changes, where the employee may be
exposed to the unexpected energy or start up of the equipment or release
of hazardous energy.

[SETTING UP]{.underline}: Any work performed to prepare a machine or
equipment to perform its normal production operation.

[TAG OUT]{.underline}: The placement of a tag out device on an energy
isolation device, in accordance with an established procedure to
indicate that the energy-isolating device and the equipment being
controlled may not be operated until the tag out device is removed.

Attachment M2

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[TAG-OUT DEVICE]{.underline}: A warning device such as a tag and a means
of attachment, which can be securely fastened to an energy-isolating
device. In accordance with an established procedure to indicate that the
energy isolating device and the equipment being controlled may not be
operated until the tag out device is removed.

Procedures for Lockout: The following lists the steps to include in the
lockout procedures for types of machines and equipment in your area of
responsibility. Do not use generalities; rather, list specifics for each
type of machine or equipment.

\(1\) [Shutdown]{.underline}. An Energy Control Procedure Form
(attached) will be used to establish an orderly shutdown and lockout
procedure. Work on cord and plug(s) connected to electrical equipment
which can be unplugged, does not apply.

\(a\) [Notify all affected employees]{.underline} when servicing or
maintenance is required on a machine or equipment and that the machine
or equipment must be shut down and locked out to perform the servicing
or maintenance. See list of occupations of affected employees, page N-1.

\(b\) [Authorized employee]{.underline} will refer to the Energy Control
Procedure Form for types of machines or equipment to be locked out in
order to identify the type and magnitude of the energy source(s)
present. Ann Arbor VAMC supervisors of Facility Management shops will
train the authorized employees to enable them to understand the hazards
of and know the methods to control the energy.

\(c\) [If the machine or equipment is operating]{.underline}, shut it
down by the normal stopping procedure, for example: depress stop button,
open switch, close valve, etc. Document the specific normal stopping
procedure for equipment on the Energy Control Procedure Form.

\(d\) Deactivate the [energy isolating device]{.underline}(s) so that
the machine or equipment is isolated from the energy source(s). Document
on the Energy Control Procedure Form. List the types and locations of
energy-isolating devices, such as switches, circuit breakers, line
valves, or blocks\--any mechanical device that physically prevents the
transmission/release of energy.

\(e\) [Lock out the energy isolating device]{.underline}(s) with
assigned individual lockout devices. List the type of lockout device
used with energy isolating devices referenced on your Energy Control
Procedure Form.

\(f\) [Stored or residual energy]{.underline} such as that in
capacitors, springs, elevated machine members, totaling flywheels,
hydraulic systems, and air, gas, steam, or water pressure, etc. must be
dissipated or restrained by methods such as grounding, repositioning,
blocking, bleeding down, etc. List the types of stored energy and the
method of dissipation or restraint as referenced, on the Energy Control
Procedure For).

Attachment M3

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(g\) [Ensure that the equipment is disconnected]{.underline} from the
energy source(s) by first checking that no personnel are exposed, then
verify the isolation of the equipment by operating the push button or
other normal operating control(s) or by testing to make certain that
equipment will not operate. CAUTION: Return operating control(s) to
neutral or \"off\" position after verifying the isolation of the
equipment. List the specific methods of verifying isolation.

\(h\) [For de-energized conductors or parts of electrical equipment
only]{.underline}, if a lock cannot be applied, a tag must be used. The
tag must be supplemented by at least one additional safety measure that
provides a level of safety equivalent to that obtained by the use of a
lock. List the safety measures to be used, for example: the removal of
an isolating circuit element, blocking a controlling switch, or opening
an extra disconnecting device.

\(i\) [For de-energized conductors or parts of electrical equipment
only]{.underline}, an authorized person (one who is familiar with the
construction and operation of the equipment and the electrical hazards
involved), will use test equipment to test the circuit elements.
Electrical parts of equipment to which employees will be exposed and
will verify that the circuit elements and equipment parts are
de-energized. The test will also determine if any energized condition
exists as a result of inadvertently induced voltage or unrelated voltage
back feed, even though specific parts of the circuit have been
de-energized and presumed to be safe. If the circuit to be tested is
over 600 volts, nominal, the test equipment will be checked for proper
operation immediately before and immediately after this test. List the
authorized person and the testing instrument to be used.

\(j\) The machine or equipment is now locked out.

\(2\) [Restoring Equipment to Service]{.underline}: (To be listed on
*Energy Control Procedure Form*.)

\(a\) Check the machine or equipment and the immediate area around the
machine or equipment to ensure that nonessential items have been removed
and that the machine or equipment components are operationally intact.

\(b\) Check the work area to ensure that all employees have been safely
positioned or removed from the area.

\(c\) Verify that the controls are in neutral.

\(d\) Remove lockout devices and tag-out tags, and re-energize machine
or equipment.

\(e\) Notify affected employees that the servicing or maintenance is
completed and the machine or equipment is ready for use.

[EXCEPTION TO EQUIPMENT RESTORATION]{.underline}: When an employee has
left his lock and tag on equipment for an unknown reason and it must be
removed, the following steps should be taken:

Attachment M4

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(1\) If the employee has left VAAAHS, every effort will be made to
contact the individual to determine the reason for leaving
equipment/energy source locked out and tagged out.

\(2\) If the employee can\'t be located on station or at home, the
supervisor of the employee must check out the equipment and make sure it
is safe to remove lock and tag. The supervisor will fill out the
backside of the tag and sign it.

\(3\) After the lockout/tag out system has been removed, operation of
the energy-isolating device (i.e. electrical panels, circuit breakers,
or valves) to restore energy to the machine/equipment, can be done.

[GROUP LOCKOUT/TAG-OUT]{.underline}: When servicing and/or maintenance
is performed by more than one authorized employee, each will place their
own lockout/tag out device on the energy isolating device(s) by
utilizing a multiple lockout device which accepts multiple locking
devices. Primary responsibility is vested in the authorized employee for
a set number of authorized employees working under the protection of a
group lockout/tag out system, who will coordinate affected work forces
and ensure continuity of protection to all personnel. The Maintenance &
Repair (M&R) Engineer is the authorized employee where the multiple
lockout devices are used by same shop. For several crafts or shops, the
M&R Engineer or assigned designee has responsibility to protect all shop
personnel under the multiple lockout devices.

[INFORMATION ON TAGOUT]{.underline}: The following information is to be
documented on the tag-out:

Authorized Employee Name

Position

Type/Location of Equipment

Department and extension number

Time

Date

Example: John J. Jones

Electrician

Electric Oven, Room 2A122

Facilities Management, Ext. 5428

3:50 P.M.

October 1, 2002

[LOCKOUT PROCEDURE FOR CONTRACTORS]{.underline}: In situations when
lockout/tag out occurs by a contracted contractor on-site, the assigned
COTR's will follow this procedure:

\(1\) Notify the M&R Engineer of planned lockout/tag out.
Lockouts/tag-outs that disrupt the operation of utility systems must be
pre-scheduled through the designated project COTR, M&R Shop, and the
involved contractor.

Attachment M5

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(2\) The C.O.T.R. assigned to the project will ensure that contractors
adhere to procedures outlined in this policy for lockout and tag out of
equipment and/or energy sources. This will be accomplished by reviewing
the lockout/tag out procedure at all pre-construction briefings, which
includes this attachment. The review will consist of the VA and
contractor insuring that all workers who are authorized, or affected by
any shut down, are knowledgeable of each specific procedure prior to
deactivation and reactivation of the equipment.

[SHIFT AND PERSONNEL CHANGES]{.underline}: If it becomes necessary to
lockout/tag-out equipment and the timing involves shift or personnel
changes to continue the work, the workers will ensure that this
lockout/tag out is replaced by the ongoing worker. This should insure
continuity of the safe lockout/tag out of the equipment needing
continued work. (Contracted contractors on-site are also responsible for
this procedure).

[TRAINING]{.underline}: Shop foreman will provide training to assure
that the purpose and function of the Energy Control Program are
understood by employees and that the knowledge and skills required for
the safe application, usage, and removal of energy controls are
understood by affected employees. This also is the responsibility of any
affected contractor employee's on-site. Each authorized employee
(including affected contractor employees) will receive training in the
recognition of applicable hazards, energy sources, the methods and means
necessary for energy isolation and control of all affected equipment
used in lockout/tag out procedures. Each affected employee will be
instructed in the purpose and use of the energy control procedure, in
association with all affected equipment and/or tools. Employee's whose
work may involve the area involved with equipment or utilities locked
out or failed, or due to power loss, will be instructed of procedures
for notifications by the designated and/or M&R Engineer. (Contract
affected employees, are the responsibility of the contractor supervisor
of the involved contract). These procedures will be reviewed annually by
the M&R engineer to ensure required elements are followed by authorized
and affected employees.

4\. [RESPONSIBILITY]{.underline}: Any affected employee using any form
of energy control equipment, i.e., compressed air, hydraulic, water, or
steam, is required to comply with this policy. Users of electrical
equipment, capacitors, or battery operated equipment capable of
discharging 100 micro amps or greater in patient care areas, or 500
micro amps or greater in non-patient care areas, are required to comply
with this policy.

Supervisors of Facility Management shops/sections and Project Engineers
have the responsibility to ensure that lockout/tag-out procedures are
followed by personnel within their supervision.

Attachment M6

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

5\. REFERENCES: OSHA-29 CFR 1910.147

LOCKOUT/TAGOUT PROGRAM

ENERGY CONTROL PROCEDURE FORM

MACHINE/EQUIPMENT TYPE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

LOCATION
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

TYPICAL ENERGY SOURCES & LOCATIONS OF ENERGY ISOLATING DEVICES:

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHORIZED EMPLOYEE(S)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AFFECTED EMPLOYEE(S)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PROCEDURE DEVELOPED BY
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SPECIFIC PROCEDURE FOR THIS MACHINE/EQUIPMENT TYPE IS AS FOLLOWS:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

RESTORING MACHINE TO SERVICE

Attachment N

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[SAFE USE OF OXYGEN]{.underline}

1\. [PURPOSE]{.underline}: To establish specific safety precautions for
the administration of oxygen, including inspection, maintenance,
monitoring and emergency procedures for the use of oxygen equipment with
the Ann Arbor Healthcare System.

2\. [POLICY]{.underline}: All Ann Arbor Healthcare System personnel
entrusted with the administration, use and care of oxygen and related
equipment will be fully instructed in the safe and proper
administration, use and handling of oxygen and will comply with this
policy. This is required since an enriched atmosphere facilitates
combustion and the fire danger in these areas is greatly increased.

3\. PROCEDURE:

a\. [Use of Oxygen]{.underline}. For all occasions of oxygen use, the
following measures will be used:

\(1\) Oxygen use areas will have proper signs conspicuously posted and
will identify the danger of using ignition sources such as matches,
lighters, and smoking materials, etc.

\(2\) Smoking is prohibited within this Ann Arbor Healthcare System. As
an added precaution, \"NO SMOKING\" signs will be posted outside rooms
where oxygen therapy is being administered.

\(3\) Persons operating oxygen use equipment will ensure all persons in
the area are informed of the hazards of oxygen enriched atmospheres. Any
plug‑in electrical appliances used in the room should be plugged into an
outlet away from the bed and the oxygen should be shut off before
connecting or disconnecting the appliance.

\(4\) Before use of oxygen, personnel responsible will ensure flammable
liquids such as oils and alcohol, flammable gas cylinders, dust or other
similar flammable/combustible materials are removed from the immediate
area.

\(5\) Location of oxygen shut‑off valves (patient head-wall unit or ward
shut off valve) in all patient care areas, will be known by medical
and/or nursing staff administering oxygen directly to patients on each
ward they are working on.

\(6\) [Horizontal Evacuation Scenario]{.underline}. Patient(s) on oxygen
connected to the head wall unit may be involved in ward evacuation. The
head nurse on the unit or ward will disconnect and shut off the oxygen
source at the head wall unit, evacuate patient from immediate danger,
and then switch to a portable oxygen supply that has been connected to
each patient (i.e., fire in patient care area). Each ward supervisor
must coordinate with respiratory therapy, and make sure adequate oxygen
tanks and regulators are available on a short notice for patient
evacuation purposes.

Attachment N1

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(7\) [Respiratory Therapy]{.underline}. Respiratory Therapy Supervisor
and the Chief, Medicine Service will coordinate adequate oxygen tank &
regulator supplies for horizontal evacuation needs in all wards.

b\. [Inspection of Oxygen Equipment]{.underline}. Will be completed as
follows in accordance with the National Fire Protection Association
(NFPA) ‑ Code 99, Health Care Facilities, manufacturer\'s instructions,
and Respiratory Therapy VHA requirements:

\(1\) At the time of acquisition and installation;

\(2\) By individual operator prior to use, with particular attention to
the presence of dust, oil, or grease and calibration controls; and

\(3\) Scheduled inspection and maintenance (Preventative Maintenance
Inspection ‑ PMI) will be recorded in accordance with VA requirements.

\(4\) During re-supply into any patient care ward.

c\. [General Precautions ‑ Oxygen Cylinders]{.underline}. Care must be
exercised in handling/storing oxygen to prevent contact of oxygen under
pressure with oil, grease, organic lubricants, rubber, or other
materials of organic nature. Also to prevent any dropping or damage to
any cylinder under pressure, the following regulations will be observed:

\(1\) Never permit oil, grease, or readily flammable materials to come
in contact with oxygen cylinders, valves, regulators, gauges, or
fittings.

\(2\) Never lubricate regulators, gauges, or fittings with oil or any
flammable substance.

\(3\) Oxygen cylinders in use will be restrained or properly anchored to
prevent falling at all times. Rough handling that might damage the
cylinders or valves will be avoided. All valves on large cylinders will
have \"valve caps\" screwed on at all times outside of immediate usage,
(i.e., immediate usage means connected to a regulator or connected to
another cylinder during usage).

\(4\) Storage of oxygen cylinders or any other cylinders (i.e., oxygen,
nitrous oxide, nitrogen, ethylene oxide, carbon dioxide, Freon, liquid
oxygen, or any other type of pressurized gas in cylinders) will be
stored only at designated user sites or storage sites.

\(a\) [Designated Storage Sites]{.underline}.

Room A22a

Loading dock on the southeast side of Building #1W

Attachment N2

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(b\) [Designated User Sites]{.underline}.

Operating Rooms & PACU Bldg. 1E

Research Labs in Buildings #1W, #22, & #31

Laboratory Service Labs Building #1E,

Facilities Management Shop locations in Buildings #1W, 1E, & #29

Respiratory Therapy Office, Building #1E, 7th floor

Intensive Care Units, Building #1E, 5th & 7th Floors.

\(c\) Portable oxygen tanks will be used on an as‑needed basis.
Respiratory Therapy will coordinate movement and supply.

\(5\) Storage of any pressurized gas cylinder in any corridor within any
building at this medical facility is strictly prohibited.

4\. [RESPONSIBILITY]{.underline}:

a\. [Patient Care Service]{.underline} personnel will inform patients,
visitors, and employees during oxygen usage, the hazards of smoking and
open flames in the vicinity of oxygen enriched atmospheres and
equipment. Medical and Patient Care Service personnel will be familiar
with the location and operation of each work site specific emergency
shut‑off valve of oxygen supply within each patient care area/ward.

b\. [Central Supply Officer]{.underline} is responsible for the
acquisition, maintenance, and inspection of the bulk oxygen supply
system, reserve system, compressed oxygen cylinders and related
equipment, and safe storage procedures associated with the delivery and
shipment of oxygen on and off the grounds of this Ann Arbor Healthcare
System. Respiratory Therapy is responsible for the handling and
replacement of oxygen tanks within patient care wards. Research staff is
responsible for the coordinated handling and movement of all compressed
cylinders in research user sites, with material handling staff
associated with on-site warehouse personnel and/or any contracted
compressed gas cylinder vendor.

c\. [Facilities Management Officer]{.underline} is responsible for the
inspection and maintenance, along with the monitoring of the oxygen
piping system via the Energy Management System (EMS). Facilities
Operations personnel responsible for using oxygen/acetylene admixtures
and equipment will comply with Hot Work/Cutting and Welding Policy
(Attachment R) when cutting, welding, and/or brazing. Oxygen cylinders
and acetylene cylinders will not be stored within the same storage area.
The mixture of both via any leak can cause an explosive atmosphere if
the amount of acetylene concentration is 6 percent or higher within 15
feet of an oxygen cylinder. No compressed gas cylinder of any size will
be taken into any Confined Space Entry activity. Will provide and
maintain appropriate signs for oxygen use areas, storage areas, and
emergency shut‑off valve identification and labeling. Also any work
order associated with the securing of oxygen cylinders.

Attachment N3

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

d\. [Medical Research and Laboratory Service]{.underline} personnel who
use oxygen cylinders within any laboratory are responsible for the
securing and safe usage within each laboratory. Storage of oxygen
cylinders or any other type of cylinder in any corridor is strictly
prohibited.

e\. All user services who use oxygen or administer oxygen therapy as
part of their work‑site specific responsibilities will conduct and
document annual safety training associated with oxygen usage, tank
storage, operating oxygen shut-off valves, shut-off valve locations, and
patient transportation procedures with regulators and portable oxygen
tanks. All service specific Emergency Preparedness Plans will reflect
procedural changes and training requirements associated with the usage
of oxygen during patient care and evacuation.

f\. The Safety Office will coordinate and/or provide the necessary
emergency preparedness training in the use of emergency shut‑off
procedures and actions in the event of an emergency or hazardous
condition. The Safety Officer will monitor compliance of this policy as
part of the weekly Hazard Surveillance Program throughout the Ann Arbor
Healthcare System.

5\. [REFERENCES]{.underline}:

National Fire Protection Association NFPA 99, Standard for Health Care
Facilities

MP‑3, Part III, Chapter

Attachment O

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[PURCHASING FLAME-RETARDANT FURNISHINGS/MATERIALS]{.underline}

1\. [PURPOSE]{.underline}: To establish guidelines for the selection and
purchase of flame-retardant furnishings and/or materials used in
connection with direct or indirect patient care, as well as window
decorations, cubicle curtains, linens, patient clothing, and draperies.

2\. [POLICY]{.underline}:

a\. The protection of life from the hazard of fire is an ongoing life
safety management priority. Therefore, not only will patients be
protected with flame resistant clothing, as needed, additional
protection will be taken in the selection of furnishings, window
decorations, cubicle curtains, linens, and draperies used in patient
care areas. It is the responsibility of the Linen Control Officer to
verify that all materials selected for patient care be flame
resistant/flame-retardant prior to authorizing the purchase of said
materials and/or clothing.

b\. If, in the opinion of the attending physician, patients are a fire
hazard to themselves or to others because of smoking habits or because
of physical or mental conditions, such patients will be classified as
smoking risks. A notation concerning the smoking risk status of a
patient will be entered on VA Form 10-2911, "Nursing Plan," by nursing
personnel or the attending physician.

c\. This facility is \"smoke free.\"

3\. [PROCEDURES]{.underline}: The Laundry Plant Manager at Battle Creek
and the Linen Control Officer, VAMC Ann Arbor (Facilities Maintenance
Supervisor) will confer with the purchasing section of Resources on the
flame resistant/flame-retardant characteristics requirement of requested
clothing/materials prior to approving purchase.

a\. The following items are required to have flame
resistant/flame-retardant characteristics:

\(l\) Pajamas

\(2\) Robes, gowns

\(3\) Cubicle curtains

\(4\) Draperies

\(5\) Vertical or horizontal blinds

\(6\) Furniture coverings

\(7\) Holiday decorations

\(8\) Window treatments

\(9\) Linen (i.e., sheets, pillow cases, blankets, mattress covers, and
pillows)

(l0) Any other furnishings that could support a fire in any area that is
occupied by patients and/or employees. Paint and wallpaper are not in
this category.

Attachment O1

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

b\. Documentation in the form of MSDS or specific manufacturer labeling
of flame resistant/flame-retardant properties of ordered products will
be kept on file in the Linen Control Officer\'s office in Facilities
Maintenance.

[Linen Service Requirements]{.underline}.

a\. Repetitive washing of Nomex or other flame resistant patient
clothing materials and linens will be monitored for flame resistant
characteristics. This can be done by adding flame resistant materials to
the wash cycle of each load. This is a tracking function at the linen
washing facilities only.

b\. Usage and ordering of flame resistant material used in wash cycles
of patient clothing and linen will be monitored by the linen washing
facilities only.

\(l\) A MSDS will be available at each linen washing facility on the
type of flame resistant material used in wash cycles.

\(2\) A copy of said MSDS will be forwarded to and kept on file in each
facility serviced by the linen washing facility.

4\. [RESPONSIBILITIES]{.underline}:

a\. Linen Control Officer in Central Supply is responsible having MSDS
on all flame resistant/flame-retardant products used in VAAAHS.

b.  Laundry Plant Manager, VAMC, Battle Creek will maintain all required

documentation on the purchase of materials and all MSDS dealing with
said purchase.

5\. [REFERENCES]{.underline}:

MP-3, Part III, Section 32.36b and d

NFPA 701 - Flame Resistant Textiles and Films - 1997 Edition

NFPA 101 - Life Safety Code - 2000 Edition

NFPA 99 - Standard for Health Care Facilities -- 2002 Edition

JCAHO Environment of Care Standards - 2003 Edition

Policy Memorandum S2 -- Hazardous Materials Management

Attachment P

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

[HOT WORK/CUTTING AND WELDING]{.underline}

1\. [PURPOSE]{.underline}: To provide the correct procedures and
responsibilities for performing on‑site torch cutting, soldering, and
welding, in regard to proper VAMC authorization and notification through
the use of Hot Work Permits.

2\. [POLICY]{.underline}: Cutting and welding operations are
particularly dangerous. It is essential safety be given a high priority.
These operations can produce literally thousands of ignition sources in
the form of sparks and hot slag. Sparks from welding can scatter
horizontally as far as 35 feet igniting combustible materials. Sparks
also fall through cracks in floors, pipe shafts, and small openings in
floors or partitions thereby starting fires, which often become serious
before being discovered. NFPA Standard No. 51B, [Fire Prevention in the
Use of Cutting and Welding Processes]{.underline}, emphasizes the
cutter, welder, immediate supervisor, and management all share full
responsibility for the safe use of cutting or welding equipment.

Hot Work, defined as \"operations including cutting, welding, thermal
welding, brazing, soldering, grinding, thermal spraying, thawing pipe,
or any similar situation\", is a source of ignition causing building
fires each year. In addition, construction, demolition, and alteration
operations often result in the accumulation of combustible debris that
compounds the risk of fire. In recognition of these combined dangers, VA
has adopted NFPA Standard No. 241, [Safeguarding Construction,
Alteration and Demolition Operations,]{.underline} and NFPA Standard No.
51B, [Fire Prevention In Use of Cutting and Welding
Processes]{.underline}, both of which require a permit system for all
Hot Work.

A permit system will be used whenever contractors or Facilities
Management personnel are conducting hot work operations on any
construction, alteration, or demolition project. Permits will not be
issued for cutting, welding, or other hot work in areas not authorized
by the Facilities Management Officer or a designated representative.

3\. [PROCEDURES]{.underline}:

a\. Authorization to proceed will be given in the form of a written
permit, after the area has been inspected by an individual responsible
for supervision of the hot work operations (See R-4). A permit to
perform hot work will not be issued until (l) it has been determined hot
work can be safely conducted at the location; (2) combustible materials
have been removed or covered; (3) the atmosphere is nonflammable; and
(4) a fire watch (with portable fire extinguisher) is posted for the
duration of the work, and for 30 minutes thereafter, to ensure sparks or
drops of hot metal have not started a fire.

b\. Cutting or welding at VAAAHS will only be approved when a VAMC
designated individual familiar with the requirements contained in NFPA
Standard No. 51B has performed a thorough evaluation. The designated
individual will ensure that:

Attachment P1

VA Ann Arbor Healthcare System Policy Memorandum S-3

September 30, 2003

\(1\) Only approved equipment in satisfactory operating condition will
be used.

\(2\) Contractors or Facilities Management personnel and their
supervisors will be suitably trained in safe operation of equipment and
emergency procedures in the event of fire.

\(3\) Contractors or Facilities Management personnel are required to
survey and be aware of existing flammable materials or hazardous
conditions.

c\. In instances where very minor repairs and/or alterations that are
not part of a construction project require hot work, a permit is not
required provided there is no accumulation of combustible debris or
openings in corridors, fire‑rated walls or shafts. It is still necessary
for the respective shop foreman or other responsible individual to
verify conditions are safe for hot work. Common sense must be used when
determining when a permit system must be used. In addition, it must be
emphasized only minor repairs may be conducted without a permit and
cutting and welding, which are very hazardous operations, require
permits at all times.

4\. [RESPONSIBILITIES]{.underline}:

a\. Management will be responsible for safe usage of cutting and welding
equipment on VAAAHS property.

b\. The job supervisor, who may be a contractor, job superintendent, or
Facilities Management personnel (herein referred to as permittee), is
responsible for the following:

\(1\) Prior to obtaining authorization, inspect area where
cutting/welding is to occur.

\(2\) Obtain authorization for cutting/welding (R-4) from Facilities
Management Service Construction Project COTR or M&R foreman by ensuring
conditions are or will be Hot Work safe before proceeding with work. The
permittee will do so by:

\(a\) Ensuring (l) combustible materials are located at least 35 feet
from the work site, or protected with flameproof covers or shielded with
metal or fire‑resistant guards or curtains; (2) openings or cracks in
walls, floors, or ducts within 35 feet of the site are covered to
prevent the passage of sparks to adjacent areas; (3) when cutting or
welding is done near walls, partitions, ceiling, or roof of combustible
construction, fire resistant guards or shields are provided to prevent
ignition; (4) cutting or welding on pipes or other metal in contact with
combustible walls, ceilings or roofs is not undertaken if the work is
close enough to cause ignition by conduction; (5) fully charged and
operable fire extinguishers, appropriate for the type of possible fire,
are available at the work area; and (6) when cutting or welding is done
in close proximity to a sprinkler head, a wet rag is laid over the head
during operation.

\(b\) Ensuring nearby personnel are protected from heat, sparks, etc.,
via usage of personal protective equipment.

Attachment P2

VA Ann Arbor Healthcare System Policy Memorandum S-3 September 30, 2003

\(c\) Ensuring firewatchers are available at the site when required and
final check‑ups 30 minutes after work completion are performed.

c\. The cutter or welder must perform the following equipment safety
procedures:

\(1\) Obtain hot work permit from the supervisor before starting to cut
or weld and coordinate the actual work completion time with the Safety
Specialist or other Safety Staff at extension 3803 or 5417.

\(2\) Cut or weld only when conditions are safe as described above.

d\. Fire watchers will be provided whenever cutting, welding, or other
hot work is performed in VAAAHS and are responsible for:

\(1\) Having fire-extinguishing equipment readily available and
personally prepared in its use. (10# BC or 10# ABC Type)

\(2\) Being familiar with the facilities alarm system and procedures for
sounding an alarm in the event of fire.

\(3\) Watching for fires in all exposed areas, and attempting to
extinguish them only when obviously within the capability of the
equipment available.

\(4\) Maintaining a watch for at least 30 minutes after completion of
cutting or welding operations to detect and extinguish smoldering fires.

5\. [REFERENCES]{.underline}:

NFPA 51B ‑ 2000 Edition

IL08‑89‑01 \"Hot Work\" ‑ February 27, 1989

29CFR1926 ‑ Subpart J ‑ Welding and Cutting ‑ 1996 Edition

29CFRl910 ‑ Subpart Q ‑ Welding, Cutting, & Brazing ‑ 1996 Edition

VA Ann Arbor Healthcare System Attachment P3

Policy Memorandum S-3

September 30, 2003

**[HOT WORK PERMIT]{.underline}**

This permit applies only to the area and date below:

LOCATION:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_SERVICE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DATE/TIME TO START: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_DATE/TIME TO FINISH:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NATURE OF JOB:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The above location has been examined. The precautions checked below have
been taken.

/ / Fire extinguishing equipment is on hand in case of fire.

/ / Personnel instructed in the use of fire equipment and activation of
fire alarms.

/ / Sprinklers are in service, if installed.

/ / Immediate area smoke detectors have been appropriately covered.
(Number covered \_\_\_\_\_\_\_\_\_\_\_\_)

/ / Cutting, welding, and soldering equipment in good condition.

/ / Floors swept clean of combustibles.

/ / Flammable liquids removed from work area (within 35 feet for welding
or cutting; within 10 feet

for other hot work operations).

/ / All wall and floor openings covered.

/ / Walls and ceilings protected from sparks/open flames (check opposite
sides of walls).

/ / Non-flammable covers in place as necessary.

/ / Combustible floors protected by wetting or covering with wet sand.

/ / Utilities such as oxygen, LP gas, natural gas, etc., have been
secured and protected.

/ / Personal protective equipment is available and will be used.

/ / For enclosed equipment, equipment cleaned, purged, and gas-free
tested as required.

/ / Fire watch provided during and 30 minutes after welding/cutting work
is stopped.

I understand the provisions of this permit. I understand the work can be
interrupted at any time for failure to follow the safety provisions
within the Hot Work policy and as outlined above.

Signed:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Shop:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Immediate Sprv.)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Notification of this work is acknowledged.**

Permit expires: DATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TIME: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNED:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DATE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DATE/TIME STARTED: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DATE/TIME FINISHED: \_\_\_\_\_\_\_\_\_\_\_\_\_\_

[Final Check]{.underline}: Work area and all adjacent areas to which
sparks and heat might have spread (including floors above and below, and
on opposite sides of walls) were inspected for at least 30 minutes after
the work was completed and found fire safe. All smoke detectors covered
to prevent nuisance alarms have been uncovered (Number uncovered
\_\_\_\_\_\_\_\_).

Signed:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Immediate Supervisor)