JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENT √ If Present

PLAN – OUTLINE

 Purpose
o To ensure that buildings, grounds, equipment and systems pose no
hazards to occupants
 Prevent accidents
 Maintain safe conditions for patients, families, visitors, and staff
 Reduce and combat hazards and risks

 Goals (measurable for what is to be accomplished or maintained (annually

updated)

 Responsible individual designated with scope of authority defined

o Safety officer designated with qualifications including training and
experience
o Responsibilities defined
 Include relationship of safety officer to department and other
leaders

 Risk assessment
o Facility-wide inspection process for current information
o Location of up-to-date building plans (blue prints)
o Risk assessment safety and security using a structured format
 Define process for who and when and how and where reported
(Could be the ongoing hospital building inspection or a more
structured approach)
 Describe how data from risk assessment is used to support goals
for the plan and policy and procedure development

 Facility Inspections – periodic

o Process defined, frequency, how findings are summarized and analyzed
and findings tracked for improvement. State where facility inspection
results are reported and the frequency of the report.
o Define who conducts facility inspections, such as the “safety officer” with
clinical and support staff as part of team, department directors such as
directors of laboratory, radiology, administration
o Use of checklist for the inspections (attach to plan)
o State how data are used to make improvements

 Preventive safety program strategies

o Safety prevention strategies and practices are in place to support safe
environment and comply with law and regulation
 Identify supporting policies and procedures
 Identify country laws/regulatory safety requirements
o Statement about use of periodic safety round inspections to identify and
take to reduce evident risks
 Feedback to department/units and response/corrective action

JCI Safety and Security Plan – Outline

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 JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENT √ If Present

PLAN – OUTLINE
expectations
 Initiate corrective actions/ work requests/ etc.
 Reporting process – submit aggregate findings to hospital safety
committee

o Use of external reviews to identify safety risks and taking of actions

o Construction and renovations: Preventive risk assessment and interim

plans during construction and renovations
 Supporting policies
 Risk assessment tools
 Construction permits
o Security and safety for vulnerable patient populations such as infants,
elderly, disabled, abuse cases for protection, and other vulnerable patient
populations
 Identify supporting policies that address how you provide safety
and security, such as infant abduction policy

o Security procedures for identified sensitive areas such as ED, OR,

Pharmacy, Radiology, Laboratory, MR storage, Cashier, Human
Resources

 Active safety program - Describe the strategies for the following: 

o Management of safety incidents for staff, visitors, and patients 

 Statement that describe integration of employee and patient
safety data (usually from incident reports) integrated into safety
program (reference incident reporting policy)
o Integration with Infection Control program data on safety risks 

 For example, needle stick injuries or Blood Borne Pathogen 

exposures
o Describe how laboratory and radiology safety program data are integrated 
into safety program and reporting frequency to Safety Committee
(reference safety program policies)
o Reporting and response process 
 To safety officer
 To Safety Committee
o Include responsibilities and training of independent entities 

 Preventive security program strategies 

 Plans to reduce evident risks based upon the inspections and drills 

JCI Safety and Security Plan – Outline

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JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENT √ If Present

PLAN – OUTLINE
o Infant abduction drills 

o Security guard procedure 

o Identify supporting policies and procedures 

 Access to hospital 

o Identification of security sensitive areas 

o Control of entrances and exits 

o Check points in hospital 

o After-hours checks 

o Surveillance of locking entrances after hours 

o Reference supporting policies 

 Coordination with local police department 

o Communication, phone numbers 

 Identification system (badges) for staff, visitors, vendors/ contractors, 

volunteers and patients
o Process/ technical: Badges and pictures, swipe cards for staff 

o Badges for visitors, vendors/ contractors 

o Volunteers identification process 

o Screening visitors, families, vendors after hours 

o Reference supporting policies 

 Remote monitoring systems such as surveillance cameras/ tele monitors 

o Interior monitoring - corridors/ areas 

o Exterior monitoring - parking lots, garages 

o Security surveillance monitoring area 

 Staffing and back-up tapes


JCI Safety and Security Plan – Outline

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 JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENT √ If Present

PLAN – OUTLINE
 Active security program strategies 

o Management of incidents: staff, visitors, and patients 

o Security alert codes – see policy 

o Incident reports; format or form 

o Identify supporting policies and procedures for above 

o Reporting and response process 

 To security officer 

 To safety committee 

 Role of Safety Committee to support maintain a safe and secure environment

o Reference any document or policy describing the committee

 Monitoring data (measures) for improvements in the safety and security

program
o Define monitoring measures - could be use of inspection findings or
something from incident reports such as visitor falls or thefts
o Define collection, aggregation, report structure, reporting process and
frequency (according to schedule)
o Flow or integration of data and analysis to Quality Improvement
Committee

 Training / education program

o Education of staff at initial hire and annual thereafter for safety and
security awareness
 Integrate training topics from monitoring findings, rounds
data, other reports into the Safety Committee
 Modification of training according to safety and security risks
that are departments/ service specific
o Vendor, contractor, volunteer requirements for training related to their
jobs and roles
 On initial visit
 Any annual training (such as for volunteers)
o Patient education
 Topics for patient handbook on Safety program including
International Patient Safety Goals
 Specific safety and security information for sensitive areas
such as newborn nursery, NICU, Obstetrics, psychiatry, ER

JCI Safety and Security Plan – Outline

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JCIA 4th Edition

FMS.2 and FMS.4 -4.2 SAFETY and SECURITY MANAGEMENT √ If Present

PLAN – OUTLINE
o Include training of independent entities

 Annual program plan evaluation

o Statement describing the process for the annual evaluation including
use of existing surveillance and rounding data, performance
improvement data, staff training findings, annual risk re-assessment,
review of program goals, and recommendations for program or policy
and training changes.

JCI Safety and Security Plan – Outline

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