Risk Management and Patient Safety
This report explores the 2022 Safety Management Plan for Management of the Environment
of Care (EOC) in Duke University Hospital (DUH), North Carolina. In particular, the report
examines DUH Plan’s compliance with the directives stated by the American Society for
Healthcare Risk Management (ASHRM). In addition, the areas of potential risk management
and safety improvement are assessed, and the role and scope of responsibilities of the DUH
Safety Officer are examined.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
DUH Safety Management Plan: Summary and Responsible Stakeholders
DUH Safety Plan covers fifteen components related to risk management and patient safety in
various settings and domains. The critical component’s content is summarized in this section;
the summaries are supplemented with a brief description of stakeholders responsible for
implementing a particular component. According to Guler (2017), patient experience is the
critical indicator of a hospital’s performance, which demands diligent leadership and strong
standard practices. In this regard, one can claim that DUH strives to create a highly-
standardized EOC, where patient safety and positive experience are ensured through
multifaceted risk management activities.
Grounds and Equipment
The Grounds and Equipment component includes supervising and maintaining all DUH’s
grounds and equipment via TRIMMS — a special computerized management system. The
responsibility for properly implementing this component falls on the Duke University Facilities
Management Department’s Grounds Operation (DUH, 2022). TRIMMS retains all information
related to work orders, histories, and maintenance schedules.
Employee Safety
The Employee Safety component covers the processes aimed at reducing workplace injury risk
for DUH personnel. The leaders of the Employee Occupational Health and Wellness functions
are responsible for this component’s implementation (DUH, 2022). Their role lies in managing
the programs for reporting, investigating, and following up on incidents of occupational
illnesses and injuries.
Smoking Policy
The Smoking Policy is dedicated to reducing the risk of fire and patient exposure to passive
smoking. According to DUH (2022), all managers are responsible for monitoring compliance
with the “Tobacco-Free Environment Policy.”
Risk Assessment
The Risk Assessment component is related to proactive actions aimed at evaluating the risks
for the safety of the patients, staff, visitors, and hospital facilities. The primary responsibility
for risk assessment lies on the heads of functions, such as Mr. Trunzo, who leads the Chemical
and Radioactive programs of Hazardous Materials function (DUH, 2022). Specific findings
and recommendations are headed to the Duke University Safety Committee (DUSC), presided
by Dr. Matthew A. Stiegel, who also occupies the Safety Officer position.
Reporting
The function leaders report the results of their activities to DUSC according to the published
reporting schedule. The DUSC approval is necessary for planning each function’s objectives
(DUH, 2022). In addition, reporting allows the function heads to evaluate their progress toward
accomplishing the planned objectives.
Policy Development and Periodic Review
The institutional safety policies related to EOC management are subjected to periodic reviews.
According to DUH (2022), the policy reviews are conducted by the DUSC at least once every
three years.
Performance Improvement
Each function’s leader is supposed to develop Performance Improvement indicators within
their function. The indicators are based on priorities identified by the function and the DUSC
(DUH, 2022). In addition, DUSC is responsible for the approval of indicators, including their
thresholds and monitors.
Effectiveness Monitoring
The Effectiveness Monitoring is conducted via environmental tours, audits, and inspections.
According to DUH (2022), all hospital areas where patients a served musted be monitored for
compliance with safety requirements on a bi-annual basis. Unlike the activities within the
Performance Improvement component, Effectiveness Monitoring is performed by external
agencies, such as the Durham City Fire Marshal’s Office (DUH, 2022).
Integration With the Patient Safety Program
The individual functions safety plans and the general DUH Safety Management Plan are
integrated through interactions between responsible functions’ personnel and specific oversight
committees. For instance, the DUH Safety Officer participates in the Performance
Improvement Oversight Committee (PIOC) meetings (DUH, 2022). As a result, the DUSC
successfully coordinates its activities with oversight committees, creating an integrated patient
safety program.
Safety Training
Finally, direct supervisors are responsible for the safety training of all new employees.
Additionally, safety training procedure is usually updated on an annual basis (DUH, 2022). In
the end, the regulatory safety policies developed by the DUSC serve as a means of achieving a
consistent level of risk management and patient safety within DUH.
Compliance with ASHRM Directives
In total, ASHRM stated eight critical directives of enterprise risk management. The operational
directive covers risks created by flawed documentation, an unclear chain of command, and
deviations from standard practice. The patient safety directive includes medication errors,
serious safety events, and hospital-acquired conditions. The strategic directive relates to care
partnerships, marketing, and various business arrangements. The financial directive deals with
the risks stemming from costs and billing issues. The human capital directive relates to
workforce conditions, such as injuries and fatigue. The legal directive covers risks associated
with the hospital’s inability to manage and monitor legal, regulatory, and statutory mandates.
Next, the technology directive addresses potential risks and safety issues related to hardware,
tools, or specific techniques. Finally, the hazard directive covers risks from improper facility
management or environmental conditions (ASHRM, n.d.). These directives are followed in the
DUH Safety Management Plan since functions are specifically assigned to match a particular
directive.
For instance, operational and patient safety directives are covered by the Patient Safety
function. Compliance with the human capital and legal directives is ensured by the Employee
Health and Corporate Risk Management functions. In addition, the Corporate Risk
Management function covers potential strategic and legal risks. Furthermore, potential
technological issues are handled by the Medical Equipment Function. Lastly, the Hazardous
Materials and Hazardous Wastes functions manage the risks stated in the ASHRM hazard
directive (DUH, 2022). Therefore, one can argue that DUH managed to ensure general
compliance with the ASHRM directives.
Potential Additions to the Plan for Risk Management and Patient Safety Improvement
Whereas the DUH 2022 Safety Management Plan covers all ASHRM directives, certain
improvements could be added to the Plan’s policies to enhance patient safety. In particular, the
DUH safety plan is seemingly lacking in terms of the communication culture component.
Meanwhile, multiple sources pointed to the importance of effective teamwork and
communication between the medical team members. For instance, Santa et al. (2018) found
that error feedback and communication quality substantially impact the quality and safety
culture. According to Gunawan and Hariyati (2019), effective teamwork promotes a patient
safety culture. As such, DUH could have improved its Safety Management Plan by adding a
dedicated Teamwork and Communication function.
Patient Safety Officer (PSO): Role and Scope of Responsibilities
DUH has a designated Safety Officer — Dr. Stiegel, who plays a critical role in the activities
under the Safety Management Plan. Dr, Stiegel participates in the DUSC meetings, coordinates
individual functions’ plans with the general patient safety program, and examines
recommendations submitted by the functions’ leaders as a part of risk assessment activity
(DUH, 2022). In this regard, Safety Officer’s role in DUH corresponds with the ASHRM
observation of the patient safety officer’s growing role (2004). Dr. Stiegel coordinates the
whole system, making a crucial impact on the creation of the integrated Environment of Care.
Therefore, his expertise is essential for the timely and correct adjustment of hospital-wide risk
management and patient safety program.
