JCIA 4th Edition

1. Tujuan
2. Sasaran
3. Tugas dan Tanggung jawab
4. Inspeksi fasilitasi
5. Penilaian risiko
6. Progran strategi keselamatan yg dapat dicegah
7. Program strategi keselamatan secara aktif
8. Progran strategi keamanan yg dapat dicegah
9. Program strategi keamanan secara aktif
10. Tanggung jawab Komite safety
11. Monitoring data
12. Pelatihan
13. Evaluasi tahunan

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

PLAN – OUTLINE

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

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

updated)

 Responsible individual designated with scope of authority defined

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

 Risk assessment
o Facility-wide inspection process for current information
o Location of up-to-date building plans (blue prints)
o Risk assessment safety and security using a structured format
 Define process for who and when and how and where reported
(Could be the ongoing hospital building inspection or a more
structured approach)
 Describe how data from risk assessment is used to support goals
for the plan and policy and procedure development
ID, Akses, security, CCTV, Alarm, Key management
Ceritakan apa yang dilakukan
Check list (menjadi lampiran)
 Facility Inspections – periodic

JCI Safety and Security Plan – Outline

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 JCIA 4th Edition

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

PLAN – OUTLINE
o Process defined, frequency (berapa kali), how findings are summarized
and analyzed and findings tracked for improvement. (bgmn hsl temuan
dianalisa dan dibatkan perbaikan). State where facility inspection results
are reported and the frequency of the report. (dilaporkan)
 Define who conducts facility inspections, such as the “safety officer” with clinical
and support staff as part of team, department directors such as directors of
laboratory, radiology, administration. (Tentukan siapa yg melakukan inspeksi)
o Use of checklist for the inspections (attach to plan)
o State how data are used to make improvements (bgmn data dibuat untuk
perbaikan)

 Preventive safety program strategies

o Safety prevention strategies and practices are in place to support safe
environment and comply with law and regulation
 Identify supporting policies and procedures
 Identify country laws/regulatory safety requirements
o Statement about use of periodic safety round inspections to identify and
take to reduce evident risks
 Feedback to department/units and response/corrective action
expectations
 Initiate corrective actions/ work requests/ etc.
 Reporting process – submit aggregate findings to hospital safety
committee

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

o Construction and renovations: Preventive risk assessment and interim

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

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

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

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

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

 Statement that describe integration of employee and patient
safety data (usually from incident reports) integrated into safety
program (reference incident reporting policy)

JCI Safety and Security Plan – Outline

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 JCIA 4th Edition

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

PLAN – OUTLINE
o Integration with Infection Control program data on safety risks 

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

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

 Preventive security program strategies 

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

o Infant abduction drills 

o Security guard procedure 

o Identify supporting policies and procedures 

 Access to hospital 

o Identification of security sensitive areas 

o Control of entrances and exits 

o Check points in hospital 

o After-hours checks 

o Surveillance of locking entrances after hours 

o Reference supporting policies 

 Coordination with local police department 

o Communication, phone numbers 

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

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

JCI Safety and Security Plan – Outline

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 JCIA 4th Edition

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

PLAN – OUTLINE
o Badges for visitors, vendors/ contractors 

o Volunteers identification process 

o Screening visitors, families, vendors after hours 

o Reference supporting policies 

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

o Interior monitoring - corridors/ areas 

o Exterior monitoring - parking lots, garages 

o Security surveillance monitoring area 

 Staffing and back-up tapes


 Active security program strategies 

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

o Security alert codes – see policy 

o Incident reports; format or form 

o Identify supporting policies and procedures for above 

o Reporting and response process 

 To security officer 

 To safety committee 

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

o Reference any document or policy describing the committee

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

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

JCI Safety and Security Plan – Outline

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 JCIA 4th Edition

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

PLAN – OUTLINE
Committee

 Training / education program

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

 Annual program plan evaluation

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

JCI Safety and Security Plan – Outline

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