Office of Research: Environmental Health and Safety

Joint Commission on Accreditation of Healthcare Organizations

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) conducts periodic inspections of institutions that provide healthcare services to the public including UCSF Stanford Healthcare and Langley Porter Psychiatric Institute. The healthcare organization is inspected and results are compared to JCAHO standards. The evaluation includes a review of written documents provided by hospital administration, a building tour to observe physical aspects of the facility, and staff interviews to determine how programs described in the written documents are implemented. The surveyors assimilate information gathered during the inspection and make one of seven accreditation decisions for each organization:

1. Accreditation with Commendation

2. Accreditation

3. Accreditation with Type I Recommendations

4. Provisional Accreditation

5. Conditional Accreditation

6. Preliminary Nonaccreditation

7. Not Accredited

The Office of Environmental Health and Safety, the UCSF Stanford Healthcare Environment of Care Committee, and the Langley Porter Psychiatric Institute Safety Committee have implemented a program to address the JCAHO titled the Management of the Environment of Care. This standard defines criteria that, if implemented, will provide a safe, functional, and effective environment for patients, staff members, and visitors. JCAHO expects that the healthcare organization will have a management plan and processes in place to address:

  • Safety Management
  • Security
  • Hazardous Materials and Hazardous Waste Management
  • Emergency Preparedness
  • Fire and Life Safety
  • Medical Equipment Management
  • Utility Systems Management

OEH&S provides technical support as administrative policies and procedures are developed and implemented to meet the requirements of both JCAHO standard and environmental health and safety regulations. Some services provided by OEH&S to support the Environment of Care Program are:

  • Member of the Environment of Care Committee and Safety Committee that ensures that JCAHO issues and environmental health and safety regulations are addressed.
  • Serve on Subcommittees and Task Groups Develop and develop programs to address the Environment of Care.
  • Conduct inspection rounds as part of the inspection team.
  • Member of the training team that provides new employee orientation on a monthly basis.
  • Provide Annual Safety Review training to all employees to maintain and improve the knowledge and skills on environmental health and safety issues.
  • Manage Employee Exposure Monitoring Programs to evaluate employee exposures to chemicals and radiation.
  • Manage the pick up and final disposal of radioactive, chemical, chemotherapy, and medical wastes.
  • Conduct respirator fit tests and train employees on the use of respiratory protection when it is required to protect employees from airborne hazards.