3.2.01 Occupational health and safety

1 Aim and purpose

Occupational safety is regulated by law and must be implemented accordingly. The management takes all necessary measures to protect employees from health hazards. Health suitability must be checked before tasks are assigned and at regular intervals. The management is responsible for implementing the requirements of radiation protection and hygiene guidelines as well as other safety requirements.

These procedural instructions regulate the responsibilities and procedures for the implementation of occupational health and safety for all employees at the HOSPITAL. It implements the requirements of the legislator, the Employer's Liability Insurance Association for the Health Service and Welfare Care and the accident prevention regulations for occupational safety.

2 Application

All areas of KRANKENHAUS GmbH

3 Description

3.1 Responsibility for occupational health and safety

The managing director is responsible for occupational health and safety. He is supported in this by the operational management (medical director, nursing director, administrative director), the medical directors and the division/department heads of the hospital.

3.2 Regulations on occupational health and safety management

At the KRANKENHAUS, the management has integrated occupational health and safety measures into the comprehensive quality management system in accordance with the requirements of the Employer's Liability Insurance Association for Healthcare and Welfare.

3.2.1 Occupational health and safety mission statement

The hospital's management and employees create a safe working environment that promotes health by taking preventive, comprehensive occupational health and safety into account when designing workplaces and work processes, combined with regular training for our employees.

This occupational health and safety mission statement is part of the hospital's mission statement (see 1.1.01 Hospital mission statement).

3.2.2 Occupational health and safety objectives

By integrating occupational health and safety into our quality management system, the management and employees of the hospital aim to achieve the following goals:

- Setting up and establishing occupational health and safety structures to improve and guarantee a high level of health protection for our employees - Reducing absenteeism and fluctuation, thereby ensuring continuity of service
- Activation of suggestions for improvement in occupational health and safety, e.g. via the occupational health and safety committee
- Fewer disruptions to operational workflows by increasing employees' personal responsibility
- Increased legal certainty through systematic identification and implementation of the relevant regulations

3.2.3 Evaluation of occupational health and safety management

The quality management officer and the occupational safety specialist prepare an annual report on the working methods and results of occupational safety activities. (see VA 3.1.12). The records mentioned under point 4 can serve as a basis.

The Managing Director has instructed the Deputy Head of Administration in writing to implement and monitor the occupational health and safety measures.

The deputy head of administration evaluates the effectiveness of the management system on the basis of the report. Any improvement measures that arise are developed in the health and safety committee. Their implementation is monitored by the health and safety committee.

3.3 Legal basis

The statutory and trade association regulations listed in Annex 2, as amended, must be observed for occupational health and safety.

This applies in particular to the following regulations and rules cited in Appendix 2 of the BGV A1 "Principles of Prevention" and in the "Risk Assessment at the Workplace" guidelines of the North Rhine-Westphalia Occupational Health and Safety Administration:

Legal texts and regulations are kept up to date by the occupational safety specialist. Accident prevention regulations are made accessible via the list of "recognized rules" by linking to the BGW media service.

3.4 Occupational health and safety organizational structure

3.4.1 Tasks and responsibilities of managers

The hospital's managers are responsible for fulfilling the following tasks within their area of responsibility. The tasks are assigned to the functions in the task descriptions.

- Implementation of the occupational health and safety organization
- Transfer of responsibility, authority and tasks to subordinate employees (in writing, e.g. in the form of task descriptions)
- Implementation of the process organization regulations (see subsection 3.6)
- Cooperation with the occupational safety specialist, the company doctor and the safety officers
- Identify employees' training and qualification needs and select appropriate measures
- Establishment of a training and qualification program - Provision of funds for training and for investment measures relevant to occupational health and safety, e.g. ergonomically correct office equipment
- Arranging or ensuring instructions and (initial) briefings and monitoring their implementation and effectiveness
- Conducting employee appraisals - Organizing/conducting and participating in site inspections - Creating operating instructions
- Arranging, ensuring and monitoring the safety inspection of technical work equipment in the respective area of responsibility
- Organizing the communication channels and methods as well as the reporting and documentation system in the respective area of responsibility
- Informing employees about health and safety regulations in connection with the respective activity
- Check compliance with legal regulations and internal specifications on occupational health and safety
- Checking that employees and representatives in the area of independence are fulfilling their duties

3.4.2 Occupational health and safety representatives

The Managing Director appoints the special representatives in writing:

• System representative for the occupational health and safety organization
• Company doctor
• Occupational safety specialists
• Head representative
• Safety officer
• First aiders in non-medical areas

e.g. administration, technology, central laboratory, commercial operations, central laboratory

• Waste manager
• Fire safety officer
• Hazardous substances officer
• Dangerous goods officer
• Hygiene officer
• Laser safety officer
• Radiation protection officer (managing director)
• Radiation protection officer

The tasks of the officers are described in more detail in the job descriptions.
The tasks relating to occupational health and safety should be specified in each job description.

3.4.3 Tasks of the employees

Employees are obliged to take care of their health and safety at work to the best of their ability and in accordance with the instructions of those responsible. This includes the immediate reporting of immediate hazards or safety deficiencies as well as accidents at work, on the job or on the way to work to those responsible.

3.4.4 Tasks of the special representatives

Occupational safety specialist	7.5.10
Company doctor	7.5.12
Safety officer	7.5.11
Laser representative
Head representative	7.5.35
Dangerous goods officer	7.5.13
Hazardous substances officer	7.5.36
Fire protection officer	7.5.37
Waste manager	7.5.19
Hygiene officer	7.5.38
Radiation protection officer	7.5.39

3.4.5 Coordination of occupational health and safety management

In cooperation with the above-mentioned special representatives, the occupational health and safety organization representative is assigned the task of maintaining the effectiveness of the occupational health and safety management system. He is responsible in particular for
- Identifying and rectifying errors in occupational health and safety
- Organization and implementation of corrective measures in occupational health and safety
- Organization and implementation of improvement measures in occupational health and safety
- Control of documents in occupational health and safety
- Control of records in occupational health and safety
- Organization and implementation of occupational health and safety audits
- Organization and maintenance of the effectiveness of monitoring and measuring equipment in occupational health and safety
- Advising the management on the implementation and maintenance of the continuous improvement process
- Supporting the management in the preparation of the management review
- Cooperation with the quality management officer and collaboration in the integration of occupational health and safety management
- Regular reporting to the Managing Director on the implementation and effectiveness and any problem areas of occupational health and safety management

3.4.6 Employee representation

The employee representative body is involved in the implementation of existing laws, regulations and guidelines on occupational health and safety. For details, see VA 1.3.20 "Employee representation".

3.4.7 Radiation protection officer/officer

The implementation of the Radiation Protection Ordinance and the X-Ray Ordinance as well as the assignment of responsibilities and tasks for the radiation protection officer and the radiation protection officers are the subject of the "Radiation Protection Instruction" VA 3.2.6 in the QM Manual.

3.4.8 Health and safety committee and working groups

- Occupational health and safety committee
The Occupational Health and Safety Committee discusses matters relating to occupational health and safety at work. It meets at least once every three months.
The rules of procedure of the health and safety committee are annexed to the Health and Safety Committee * * Health and safety circles
e.g. working group to revise care standards, quality circles after integration of occupational health and safety into the job description

3.4.9 First aid and emergency organization

First aiders are appointed in the non-medical areas. There is a list of departments in which a first aid book is kept. Alarm and rescue plans are in place in all areas of the hospital. The contact point for medical emergencies is the surgical outpatient clinic. The contact point for technical emergencies, e.g. power failure or gas leakage, is the technical department.
The fire safety officer is responsible for drawing up fire protection, escape and rescue plans, including carrying out any necessary training and drills. The organization of preventive fire protection and the responsibilities are defined in VA 3.4.02 "Fire protection" and in the hospital's fire protection regulations.

3.5 Process organization occupational health and safety

The process organization concerns the regulation of the chronological sequence of the tasks defined and assigned in the organizational structure. The process organization in occupational health and safety at St. Katharinen-Hospital is designed using procedural instructions, work instructions, checklists and forms of the quality management system. They are compiled in Appendix 1. The focal points are

the risk assessment	3.2.13
the handling of hazardous substances	3.2.12
Occupational health and safety measures during procurement	3.2.01
Testing of technical work equipment	3.4.18
Occupational health care	3.2.09
Operation under emergency conditions	3.1.17
Procedure after accidents at work	3.2.03
Operating instructions	3.2.08
Instructions	3.2.02
Organization and implementation of meetings	4.2.01
Cooperation between the company doctor, occupational safety specialists and employee representatives and with management	4.2.20

The following procedural instructions also have an impact on the organization of occupational health and safety:

Internal audits	3.7.10
Inspections	3.7.14
Control of documents	4.1.09
Control of records	4.1.01
Control of errors in occupational health and safety	5.3 "Dealing with adverse events"
Procurement	3.5
Corrective measures	5.4.03
Preventive measures	5.4.03

Edit

4 Documentation

List of authorized representatives
Order letter to the managing director
Occupational health and safety records required by the QM system:
- List of legal regulations
- Occupational health screening (with the company doctor)
- Protocol and report Hazard analysis with evaluation of work processes and action plan to eliminate the hazards
- List of hazardous substances, proof of substitution check
- Instruction/instruction documentation
- Training/education programs
- Training documentation, qualification certificates
- Proof of testing of technical work equipment, test books
- Minutes of the Health and Safety Committee
- Accident reports
- Register entries
- Inspection logs
- Protocols of the fire safety officer
- Fire department fire prevention inspection logs
- Register of fire extinguishers
- Protocols of the occupational safety specialist
- Information sheets from the company doctor

5 Resources

Time required Managing Director
Time required Administrative Director
Time required by division/department heads
Time required by managers
Time required Occupational safety specialist
Time required by external consultants
Time required by safety officers
Time required by other representatives
Time required by company doctor
Office and room equipment Company doctor
Company doctor's office Office and room equipment Occupational safety specialist
Secretariat Occupational safety specialist

6 Responsibility, qualification

Occupational safety specialist, company doctor with specialist knowledge Safety officer with specialist knowledge

7 Notes and comments

8 Applicable documents

8.1 Literature

Quality management with integrated occupational health and safety MAAS-BGW brochure Commentary on MAAS-BGW

8.2 Terms

Special representatives
Persons who have been appointed in writing by the managing director on the basis of legal or trade association requirements to perform specific tasks defined in occupational health and safety legislation. These tasks can be legally relevant, i.e. with the assumption of partial legal responsibility, e.g. waste management officer, or purely advisory in nature, e.g. safety officer. Class 3B laser
Class 3 B lasers are devices or systems that generate electromagnetic radiation that is dangerous to the eye and, in special cases, to the skin

9 Systems

Appendix 1: Overview of the requirements of the QM management system for occupational health and safety in accordance with the rules of the German Social Accident Insurance Institution for the health and welfare services

Overview

Written specifications required by qu.int.as	Comments on the assignment GHP ®
Occupational health check-ups	3.2.09
Procurement processes for equipment, tools and aids	5.5.05
First aid and emergency management
Risk identification and assessment	3.2.12
Determination and implementation of regulations, rules and official requirements	1.1.04
Regular testing and maintenance of devices	3.4.30ff
Identification and handling of hazardous substances	3.2.12
Documents required according to qu.int.as
Current organization chart of the hospital	3.1.02
The hospital's guidelines on occupational health and safety	insert
Management policy statement on occupational health and safety	dto
Occupational health and safety goals of the hospital	For Q-targets
Resource plan for implementing the occupational health and safety objectives
Audit program	3.7
Specifications for the destruction of records	4.1.24
Records cited in the qu.int.as manual
List of relevant rules and regulations	9
List of relevant documents and records	Table of contents
Determining the occupational health and safety requirements of the hospital's insured persons Records e.g. completed questionnaires Evaluation protocols	1.3.20, 1.3.22
Records for the evaluation of occupational health and safety management	3.1.12
Records of training and further education Instruction documentation, protocols Certificates of attendance, special training courses Special skills e.g. IT training Qualification certificates, certificates of competence Certificates of competence, e.g. as an electrician Welding license, forklift license, driving license for company vehicles Operating licenses according to BG regulations, e.g. for cranes for winches, lifting and pulling devices etc.	1.3.12
Familiarization plans Familiarization concepts and records of their implementation	1.3.08
Records of preventive occupational health care Examination plan, certificates of professional suitability Vaccinations, medical record, health file	3.2.09 - 3.2.11
Records of the risk analyses in accordance with ArbSchG GefStoffV, BioStoffV, BetrSichV, LasthandhabV, MedBetreibV BildschirmarbV etc.	3.2.13
Records of the implementation of the measures defined there	3.2.13
Protocols for the active participation of employees in occupational health and safety in the hospital Suggestion scheme, dealing with employee complaints
Records on the integration of occupational health and safety into the work processes and activities of the hospital (Structural and procedural organization: proof of a systematic approach)	2.3.01 ff
Records of monitoring and testing activities Test logs, maintenance logs, release regulations after maintenance work	5.1 or 3.4?
Device manuals, operating instructions from the manufacturer of all relevant technical equipment	3.4
Records for the integration of occupational health and safety aspects in the procurement process, criteria catalog, incoming goods inspection Avoidance of confusion	3.5
List of hazardous substances, records of substitute substance testing Operating instructions for hazardous substances, safety data sheets for all identified hazardous substances	3.4.60
Measurement protocols for hazardous substances etc.	5.1
Test protocols for monitoring the measuring equipment, calibration protocols, calibration certificates	5.1
Minutes of internal audits, audit reports	3.7
Records for evaluating the occupational health and safety organization of the hospital by the management	3.1.12
Instruction on the keeping of association books, association books in all care and functional areas Description of first aid measures	3.2.18
Accident statistics, evaluation of the association books	3.2
Procedural instructions for the evaluation of events with and without Personal injury and near misses	3.2
Procedural instructions for defining measures and tracking the implementation of these measures (corrective measures)	3.2
Written determination to evaluate the effectiveness of the measures (preventive measures)	3.2
Invitations and minutes of the Health and Safety Committee with determination of Improvement measures and monitoring of implementation and effectiveness	3.2.15
Instruction plan and training plan	1.3.12
Job/task descriptions : Integration of occupational health and safety tasks in the job/task descriptions, assignment of responsibilities Responsibility matrix	1.3.3
Records of transfers of duties
Invitations to works meetings and minutes thereof	1.3.20
Specifications on cooperation with the company doctor and the MAV	1.3.20
Letter of appointment for the company doctor, the occupational safety specialist the safety officers, the hygiene officers, the doctor responsible for hygiene the QM officer, the hazardous goods officer, the medical devices officer Head officers, fire safety officers and other officers with tasks in occupational health and safety	3.2.09
Operating instructions, operating manuals for after the risk assessment Technical work equipment with hazard potential	3.2.08
Functional descriptions for the company doctor, the occupational safety specialist the safety officers, the hygiene officers, the doctor responsible for hygiene the QM officer, the hazardous goods officer, the medical devices officer Head officers, fire safety officers and other officers with tasks in occupational health and safety, e.g. the waste management officer	1.3.3
Checklist for ladders and steps	3.7
Reporting protocols to StAfA, BGW, health authorities etc. about adverse events	5.3.8
Proof of compliance with official reporting obligations, e.g. when handling carcinogenic substances, when handling medical devices	5.3.8
Records of internal communication: circulars, intranet, notices Service instructions, management meetings, team meetings, quality circles Specialist working groups, patient information, etc.	4.2. miscellaneous
Records of inspections relevant to occupational health and safety, e.g. according to AsiG Inspections by the management, the occupational safety specialist the company doctor, the safety experts, the department and ward managers	3.2 miscellaneous
Records for the implementation of the Narcotics Act (control, key management) and the Pharmacy Operating Regulations (checking the expiry dates of medicines)	3.5.16
Selection procedure for external companies, notification procedure for external companies Instruction of external companies with proof of instruction, monitoring of external companies	3.5.06
Clearance certificates for hazardous work, e.g. welding work or Work involving a risk of falling or work on electrical systems.	3.5.07
Protocols for temperature monitoring when storing temperature-sensitive medicines and foodstuffs	3.5.11
Escape and rescue plan, alarm plan, fire protection regulations, disaster control plan	3.4.02 3.1.17/18