Environment of Care Performance Specialist - Biological Safety Division

 

Primary Purpose of Organizational Unit: The Occupational and Environmental Safety Office (OESO) provides the focus for the administration of all safety programs to Duke University, Duke University Medical Center, and Duke University Health System. OESO has the responsibility for developing institutional safety plans and policies; providing information and training to meet all regulatory requirements; providing technical consultation and guidance; conducting exposure and risk assessments; conducting safety audits; monitoring compliance with all safety policies; and investigating accidents, injuries, and reported unsafe conditions.

 

Specific to the Biological Safety Division: The Biological Safety Division addresses the safety and well-being of Duke personnel regarding potential occupational exposure to biological materials such as bloodborne pathogens (HIV, Hepatitis B virus, Hepatitis C virus, etc.), Mycobacterium tuberculosis (TB), biologically-derived toxins, recombinant/synthetic nucleic acids, Federal Select Agents and Toxins, etc. This is accomplished through the development and implementation of policies and procedures, safety training and oversight measures that are intended to provide guidance for worker safety when handling biological materials. Current regulatory requirements and safety guidelines inform the development of these measures, enabling a safe and secure workplace.

 

Primary Purpose of Position:  This position serves as a resource for any Joint Commission (JC) Environment of Care (EOC) issues that may be encountered by the Duke University Heath System. This includes surveillance, reports of the results of the surveys, data collection, assurance of compliance, training as needed, development of site-specific safety plans, and review of employee exposures reported to Employee Occupational Health and Wellness for corrective actions.

 

Duties and Responsibilities:

• EOC Performance Specialist will ensure that both ambulatory care clinics and hospital areas are surveyed/audited twice a year, as required by the JC. This will include both conducting surveys and overseeing additional EOC surveyors to assure all areas are reviewed. Responsibility includes interpreting the JC's standards as they relate to Duke.
• The EOC Performance Specialist will evaluate the results of the surveys and provide the details and expectations for both hospital areas and/or clinics that are non-compliant with the JC requirements. This may result in an escalated enforcement scheme involving reports to upper administration for assurance of compliance.
• Conduct mandated EOC audits in the hospital units and departments (Duke University, Duke Regional, and Duke Raleigh hospitals) as well as in the ambulatory clinics (DHIP and DPC) at least twice a year. There are six functional areas designated by the JC: Safety, Security, Hazardous Materials and Waste, Fire Safety, Medical Equipment, and Utilities.
• Provide written reports of the audits to supervisors/managers in these areas.
• Ensure that all hospital units/departments and ambulatory clinics are surveyed for EOC issues by overseeing other safety and health specialists needed to conduct and complete surveys.
• Evaluate the results of the surveys and provide the details and expectations for both hospital areas and/or clinics that are non- compliant with the JC requirements. This may result in an escalated enforcement scheme involving reports to upper administration for assurance of compliance. Any training needs are identified that will bring the area into compliance. Training for management may be provided/recommended.
• Provide quarterly reports of EOC compliance to the Duke University Safety Committee and other committees of the DHIP and DPC.
• Serve as the resource for EOC issues or other safety issues for off-site clinics.
• Develop and update the EOC audit tools for both the clinics and hospital units and departments.
• Develop site specific safety plans for off-site facilities.
• Review ambulatory clinic construction plans and meet with planning committees regarding safety and regulatory standards. Conduct pre- opening assessments of all new space.
• Review employee injury/exposures reported to Employee Occupational Health and Wellness for follow and corrective actions. Review and utilize employee injury/exposure data and trends in targeted trainings as needed.
  
  Other Position Characteristics:

• Failure to manage safety programs properly as required by local, state, or federal regulations could result in significant monetary fines to the institution. In addition, personal civil or criminal liability for gross errors is possible.
• Provides consultative services to OESO division managers and to off-site Health System organizations, such as Duke Regional Hospital and Duke Raleigh Hospital