Ohio Admin. Code 3364-60-02 - Safety and health management

Current through all regulations passed and filed through September 3, 2021

(A) Policy statement

The university of Toledo shall have a safety and health management plan in order to manage safety risks.

(B) Purpose of policy

To meet the mandates set forth by local, state and federal governments and relevant regulatory agencies including but not limited to the joint commission, environmental protection association "EPA," centers for disease control and prevention "CDC," occupational safety and health administration "OSHA," national fire protection association "NFPA," department of transportation "DOT," and department of homeland security "DHS." To provide for the safety, health and well-being of patients, staff and the public by creating an environment of care free of hazards.

(C) General overview

The safety management plan describes how the organization will provide physical environment free of hazards and manage staff, faculty, student, patient, visitor and volunteer activities to reduce the risk of injuries. The university identifies these risks and plans and implements processes to minimize the likelihood of those risks causing incidents.

(D) Development of plan
(1) Develop and maintain a written management plan describing the processes it implements to effectively manage the environmental safety of staff, faculty, students, patients, visitors and volunteers coming to the university facilities.
(2) Buildings on the campus are constructed in accordance with all applicable fire and building codes, so as to ensure compliance with all requirements regarding fire egress and exits, construction materials, corridor width and electrical safety.
(E) Roles and responsibilities
(1) The environmental health and safety department is to identify a person(s) to intervene whenever conditions immediately threaten life or health or threaten damage to equipment or buildings: the president of the university of Toledo and/or her designee have appointed the chairmen of the university of Toledo safety and health committees, or his/her designees, to fulfill this responsibility.
(2) Conduct proactive risk assessments that evaluate the potential adverse impact of buildings, grounds, equipment, occupants and internal physical systems on the safety and health of staff, faculty, students, patients, visitors and volunteers coming into the institution's facilities.
(3) Identify risks and select and implement procedures and controls to achieve the lowest potential for adverse impact on the safety and health of staff, faculty, students, patients, visitors and volunteers coming to the hospital's facilities.
(4) Through proactive risk assessments the environmental health and radiation safety department identifies risks to individuals and structures on campus and make recommendations to lower or eliminate these risks on campus.
(5) Establish safety procedures, plans and programs that are distributed, practiced, enforced and reviewed on a regular basis.
(6) Ensure that all grounds and equipment are maintained appropriately:

Environmental safety rounds, facilities maintenance routine preventive maintenance in accordance with manufacturers' warranty recommendations, and department-specific inspections of equipment accomplish this goal, in addition to the grounds department's daily scrutiny of any problems with university grounds; adherence to institutional safety procedures that address the use of equipment also assure compliance with this requirement.

(7) Executive leadership supports the safety and health program by assuring the formation and development of the university safety and health committees.
(8) Administration also supports the safety and health program by appointing an employee who will act as the director of environmental health and radiation safety.
(9) The director of environmental health and radiation safety is authorized to take immediate action when a condition exists that poses an immediate threat to life, safety and/or property. All such action is to be reported by the director to his/her supervisor as soon as possible following the incident.
(10) Conduct safety and health programs including:
(a) Safety and health management;
(b) Fire prevention/life safety;
(c) Emergency management;
(d) Hazardous materials and environment.
(11) The director of environmental health and radiation safety is responsible to:
(a) Report safety and health activities to the public safety officer, the board of trustees or governing body, and makes reports, as applicable, to department managers. The director further reports to the university safety and health committees the results of ongoing monitoring, actions taken or actions proposed, and follow-up recommendations.
(b) Participates in incident/accident investigation and reporting; facilitates the development of hospital-wide safety and health policies and procedures, and ensures that these policies and procedures are reviewed as needed but at least every three year.
(c) Participates in the organization, development and implementation of an ongoing safety education orientation program, and is responsible for assessing the effectiveness of that program.
(d) Collect and evaluate information on safety issues, concerns and problems, and communicates this information as needed to the appropriate department chairman, directors, managers, or supervisors.
(e) Receive and evaluate summaries and reports of activities related to safety, fire prevention/life safety, medical equipment, utility systems, security/campus police, emergency management and hazardous materials.
(f) Ensure that policies are in place for maintaining all grounds and equipment, for conducting risk assessments on various elements, such as grounds, equipment, buildings and internal physical systems, and their impact on patient and public safety (this is done through analysis of campus police reports and occurrence reports through the OSHA three hundred illness and injury log); for seeing that all incidents of property damage, occupational illness and patient, personnel or visitor injury are reported and investigated (these issues are handled by a three-pronged approach between risk management, campus police and environmental health and radiation safety, by which the appropriate department handles crimes against persons: campus police; illness in the workplace: safety and health; and personnel and visitor injury: risk management and safety and health, via the occurrence reporting system, and the OSHA three hundred illness and injury log system).
(F) University of Toledo safety and health committees
(1) There currently are two safety and health committees at the university of Toledo, one for the health science campus and one for all of the other university campuses.
(2) A multi-disciplinary team comprised of representatives from administration, laboratory research, departmental directors, managers and supervisors from a variety of institutional and academic departments.
(3) The university safety and health committee meets regularly to review, discuss and vote as needed on issues that impact the safety, health and well-being of patients, staff, faculty, visitors, volunteers and students.
(G) Conduct a process of hazard surveillance (called environmental safety rounds at the university) on a regular basis, with various in-house expert staff evaluating the areas toured for safety problems.
(H) Responsibilities of department/lab managers/directors
(1) The ultimate responsibility for the development and maintenance of current department standard operating procedures related to safety and health shall lie with individual department/lab managers/directors with the assistance of the director of environmental health and radiation safety and other environmental health and radiation safety department personnel as needed/appropriate.
(2) Assure that new employees are properly educated and have attended new employee safety orientation. The safety orientation and education program will address:
(a) General safety processes;
(b) Area-specific safety;
(c) Specific job-related hazards;

(d) Provision of safety related information through distribution of written safety orientation materials at each orientation session;

(e) (d) Provide documented continuing education on departmental/lab-specific safety policies and procedures annually;
(f) (e) Stimulate and encourage employee interest and participation in the safety and health program at the university;
(g) (f) Assist in any way possible with the investigation of any injuries that occur within their department/lab;
(h) (g) Continually work to ensure that unsafe conditions are identified and eliminated;
(i) (h) Assist in monitoring safety recommendations pertaining to the specific department.
(I) Employee, faculty, student, and volunteer responsibilities
(1) To cooperate in making a safe environment by attending safety education training as necessary and to obey all posted safety information.
(2) Required within established time periods, reporting and documenting all incidents or injury and near-injury, and reporting unsafe conditions immediately to their immediate supervisor, the environmental health and radiation safety department (419-530-3600), or to campus police (419-530-2600).
(J) Joint commission annual reporting and evaluation
(1) The scope, objectives, performance and effectiveness of the safety and health management plan will be evaluated in an annual report to administration and shared with the board of trustees.
(2) Evaluation will include all areas of safety management.
(3) Performance monitors will be identified that will assist in the overall management of safety. These monitors will be tracked and trended in order to determine the overall effectiveness of the safety program.


Ohio Admin. Code 3364-60-02
Effective: 9/8/2020
Promulgated Under: 111.15
Statutory Authority: 3364
Rule Amplifies: 3364
Prior Effective Dates: 05/12/2018

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