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Joint Commission on Accreditation of Healthcare Organizations
Emergency Response
Director/Committee Chairperson
Security Management Plan

JCAHO Police and Security Website Information


Joint Commission on Accreditation of Healthcare Organizations

What is JCAHO?

  • JCAHO is the acronym for Joint Commission on Accreditation of Healthcare Organizations.
  • JCAHO is an independent, not for profit organization that evaluates and accredits healthcare organizations throughout the United States to help assure the quality of care provided to the public.

Why is JCAHO accreditation important to us?

  • It provides MGH an opportunity to demonstrate our continued commitment to patient care and provides a means for the public to have access to and understand the excellent services we provide for them.

Why do we in security need to prepare for this survey?

  • National hospital security incidents such as violence in the workplace and infant abductions have forced JCAHO surveyors to prioritize scrutiny of security standards.
  • Employee, visitor and patient safety have become a priority of the Environment of Care.
  • A great opportunity to show that MGH has an excellent security program.

How do we prepare for the survey?

  • The FYI Campaign: Preparing for the JCHAO 2006 Survey (Orange flyers)
  • Police and Security website
  • Quarterly presentations
  • Monthly presentations
  • Documentation review to comply with the JCAHO Environment of Care security standards.

What is the “Environment of Care (EOC) standards?

  • EOC refers to the standards of providing a safe functional and effective environment of care for the patients, visitors and staff.
  • Applies to all buildings, equipment and conditions at all sites which patients receive care.
  • EOC standards cover seven areas: safety management, security management, hazardous materials and waste management, emergency management, fire safety, utility management and equipment management.

What is ICES? How do we use this to improve our department?

  • ICES stand for Information Collection and Evaluation System.
  • We prepare an incident report documenting any incident either reported to our department or identified by our department.
  • On a daily basis the reports are monitored by the Director, Special Investigations Manager, Operations Manager and the Systems Manager to ensure that the report is complete, identify follow-up steps, and identify countermeasures that need to be taken.
  • The information form this report is then put in to the IRIMS (Incident Reporting Information Management System) database and a daily overview report of incidents is made and disseminated to members of Administration, Safety Committee, etc.



What is the mission of the MGH?

  • To provide the highest quality care to individuals and to the local and distant communities we serve, to advance care through excellence in biomedical research, and to educate future academic and practice leaders of the health care professions.

What is the mission of the MGH Police & Security Department?

  • The mission of the Massachusetts General Hospital Police and Security Department is to provide protective services to the MGH Community in a professional and supportive manner.

What is our role at MGH?

  • Our role in the Police and Security Department is to provide protection and service in order to support the hospital’s mission of excellence in patient care, research and teaching.


Emergency Response

What is the hospital’s approach to responding to emergencies—either internal or external?

  • The MGH has had a disaster preparedness plan in place for many years and has recently taken significant steps to modify and enhance our disaster response plans to better prepare for any type of internal or external incident.
  • The MGH Emergency Management Committee leads these efforts and Craig Cochran, who is a full-time staff person dedicated to ensuring the hospital’s emergency response program is in place.
  • The success of the emergency management program is dependent upon participation from all hospital departments.

What is HEICS?

  • Hospital Emergency Incident Command System.
  • HEICS is meant to improve the hospital’s command structure used during a crisis, so that it corresponds to other emergency response agencies such as local fire and police departments and emergency medical services.  

How does HEICS work?

  • HEICS engages a management structure with defined responsibilities of key personnel; clear reporting channels and the use of common terminology to help unify hospital staff with other emergency responders.
  • Organized with four sections: logistics, planning, finance and operations. Each reports to the emergency incident commander.
  • Each section has an appointed chief who designates directors and unit leaders to fill certain job responsibilities with supervisors and officers filling in other crucial roles.
  • This structure limits the span of control for each manager to distribute the workload more effectively during a disaster.

What other modifications are being made to the hospital’s disaster preparedness plan?

  • More information about bio-terrorism and hazardous material contamination responses.
  • Uses JCAHO recommended guidelines created in the aftermath of 9/11.
  • Departmental disaster response plans have been revised and are now more accessible in the event of an emergency.
  • The new format includes a summary of what each department is responsible for when a disaster is declared in addition to the full departmental plan.

What is the hospital’s new code identification system?

  • Will improve the way employees identify an emergency for a fire or cardiac arrest.
  • During a Code Blue for cardiac arrest, Code Red for a fire, or Code Disaster (internal, external) employees can call a simplified phone number 617-726-3333.
  • Using this system for codes and other stat calls, the appropriate response team can be notified immediately.
  • Other institutions and agencies nationwide also utilize these codes.

What does emergency preparedness mean for MGH employees and staff?

  • Employees and entire departments play a critical role in the MGH response plan.
  • Individual and department roles remain generally the same as in previous disaster response plans.
  • A copy of Police and Security’s role is located at each communications center.

What is the role of security in a disaster situation?

  • In accordance with HEICS protocol, the Director of Police and security or designee provides direct support and consultation to the Incident Commander.
  • Primary functions include: crowd control; media control; traffic control; employee, patient, visitor and Professional staff access control at various points of entry.
  • Providing communications liaison with outside agencies and the internal disaster team.

What is security’s role in Life Safety? (Life Safety is the fire safety program)

  • Respond to life safety emergencies.
  • Report fire safety hazards.
  • Provide Interim Life Safety Measures patrols.

What is security’s role in a hostage situation?

  • We would contact the Police Department (911).
  • Contact the MGH Hospital Administration and senior security staff upon notification of a hostage situation.
  • Control access to the area so that others would not enter the area under siege.
  • Provide the police response team with assistance such as information about the building, hostages, hostage taker, availability of utilities, telephones etc.
  • A member of Police & Security will document the incident with a security incident report.

What is the security’s role in a bomb threat situation?

  • We would contact the Police Department(911).
  • Provide access control.
  • Assist as part of search teams identifying any suspicious package.
  • Assist in evacuation of area as needed.
  • A member of Police & Security will document the incident with a security incident report.

What is security’s role in a chemical spill situation?

  • Assist anyone injured.
  • Cordon off the area to prohibit others from entering the affected area.
  • Assist emergency personnel trained to respond to the spill.
  • A member of Police and Security will document the incident with a security incident report.

Where is the disaster manual kept?

  • Copies of the Disaster Manual are kept at the Dispatch Center in the main campus and at CNY, Murphy Green Conference Room, Director’s office, and the Operations Room.

Have you read the role of Police and Security in the disaster manual?

  • All Police and Security staff is required to read, understand and be competent in the role of the Police and Security Department in a disaster situation.
  • Every employee should know the expectations and functions of the dispatcher, supervisor, and various assignments during a disaster.



How often do we receive an annual performance appraisal?

  • Annual evaluations are done annually on the Hire Effective Date (HED).
  • Feedback on performance is done throughout the year.

Do you have a job description?

  • Employeeshave access to their job description at anytime.
  • A copy of the job description is also provided at the performance evaluation.

Where are personnel files located?

  • There are two sets of personnel files (hospital and Departmental).
  • One is kept in Human Resources ( Merrimac Street).
  • One is kept in the Administration Office (Clinics basement).

Who has access to personnel files?

  • The Director, Manger, Supervisor, and the employee.
  • Appointments can be made to view your file.


Director/Committee Chairperson

Who is responsible for security?

Bonnie Michelman is responsible for Police and Security at MGH.

  • The President and Chief Executive Officer Dr. Peter Slavin and Senior Vice President Dr. Jean Elrick has designated Bonnie Michelman CPP, CHPA with the responsibility of developing, implementing and monitoring the Security management Program.

Who is the Director of Safety?

  • Robert Castaldo is the Director of Environmental Health and Safety.
  • His office is located in the West End House basement.   

Who is chairperson of the Safety Committee?

  • Maryanne Spicer, the Corporate Director of Compliance is the chairperson of the Safety Committee.

What departments are members of the Safety Committee?

  • Safety Department · Radiation Safety
  • Police & Security · Nursing
  • Administration · Legal
  • Biomedical Engineering · Environmental Services
  • Buildings & Grounds


Security Management Plan

What is a Security Management Plan?

  • A Security Management Plan describes how an organization develops and maintains a security management program to protect staff, patients and visitors from harm.

What are your Performance Standards?

  • 65% of Police and Security Officers cross-trained at a minimum of one other site.
  • Increase crime prevention programs to reduce theft by 10%.
  • Increase the Community Policing program by 10% .

Define High Risk or Security Sensitive Areas?

  • Areas of vulnerability based on threat assessment, past history of incidents and potential loss.

What areas at MGH are deemed high risk?

  • Emergency Department · Pharmacy
  • Cash handling areas · Main Lobbies
  • Labor and delivery/Mother and Child Center · Psychiatry Services
  • Women’s health Service · Information Systems
  • Health Information Management · Research Laboratories

What are the goals of the Department as outlined in the Security Management Plan?

  • Protection of Life and Property.
  • Prevention of Criminal/Illegal/Unethical Activity or the Violation of Protocol.
  • Detection and Investigation of Criminal Activity or the Violation of Protocol.
  • Apprehension of Offenders.
  • Maintenance of Public Order.
  • Provide Patient Assistance, Restraint, and Safety.
  • Recovery of Property, Lost and Found.
  • Crime Prevention.
  • Training and Development of Staff.
  • Compliance to Ethical Standards.
  • Vehicular and Pedestrian Traffic Control.
  • Community Relations and Community Service.
  • Department Administration
  • Service Support, Medical Support and First Responder Functions.

Describe the role and responsibility of each position within the hospital in respect to maintaining a safe and secure environment?

  • An essential element of the Security Management Plan is that there is shared responsibility of the protection of people and assets.
  • It is the responsibility of every employee to perform their duties in accordance with the policies and procedures of the Hospital.
  • Employees must safeguard the assets in their care and report any suspicious activity.

The roles and responsibilities are as follows:

  • The Administration of the Hospital will provide leadership for the Security Management Program. Provide resources to ensure a secure environment, monitor the effectiveness and continuous improvement of the program.
  • The Director of Police and Security develops and evaluates programs to protect patients, staff, visitors and assets of the Hospital and satellite facilities. The Director serves as the primary internal security advisor for the Hospital and ensures that the policies, procedures, systems and programs are in accordance with accepted standards.
  • Department Directors, Managers and Supervisors are responsible for the security within their departments with the assistance of the Police and Security Department. They are responsible to et the example and ensure that the policies and procedures are adhered to.
  • The Managers of the Police and Security Department are responsible for the operation of their functional areas of the department. They assist in planning, developing and implementing departmental goals, direction and policy. The Department Managers are responsible for overseeing a process of continual improvement in performance.
  • The Supervisors of the Police and Security Department are responsible for the day-to-day operation of an assigned shift; oversee selection assignment and discipline of personnel. Ensure that the daily functions of the department are carried out.Security Officers of the Police and Security Department are responsible for providing a safe and secure environment for patients, staff and visitors by enforcing hospital policy and state laws. Provides emergency response, patrol functions identifies unsafe conditions, investigates complaints of wrongdoing, provides escorts, assists in patient restraints, opens doors.
  • Employees are responsible to perform their duties in accordance with the policies and procedures of the Hospital. Report any suspicious person or incident, cases of vandalism, loss of valuables or hospital property to the Police and Security Department immediately.
  • A monthly, quarterly and annual report is generated and examined for crime trends and patterns.New procedures and deployment are initiated, partially based on the analysis of these reports.
  • Prioritized patrols, BOLO’s, workplace violence training, crime prevention activities, physical security systems, and the bike patrol program have been initiated as these countermeasures to the analysis from our Information Collection and Evaluation System.

Why is it important that we have a vehicular access and traffic control plan?

  • One of the JCAHO standards within the Security Management Plan is that all hospitals must have a plan to ensure that emergency vehicles (ambulances, police vehicles, and fire department vehicles) have direct access to the Emergency Department. Not only JCAHO, but also during anytime there is an emergency and/or disaster. See Traffic Control Policy in our Policy and Procedure Manual.



What training do you have to complete for your job?

  • New Employee Orientation
  • Service MGH
  • On-the-Job Performance Based Training
  • First Responder
  • Private Security Training Network (PSTN) Officer Course
  • CPR
  • International Association of Healthcare Security and Safety (IAHSS) Security Officer Course
  • Universal Precautions
  • Fire Safety
  • OC
  • Management of Aggressive Behavior ( MOAB)
  • Handcuff
  • Patinet Restraints

What is the process of new employee orientation for your department?

  • Mandatory new employee orientation (1.5 days MGH & 3.5 days Dept).
  • OJT Training (with a Training Officer).
  • Competency based training before end of orientation process.



What kind of security issues do you deal with at MGH?

  • Threats and harassment
  • Domestic violence
  • Theft
  • Medical assistance (restraints).
  • Activism
  • Disasters
  • Drug issues
  • High risk areas
  • Workplace violence

What is the MGH policy regarding restraints?

  • A restraint is used only at the direction of a Physician or Nurse.
  • The patient must be a risk of causing harm to themselves or others.
  • Least restrictive measures are ineffective or inappropriate.
  • The restraint is clinically appropriate and adequately justified.
  • The restraint is considered the least restrictive method of restraint that meets the patients assessed needs.

What is the security’s role in a restraint situation?

  • Upon an order from a physician the security officer(s) will provide seclusion and apply restraints.
  • Use the least amount of force necessary.
  • Use measures to protect the rights, dignity, safety and well being of the patient.

What is security’s role in finding an eloped or missing patient?

  • Conduct a search of hospital property until patient is found.
  • Gather any additional information about the patient that will be helpful toward finding the patient.
  • Assist staff in notifying the appropriate Police Department.

How do you report a Safety Issue?

  • Notify the Safety Office at 726-2425.
  • If immediate assistance is needed, page the Safety Department. A Safety representative is on call 24 hours / 7 days.

What is the policy on identification badges?

  • All employees will display their MGH photo identification badge at all times while on MGH property.
  • The following is description of individual badges that can be obtained:

- MGH White Badge (no patient contact)
- MGH White Badge with Blue block outlining picture (patient contact)
- MGH Blue Badge – Bulfinch employee
- MGH Blue Badge with Black block outlining picture (patient contact)
- MGH White Badge with Red block outlining picture (OB Nursing)
- MGH Green Badge - Contractor Badge (non employee)
- MGH Gray Badge – Volunteer
- PHS White Badge (no patient contact) with their logo
- PHS White Badge with blue block outlining picture (patient contact) with their logo

What is the significance of a pink background around the picture on the ID badge?

  • An ID badge with a pink background signifies that the employee is assigned to and has access to the Mother and Child area.

What is the process for investigating a loss or security incident?

  • Any security incident should be reported to Police & Security as soon as possible.
  • A Police & Security staff member will investigate, interview and document the incident in a security incident report.

What is the process for reporting suspicious activity?

  • Any suspicious activity should be reported to the Police & Security department.
  • Police & Security members will respond to investigate the activity.

What improvements have the Police & Security Department made in the last year?

  • The Police & Security Department has been successful in a number of areas.
  • The security program for the Emergency room and Acute Psychiatric Service (APS) milieu has been upgraded to minimize the threat of violence for the patients, staff and visitors. We increased our integrated access control points, limiting unauthorized entry and added a second officer during designated peak hours.
  • The Community Policing Program expanded into the following areas:

-MGH Institute of Health Professions resulting in reduction of thefts and identification accountability.
-Same Day Surgical Unit resulting reduction of thefts and improved accountability of stored patient belongings.
-Blake 13,14 and Ellison 13 resulting in reduction of false infant tamper alarms and reduction in unauthorized entry into the units.
-General Clinical Research Center resulting in reduction in disturbances and calls for service.
-Yawkey 4 and 10 resulting in increased security awareness education and increased sense of safety within new environment.

  • Traffic Officer position created with an officer stationed at the main entrance Monday through Friday, 8:00 am until 4:00 pm.
  • All in-patient units now have the capability via security systems to be locked down at anytime.
  • Instituted upgrade to the Hugs infant protection system.
  • Peoplesoft integration with EBI allowing access to be automatically terminated the day of termination.

Define the program components of the Police and Security Department?

  • There are 5 program components to the Police and Security Department. They are Administrative, Investigative, Operations, Outside Services and Physical Security.

How do you receive policy changes and new department initiatives?

  • Each shift has regularly scheduled meetings monthly with their shift manager where any policy changes or new initiatives are defined and discussed.
  • There are quarterly department meeting where issues are discussed and strategic planning is done.
  • Special meeting are scheduled when the need arises to discuss changes.
  • All new policy changes are also communicated via email and policies changes are added to the Policy and Procedure Manual.

What are the expectations of MGH employees regarding patient confidentiality?

  • Employees may only obtain information that is necessary to perform their job. Accessing information for any other reason is inappropriate.

How do we evaluate our effectiveness?

  • The Police and Security Department conducts an annual assessment in an effort to identify improvement opportunities. This assessment is done with input from several sources.
  • Information is gathered from the security service task forces, annual report, Office of Patient Advocacy Reports, benchmarking other security functions, internal improvement committees, surveillance rounds, and staff input.

How does MGH ensure that emergency medications are accessible but kept secure?

  • MGH policy requires that medications, syringes and needles be secure from indiscriminate access by unauthorized persons.
  • Medication carts and closets must be locked when not in use.


Infant Protection Program "Code Pink"

What is security’s role in an infant abduction?

  • Stop the person from leaving the premises or worse case get license number.
  • Locate the infant and the abductor.
  • Immediately return the infant back to the Mother and Child center.
  • Upon an alarm or call of an abduction, members of the Police & Security Department will respond immediately to the area of the alarm.
  • Monitor all persons exiting the hospital.

What is a Code Pink?

  • Code Pink is the hospital-wide response to a possible infant abduction.
  • The response incorporates the services of Police & Security, Parking/Commuter Services, Photography, Patient Transportation, Buildings and Grounds, OB/GYN Nursing, Environmental Services, MGH Volunteers, News and Public Affairs and Massachusetts Eye and Ear Infirmary Security Department


The FYI Campaign: Preparing for the JCAHO 2006 Survey

What topics will be covered in the FYI papers?

Many topics will be covered, including the following

  • Patient assessments
  • Hazmat materials
  • HR standards
  • Infection control
  • Restraint use
  • Unsigned verbal orders
  • Medication reconciliation
  • Pain management
  • Tracer methodology
  • Patient safety goals
  • Critical results reporting
  • Physician identification verification
  • Disaster recovery of information systems

Other topics will be added to this list.

When will the FYI papers be published?

The FYI papers will be published regularly from now until the JCAHO survey takes place.

Where will the FYI papers be distributed?

Distribution of the FYI papers will include operational and patient care units throughout the hospital as well as ambulatory care areas.

Where can I get additional information about how to prepare for the survey?

Many resources, including the FYI papers, can be accessed from the MGH's JCAHO website at This website will be updated continuously until the survey takes place. For more information about the JCAHO survey, call the Compliance Office at (617) 726-5109.