University of Kentucky Hospital

Security Management Plan

 

Evaluated July 2004

Revised July 2004

 

 

Objectives

 

The University of Kentucky Hospital is committed to providing a safe and secure environment for its patients, visitors, employees, faculty, and students.

 

Specifically, through the Security Management Program, the Hospital seeks to:  

 

1. Ensure the security of the built environment, including perimeter and identified security sensitive areas.
2. Ensure security of occupants of Hospital building and grounds.
3. Safeguard the organization’s property.
4. Respond to campus, hospital, and community emergencies.

 

Scope

 

This plan covers the following facilities and areas:

 

1. Main Hospital
2. Critical Care Addition
3. Gill Building
4. Roach Building
5. Whitney-Hendrickson Building 
6. Parking Structure 4
7. Hospital occupancies in Kentucky Clinic
8. Hospital construction sites
9. The immediate environment surrounding these areas.

 

Off-campus business occupancies and clinics are not covered by this plan. These areas have developed their own security policies and procedures. 

 

Authority and Responsibility

 

To ensure that the security needs of the Hospital are identified and addressed, the Hospital has designated appropriate personnel to develop, implement, and monitor the Security Management  Program as a whole and specific aspects of the program.

 

·         The Security Management Subcommittee oversees security management plan development,  establishes and monitors performance standards, and evaluates the program annually. A multi-functional work group, the subcommittee also:

·         Coordinates area security risk assessments and reviews findings

·         Reviews departmental requests for security technology and makes prioritized recommendations to Hospital Administration

·         Reviews Hospital policies related to security management

·         Makes recommendations regarding mitigation and preparedness activities related to  institutional security needs. 

·         The Security Coordinator, as a designated representative of University of Kentucky Police, ensures comprehensive implementation of the security management program.

 

In addition, the Security Coordinator meets regularly with the Hospital Security Liaison to ensure that the security plan is implemented to meet identified hospital need and to discuss current security concerns.

 

Every Hospital employee is responsible for reporting all security incidents and complying with and enforcing all security policies and procedures.

 

Basic Security Measures

 

1. Security Force

University of Kentucky Police (UKPD) provides an on-site security force for the Hospital 24-hours-a-day, seven days a week. The security force includes:

·         Certified security officers

·         Sworn police officers

·         Dispatch (provided by UKPD)

 

The security force is the primary means of preventing security incidents.  Their primary responsibilities include:

·         Basic Security Services

·         Post and patrol

·         Traffic control

·         Access control

·         Escort services

·         Information (e.g., directions)

·         Police liaison (with all levels of law enforcement)

·         Special Event Response (e.g., media events)

 

·         Emergency/crisis response

In emergencies, UK police are dispatched to provide primary response and to direct security officer response.

 

·         Incident Reporting and Investigation

The security force is charged with reporting and investigating security incidents, in cooperation with law enforcement and regulatory agencies.

 

·         Security staff document non-routine events according to policy and standard operating procedures (SOP). Each report is reviewed by the shift commander at the end of shift (EOS) in order to ensure a timely response if follow-up is needed quickly. 

 

·         Investigations are begun as soon after the incident as is warranted, and police are involved in criminal matters as soon as possible after Security receives notification that a criminal activity is occurring or has occurred.  Follow-up investigation activities are implemented when warranted, regardless of police action, unless the law enforcement agency requests otherwise.

 

·         Other Reports

Security officers record other occurrences on a variety of documents.

 

·         Routine activities during a shift are documented on shift reports to maintain a permanent record of officers’ activities.

·         Injuries are reported on the Reportable Occurrence form.

·         Officers also report by memorandum or make verbal reports to address staff concerns not fitting any other category.

 

·         Security System monitoring

 

·         Employee and Visitor Identification services

 

2.       Perimeter Security and Access Control

 

The perimeter security and access control system is designed to safeguard occupants and property by:

·         Limiting public access to the facility

·         Controlling and monitoring employee and student access to the facility

·         Monitoring secured perimeter doors

·         Monitoring perimeter and some interior spaces using Closed Circuit Television (CCTV).

·         Monitoring the Hospital Parking Garage (PS4) using CCTV.

·         Allowing for facility lock down

 

3. Identification

 

·         Employee and Faculty Identification

Security issues an official identification badge to all staff members — permanent, temporary, and contract — faculty and students who have assigned responsibilities within University of Kentucky Hospital. Employees, students, and faculty are required by Hospital policy to wear their ID badge whenever they are on duty on Hospital property.

 

The identification badge is designed to assist security staff, employees, patients, and visitors to identify staff and to ensure appropriate access to employee entrances and security sensitive areas or functions.

 

Employees who do not present to work with an ID badge are required to purchase a temporary badge at the Security Office.

 

·         Visitor Identification

 

After normal visiting hours, as specified by policy, visitors are required to register with Security, where they are issued a time-expiration ID badge.

 

Visitors to the Emergency Department are issued colored ID badges by a desk clerk.  The number of visitors is limited to two persons for each patient.

 

 

·         Vendor Identification

 

Vendors and other business representatives are required to register with Hospital Purchasing or Pharmacy, where they are oriented to the policies and procedures of the institution and issued an ID badge.

 

 

·         Patient Identification

 

·         Emergency Department patients are issued an identification bracelet when they are registered.

 

·         Hospital inpatients are issued an identification bracelet by the Admitting Department or nursing unit at the time of admission.

 

4. Security Policies and Procedures

 

The Hospital has established security policies and procedures, designed to provide a basic level of security within the institution and to emphasize the responsibility of all employees. These include, but are not limited to:

 

·             01-17, Visitation

·             01-27, Infant/Child Security

·             01-31, Product Sales Representatives

·             01-33, Drug Control and Security

·             06-15, AMA

·             10-03, Patient Valuables

·             10-07, Security of Prisoners

·             10-09, Building Security

·             10-13, Employee Identification

·             10-35, Carrying/Storing Weapons

 

In addition, the Hospital has established contingency plans to guide response to emergency situations. These include, but are not limited to:

 

·             01-25, Infant/Child Abduction

·             10-25, Crisis Intervention

·             12-05, Bomb Threat Response

·             Hostage Response

·             Fire Response

·             12-11, Mass Casualty Response

·             12-13, Hazardous Materials Incident Response

·             VIP Notification and Response

·             Fire Response

·             Bioterrorism Response

 

Security has developed and implemented Standard Operating Procedures (SOPs) to outline its role in operations and response.

 

Security Risk Assessments

 

All hospitals are subject to basic security vulnerabilities. The basic security measures, described above, have been implemented to mitigate those basic risks.

 

Because of its size, the complexity of care provided, the location, and the patient and visitor population, University of Kentucky Hospital must confront many security issues not faced by other facilities.

 

In order to identify vulnerabilities specific to the facility, the Hospital Security Subcommittee conducts periodic security risk assessments of the overall facility and of specific areas within the facility deemed security-sensitive areas.

 

These assessments are used to determine whether basic security measures are sufficient to meet institutional need and to identify additional risks and vulnerabilities and methods of controlling them.

 

Currently, the Hospital has identified the following areas as having a higher-than-average security risk.

 

 

Area		Enhanced Risk Factors
*	Birthing Center		Infant Abduction
	Children’s Hospital —Acute Care		Child Abduction
*	Children’s Hospital—Critical Care		Child Abduction
*	Clinical Lab		Hazardous Materials, Select Agents
*	Dietetics		Theft
*	Emergency Department		Violence, Emergency Response, Contamination
*	Endoscopy		Theft, Location
*	Information Services Areas		Theft, Location
*	Intensive Care Units		Violence
*	Materials Management — Dock		Theft
*	Mechanical Rooms		Sabotage
*	Medical Records		Confidential Information, Location
*	Nuclear Medicine		Theft, Hazardous Materials, Location
	Parking Structures		Violence, Theft, Location
*	Perioperative Services Areas		Theft, Diversion
*	Pharmacy		Theft, Diversion
*	Psychiatry (3 West)		Violence
	Radiation Medicine		Theft, Hazardous Materials, Location
*	Supply Rooms		Theft

 

Access to all areas indicated by an “*” is controlled by security technology — either magnetic locks or lock and key.  Only authorized personnel are allowed access to other than public spaces within these areas.  (Based on security risk and need assessment, some of these areas are secured only after routine business hours.)

 

Areas that are not secured are evaluated to determine how security risks can be appropriately managed and systems are implemented to control the known risks.

 

Plan Evaluation

 

The Hospital Security Subcommittee evaluates the Security Management Plan annually, based on criteria established to ensure the appropriateness of the objectives, scope, and performance indicators, and the program’s effectiveness. Results of this annual evaluation are used to revise the plan. The plan is presented to the Environment of Care Committee for review, recommendation, and approval.

 

 

Emergency Security Procedures

 

Security has established policies and procedures to direct response during emergencies requiring enhanced security measures. These documents are outlined below and detailed in the appendices.

 

·         Security Incidents or Failures:

 

When a security incident is reported, Security personnel respond to the location and evaluate the response needed. 

 

In general, security officers respond; assess; isolate and contain the scene, cordoning the area as needed; notify law enforcement personnel, if necessary; and coordinate the response of other entities until the incident is resolved.  Security personnel are trained to be flexible in their responses to incidents or events which are not covered by policy, extrapolating from existing policies, when necessary, in order to efficiently and effectively respond to the event.  Response to the following specific incidents is covered in Hospital policy:

1. Combative Individuals
2. Incidents Involving Weapons
3. Bomb Threats
4. Hostage Situations
5. Fires and Fire Alarms
6. Mass Casualty Incidents
7. Hospital Evacuation
8. Prisoners as Patients
9. Hazardous Material Incidents
10. VIP Admissions or Events

 

In the case of a security failure, such as a malfunction in the access control technology, security personnel will take appropriate steps to resolve the problem and ensure security during its resolution. Security will consult the Hospital Safety Officer or the Hospital Operations Administrator (HOA) to determine appropriate interim security measures.

 

·         Civil Disturbances: Security has established a Civil Disturbance response plan within the context of the University’s plan.

 

·         Provision of Additional Staff:

 

The Emergency Management Subcommittee and the Security Management Subcommittee have worked with Security to establish a plan for securing additional personnel during emergency response. University of Kentucky Police will supplement the security force in situations that require armed response or arrest powers. In other situations, the existing security force will be supplemented by Hospital employees who have been trained  in security procedures and methods.

 

Vehicular Access to Urgent Care Areas

 

Access control for urgent care areas is a paramount security concern during both normal and emergency operations.

 

During normal operations, signs, security force, and the general design of the traffic lanes and parking areas are the primary means of vehicular traffic control.  University police routinely monitor and patrol Hospital access roads and fire lanes to ensure free and unobstructed access for emergency transport and emergency response vehicles.

 

During emergency and disaster response operations, vehicular access to the ED and other Hospital areas is controlled and restricted by security personnel or law enforcement.  During disaster response, security personnel and/or police officers are posted in designated areas (pursuant to emergency response procedures) to ensure that emergency vehicles are able to access the area, ensuring the flow of traffic is directed appropriately, and that access to designated areas is restricted appropriately.

 

During construction that affects vehicular access, flagmen are posted to facilitate traffic flow.  Security and Hospital Safety representatives attend construction meetings to ensure that vehicular access concerns are addressed appropriately.

 

 

Security Orientation and Education Program

 

Security orientation, education, and training programs have been established to provide perspective, information, and direction to all Hospital staff.

 

1. All hospital employees are oriented to general hospital security risks and measures as a part of Hospital orientation.  This orientation includes security awareness and reporting procedures.
2. Hospital employees in security sensitive areas are oriented and educated about specific security issues related to their areas and trained to respond to a security breach or incident.  This orientation and training takes place during departmental orientation and, as needed, thereafter.  This education includes awareness of security issues and procedures specific to the area, processes for minimizing or mitigating security risks, reporting procedures, and emergency response procedures.
3. Employee knowledge of security risks and response protocols is evaluated as a part of the annual safety survey and through drills, surveillance activities, and security risk assessments.

 

All employees participate in workplace violence prevention education.  In addition, Security offers special educational sessions to address specific security issues/risks that arise.

 

 

Monitoring of Performance

 

The Hospital Security Subcommittee has established the following performance standards:

 

1. Utilizing a combination of controls, the Hospital will decrease security incidents in the ED by 20% over the next year.
2. Established security posts and patrols will be staffed per the service level agreement at least 95% of the time.
3. All current security officers will be certified by the International Association of Healthcare Safety and Security by January 31, 2005. All new security officers will be certified within 3 months of hire.
4. Security personnel will respond to “Assistance Please,” panic alarms, and other crisis situations within three minutes.

 

Data is collected routinely and analyzed to determine compliance with these established standards. Security makes quarterly reports to the Environment of Care Committee.