STRUCTURE: The SICQI Committee shall consist of at least one provider, one nurse, and the Physical Plant Department (PPD) director. The Committee shall meet on a monthly basis during the academic year. The Director of Student Health Services appoints the coordinator of the SICQI Committee.

FUNCTIONS: The SICQI Committee shall

1) Develop, implement and monitor an effective Safety Plan, including:

  1. risk management and safety programs to protect against any losses of staff and patients, or property. See details under Risk Management and Safety.
  2. the Emergency Preparedness and Evacuation Plans, as detailed under those sections.
  3. the “Hazard Communication Program,” in accordance with the current N.M. Occupational Health & Safety Act, Regulation 29 CFR 1910.1200

2) Develop, implement and monitor an Infection Control Plan, including:

  1. written policies and procedures to prevent transmission of infection in patients and staff, which will be review on an annual basis
  2. development and monitoring of a procedure for reporting diseases of public health concern to staff providers, as well as to the local Public Health Department
  3. development and monitoring of a program of continuing education in infection control for SHS personnel
  4. reports and recommendations to the Director of Student Health Services of any corrective action needed, based on records and reports of infections among SHS patients and personnel.
  5. implementation and annual review of the monitoring plan for Nosocomial Infections associated with invasive procedures

3) Develop, implement and monitor the Quality Improvement units, including:

  1. identification and coordination of all QI unit activities
  2. routine appraisals of all QI units, and recommendations regarding QI activities
  3. promotion and assistance in developing standards of care within each QI unit
  4. receipt, evaluation, and coordination of the reports of all QI units
  5. sharing information between QI units, in order to prevent duplication of effort
  6. identification of problems and the setting of priorities for problem resolution
  7. assurance that all available data sources are utilized in implementing the QI program
  8. assurance that there is appropriate utilization of all available methods for studying, assessing, and resolving perceived problems, both within the QI Committee and within the individual QI units
  9. re-appraisal of the QI plan at least annually for

Reviewed and
approved __________________________




PURPOSE: The purpose of this document is to define the Risk Management (Safety) Plan for the Western New Mexico University Student Health Services.

DEFINITION: Risk Management is the planning, organizing, and directing of a comprehensive program of activities to identify, evaluate, and take corrective action against risks that may lead to patient injury, employee injury, or property loss or damage, with resulting institutional financial loss or legal liability.


  1. The Safety, Infection Control and Quality Improvement (SICQI) Committee discusses risk management issues and concerns on a monthly basis. The Director reviews all in-house minutes, and addresses risk management issues as necessary. The Director determines whether or not such matters need to be further reviewed by the representative of the governing body (Vice President for Student Affairs) and/or the Risk Management Liaison for the University.
  2. All specific incidents are processed according to the policies outlined in INCIDENT REPORTS (“Employee Accidents,” and “Medical Record Incident Report”). The Director reviews such reports, and appropriate action is taken when necessary.
  3. Providers are to report promptly to the Director any patient hospitalization or Emergency Department actions. The Director reviews the chart as necessary. The information given to the Director should be in writing, and include patient name, social security number, referring provider, the name of the provider or facility receiving the patient, and the final diagnosis, if available.
  4. Adverse Reactions are reviewed by the Quality Improvement Committee, and subsequently are reviewed by the Director.
  5. Complaints may be brought to the Director’s attention through a Patient Satisfaction Questionnaire, or through a WNMU Department, the Quality Improvement Coordinator, the Student Health Advisory Committee, the Vice-President for Student Affairs, or any faculty member.
  6. The Student Health Services (SHS) policy is not to dismiss a patient from care or to refuse care to any eligible patient. However, there are rare occasions when patient noncompliance with the medical recommendations seriously jeopardizes patient care with a substantial possibility of serious consequences, including death. In these situations, the provider involved is advised to:
    1. a. Give the patient a written copy of Patient Rights and Responsibilities, and to document in the chart that the patient has received the copy.
    2. b. Request the patient to sign a “Refusal of Medical Treatment” form. The form should include the risks for the patient relative to non-compliance with the medical recommendations.
    3. Certified mail (return receipt requested) is sometimes necessary to communicate with the involved patient.

  7. Any contractual agreements with another facility are done in a manner compliant with general University policy.
  8. Any form of communication with the media is to be cleared with WNMU Public Information Director and the SHS Director prior to the communication. The general policy is that only the Director communicates with the media on a SHS matter, unless s/he has specifically given permission for another individual to communicate with the media.
  9. The method of resolving professional health care personnel impairment is addressed in the Health Care Professional Staff Regulations.
  10. Methods for complying with applicable State and Federal Government regulations are usually addressed by committee, presently represented by SICQI. All concerns regarding compliance are to be brought to the Director’s attention.
  11. The Qualify Improvement Sub-Committee conducts periodic reviews of clinical records.
  12. A Professional Liability Survey is also completed once a year by the Director, and sent to the University Risk Management Liaison.

Reviewed and
approved __________________




The coordinator shall:

  1. Schedule fire drills quarterly with the Fire Department, fill out and make a copy of the report, file original in nursing office and give copy to firefighter conducting the drill. Conduct in-house fire drills on the months when the fire department personnel are unable to be present.
  2. Schedule and/or document semi-annual distress drill. (If an unplanned disaster occurs, one annual disaster drill is required.
  3. Check fire extinguishers monthly to verify inspection, documentation, and report any deficiencies to Western New Mexico University Safety Officer/ Physical Plant Director (PPD).
  4. Receive reports on safety and fire hazards from staff members and issue work requests to the Physical Plant Department for corrections.
  5. Make random checks of staff to ascertain their knowledge of location of fire extinguishers and their operations, knowledge of fire drill and disaster protocol. Document corrections.
  6. Inspect laboratory to indicate presence of any volatile, dangerous or inflammable agents.
  7. Be responsible for the Equipment Maintenance Policy.
  8. Provide annual Fire and Safety Training.
  9. Prepare a “Safety Program” annual report to be submitted to the Director of the SHS.

Reviewed and
approved _______________________