Dr. Ruth K.M.

Pfau, Civil
Hospital Karachi &Shaheed
Mohtarma Benazir Bhutto
Institute Of Trauma
(SMBBIT)

POLICIES & PROCEDURES MANUAL FOR THE

DEPARTMENT OF FIRE AND SAFETY
Department: Fire & Safety Document Name: Fire & Safety Committee

Reference SMBBIT/Support
Pages: 04 Number: Services -Policy/Dept.
(F&S)/0004
Effective Date: Feb-2019 Revised:  Feb -2020

Reviewed: Version: 01

Prepared By: Manager Approved By: Chief Operating Officer

Fire and Safety
 SHAHEED MOHTARMA BENAZIR BHUTTO
INSTITUTE OF TRAUMA

SMBBIT/Support Services
Document Title: Fire & Safety Committee Issuance Month: Feb 2021
-Policy/Dept. (F&S)/0004

Contents

1. Objectives...................................................................................................................Page03

2. SCOPE......................................................................................................................Page 03

3. Responsibilities & Authorities..................................................................................Page 03

4. Responsibility............................................................................................................Page 03

5. Procedure...................................................................................................................Page 03

6. 5. Abbreviations and/or Definitions..........................................................................Page 04

7. Fire and Safety Committee Structure………………...................................................Page 04

 SHAHEED MOHTARMA BENAZIR BHUTTO
INSTITUTE OF TRAUMA

SMBBIT/Support Services
Document Title: Fire & Safety Committee Issuance Month: Feb 2021
-Policy/Dept. (F&S)/0004

1. Objective
The objective of this procedure is to coordinate and control the activities of the Fire and Safety
system being carried out by different functional groups in the SMBBTC and to review the
performance of the Fire and Safety measurements at regular intervals and to attain the quality
objectives by reviewing the system and ensuring the availability of resources and personnel

2. Scope
This procedure is applicable to all departments whose management personnel take part in the
meetings of Management Review.

3. Responsibilities & Authorities

Fire and safety manager shall set the review date and agenda in consultation with the Manager
Admin to call up meeting.
Fire and Safety Manager shall present performance and shall propose improvement options.
The Management Review shall be directed by the AMS/DMS and decide actions.

4. The Procedure
4.1 General
The top management has established a Management Review Committee to coordinate and control
the activities of the quality system being carried out by different organizational functions in the
center and to periodically review and evaluate the performance of the system.
4.2 Frequency and Scheduling of MRM
4.2.1 The Management Review meetings are conducted at least once in a year. If required
unscheduled meetings can also be called at any time to discuss any critical issue. In case
significant issues have to be discussed (like improvement in existing system, lapse of procedures
or if poor safety, quality or environmental performance is recorded, breaking into a new market
etc. environmental issues, F&S risks) management review meeting may be conducted as deemed
necessary.
4.2.2 The intervals between 2 Management Review Meetings would not exceed 12 months to
ensure its continuing suitability, adequacy and effectiveness. In exceptional circumstances, this
interval may be exceeded by not more than one month.
4.3 Attendance
4.3.1 Fire & Safety manager chairs the Management Review meetings. In his absence, Fire &
Safety Officer chairs the meeting and attended by

Fire & Safety DepartmentSMBB Institute of Trauma

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 SHAHEED MOHTARMA BENAZIR BHUTTO
INSTITUTE OF TRAUMA

SMBBIT/Support Services
Document Title: Fire & Safety Committee Issuance Month: Feb 2021
-Policy/Dept. (F&S)/0004

 Admin Manager
 Bio Medical Engineer
 Support Services Team member (Electrical , HVAC, Civil & Plumbing )
 Head of Security
 Any other designation can be called on requirement

4.3.2 If any member of the Executive Management is unable to attend the Management Review
Meeting, he will receive the minutes of the Review Meeting from Admin Officer.
4.3.3 The absent member of the Executive Management after reviewing the minutes, if he feels
necessary, submits his input and comments to the Fire and safety Manager/Admin officer.
4.3.4 Admin Officer takes signature from Members of the Executive Management on the
Attendance Sheet for Management Review Meeting.

4.4 Management Review Agenda

4.4.1 Fire and Safety Manager prepares the meeting agenda for each meeting and forwards to
AMS/DMS for Approval.
4.4.2 The Agenda is then reviewed by the Executive Management, as a minimum, the agenda
covers all items listed below, Review input.
4.4.3 As a minimum, the Agenda comprising the following topics but not limited to:
 Overall Progress in Meeting Goals, KPIs, Expectations and Policies
 Internal and External Audit Results
 Results of Other Visits/Inspections
 Significant Hazardous Incidents/Accidents/Near Misses/nonconformities and corrective /
preventive actions
 Effectiveness of the SMMBTC Fire and Safety Policies in Operations and Continual
Improvement
 Compliance with existing Rules and Regulations,
 Present Status of Fire and Safety Provisions
 Follow up items from previous review
Fire & Safety Manager shall review and compile received information. Compilation of provided
data shall be subject to Quantitative or Qualitative representation.

Fire & Safety DepartmentSMBB Institute of Trauma

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 SHAHEED MOHTARMA BENAZIR BHUTTO
INSTITUTE OF TRAUMA

SMBBIT/Support Services
Document Title: Fire & Safety Committee Issuance Month: Feb 2021
-Policy/Dept. (F&S)/0004

Admin officer distributes meeting agenda to members at least one week before the meeting or
informs them about the agenda and takes their signatures on Meeting Agenda, Members as per
agenda items prepare the input for the meeting.

4.5 Conduct Meeting

4.5.1 Form top management no more than three member may be absent from the meeting.
4.5.2 CEO SMBBIT provides direction to the meeting by following the agenda items in order of
priority and controlling the excessive discussion.
4.5.3 Fire and Safety Manager ensures that those agenda item requiring solution be thoroughly
discussed with their pros and cons and an agreed solution/consensus is reached with the
identification of designation(s) responsible to take/ implement actions and the target time frame

4.6 Preparation of MOM & Distribution

4.6.1 Admin Officer takes minutes during the meeting, minutes should describe the following
Date of Meeting.
Members present & absent.
Agenda items.
Discussion on each agenda item particularly

4.6.2 Focusing on following:

Actions decided for Improvement of processes
Actions decided to increase the effectiveness and efficiency of systems and processes related to
fire & safety.
Resources
4.7 Outputs from Meetings
4.7.1 The outputs of the management review include decisions and actions related to:
Opportunities for continual improvement
Continuing suitability, adequacy and effectiveness of system and policies.
4.7.2 Respective functions shall be responsible and accountable for taking relevant actions in line
with decisions taken and target time.

Fire & Safety DepartmentSMBB Institute of Trauma

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 SHAHEED MOHTARMA BENAZIR BHUTTO
INSTITUTE OF TRAUMA

SMBBIT/Support Services
Document Title: Fire & Safety Committee Issuance Month: Feb 2021
-Policy/Dept. (F&S)/0004

4.7.3 Target dates for each action and designations responsible for action.
4.7.4 Submit Minutes to CEO for review & approval
4.7.5 Admin officer distributes the minutes to all members including absent member(s)
4.7.6 Record meeting schedule, Agenda and minutes in one file.
4.7.7 Records of Management Review Meeting are retained for 3 years by fire and safety
department.

5. Abbreviations and/or Definitions

KPI Key Performance Indicator
MOM Minutes of Meeting
MRM Management Review Meeting

6. Fire and Safety Committee Structure

SNo. NAME DESIGNATION

1. Fire and Safety Manager Chairperson

2. Manager Administration Co-Chairperson

3. Bio Medical Engineer Member

4. Head of Security Member

5. House Keeping team Lead Member

6. Support Services (Electrical, HVAC) Member

Fire & Safety DepartmentSMBB Institute of Trauma

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