MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

FACILITY
MANAGEMENT
SYSTEM
(FMS)
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Al-Shifa Hospital and Kidney Stone Centre

MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

Contents
FACILITY......................................................................................................................................................... 1
FACILITY......................................................................................................................................................... 3
STANDARD 4. FMS-1: .................................................................................................................................... 4
The hospital is aware of and Complies with the relevant laws, rules, regulations, by Laws and relevant
building/ associated codes applicable to hospitals. ..................................................................................... 4
IND 12: The management is conversant with the relevant laws and regulations. ................................... 4
IND 13: The license / registrations/ certifications are current and there is a mechanism to regularly
update the same ....................................................................................................................................... 5
STANDARD 5. FMS-2: .................................................................................................................................... 6
The hospital has a program for Management of equipment for clinical and support Services ................... 6
IND 14: The hospital equipment in accordance with the scope of its services. ....................................... 6
IND 15: Qualified/ trained personnel operate and maintain the equipment........................................... 7
IND 16: Equipment is periodically inspected, serviced and calibrated to ensure its proper functioning.
There is a documented operational and maintenance (preventive breakdown and replacement plan). 8
STANDARD 6. FMS-3: .................................................................................................................................... 9
The hospital/HCE has plans for fire............................................................................................................... 9
And non-fire emergencies within the facilities. ............................................................................................ 9
IND 17: The hospital has provisions for i. Early detection, ii. Containment and iii. Abatement of fire
and non-fire emergencies. ...................................................................................................................... 10
IND 18: The hospital has a documented safe exit (evacuation) plan in case of fire and non-fire
emergencies. ........................................................................................................................................... 13

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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

FACILITY
MANAGEMENT
SYSTEM
(FMS) 3
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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

STANDARD 4. FMS-1:
The hospital is aware of and Complies with
the relevant laws, rules, regulations, by Laws
and relevant building/ associated codes
applicable to hospitals.
IND 12: The management is conversant with the relevant laws
and regulations.
HEALTH RELATED LAWS IN PUNJAB
1. 2012 Amendment in the PM&DC Ordinance 1962
2. PMC 2019
3. Injured Persons (Medical Aid) Act, 2012
4. Drug Regulatory Act 2012
5. Punjab Food Authority Act 2011
6. The Punjab Healthcare Commission Act, 2010
7. Boilers and Pressure Vessels Ordinance, 2002
8. The Punjab Transfusion of Safe Blood Ordinance, 1999
9. The Punjab Environmental Protection Act, 1997
10. The Pakistan Nursing Council Act, 1973
11. PM&DC Ordinance, 1962
12. The Epidemic Diseases Act, 1958

Hospital administration is aware and conversant with the above laws and attached with the file. See annexure
2.1

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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

IND 13: The license / registrations/ certifications are current

and there is a mechanism to regularly update the same

Licenses/ Registrations/ Certifications/

meetings updating mechanism

Sr Name of Particular Number Expiry Remarks

1 PBTA License MOU 31-12-2025 LIVE
2 PNRA License X206(094) 30-06-2024 Live
3 Equipment Calibrations every 6 Month FIRST WEEK OF the MONTH DONE BY
BIOMEDICAL ENGINEER
4 CQI Meeting 3 rd 30-09-23 QUATERLY
5 Record Reviews Meeting 3rd 30-09-23 QUATERLY
6 Infection Control team Meeting 09 30-09-23 MONTHLY
7 Training on Fire & Non-Fire 2nd 31-12-23 Bi-Annually
The relevant licenses and are attached. See annexure 2.2

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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

STANDARD 5. FMS-2:
The hospital has a program for Management of
equipment for clinical and support Services

IND 14: The hospital equipment in accordance with the scope of

its services.
Equipment Management Plan:
Procurement Process:
Prior to equipment acquisition, the hospital gathers demand inputs from each
section. The purchase committee, post-prioritization, makes decisions on the
equipment to be procured.
Following purchase committee has been established:

1. Managing Director DR. Rabeea Aslam

2. CEO DR. Muhammad Aslam
3. Accounts manager Asim Riaz
4. Purchasing manager Muhammad Nadeem Bhatti
5. HR Manager Dr. Mohammad Bilal
Committee decides about specifications of equipment. Equipment is
purchased according to specifications decided, at proper cost.

Testing
When the equipment is received at hospital, it is ensured that the supplying
firm installs and gives installation and testing report of the equipment.

PPM (planned preventive maintenance)

Equipment Maintenance:
During the warranty period, the supplying firm is accountable for equipment
maintenance. Post-warranty, new contracts are established with reputable
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firms for ongoing maintenance. Maintenance schedules are obtained and

Al-Shifa Hospital and Kidney Stone Centre

MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

inspection reports are recorded. Staff operating the equipment undergoes

training. Inventories, equipment history sheets, and log books are
meticulously maintained.
Repaired of each equipment when required is carried out timely.
A list of unserviceable equipment is maintained and the condemnation
committee carries out condemnation and auction process accordingly.
Inventory of all the medical equipment in the hospital is attached. See annexure 2.3
A log book of all the medical equipment is attached. See annexure 2.4

IND 15: Qualified/ trained personnel operate and maintain the

equipment.

Equipment Operation and Maintenance:

The hospital ensures qualified and trained medical staff operates all installed
equipment. A dedicated biomedical engineer is employed for equipment
maintenance, inventory management, calibration, repairs, and providing
backup support to end users.
All the documents of biomedical engineer are attached. See annexure 2.5
Job description of medical engineer is attached. See annexure 2.6

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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

IND 16: Equipment is periodically inspected, serviced and

calibrated to ensure its proper functioning. There is a
documented operational and maintenance (preventive
breakdown and replacement plan).

Preventive breakdown and maintenance plan:

Equipment Inventory:
Perform a thorough audit of hospital equipment, encompassing medical
devices, machinery, and instruments. Establish a detailed database or
spreadsheet to monitor make, model, serial numbers, warranty status, and
maintenance history for each item.
Categorization and Prioritization:
Categorize the equipment based on criticality and frequency of use. Prioritize
the high-risk and high-utilization items that are crucial for patient care, such
as ventilators, defibrillators, anesthesia machines, and patient monitors.
Establish Maintenance Schedule:
Create a maintenance schedule specifying inspection, calibration, and
preventive tasks based on equipment categories. Consider factors like
manufacturer recommendations, usage intensity, and equipment criticality.
Inspection and Cleaning:
Conduct routine inspections to identify wear, damage, or malfunctions in
equipment. Adhere to manufacturer guidelines for thorough cleaning of
surfaces, cables, and connectors. Ensure proper disposal of medical waste
generated during cleaning processes.
Calibration and Performance Testing:
Establish regular calibrations and performance tests for equipment requiring
precise measurements, including diagnostic imaging devices, laboratory
analyzers, and patient monitors. Keep a comprehensive record of calibration
results for future reference.
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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

Component Replacement:
Identify vital components or consumables, such as batteries, filters, tubing, or
sensors, requiring periodic replacement. Implement a tracking system to
monitor usage and replacement dates, preventing unexpected failures.
Staff Training:
Conduct comprehensive training for biomedical engineering technicians and
relevant hospital staff involved in equipment maintenance. Ensure proficiency
in proper operation, cleaning, and basic trouble shooting for each equipment
category.
Documentation and Record-Keeping:
Maintain meticulous records of all maintenance activities, encompassing
inspection reports, calibration certificates, maintenance logs, and equipment
service history
Emergency Response Plan:
Develop an emergency response plan to address sudden breakdowns or
equipment failures. Include procedures for swiftly identifying alternative
equipment, contacting maintenance personnel, and arranging timely repairs
or replacements.
Collaboration with Vendors:
Cultivate strong relationships with equipment vendors and service providers.
Regularly communicate about maintenance schedules, warranty coverage,
and encountered issues. Seek vendor assistance for complex repairs or
technical support.

STANDARD 6. FMS-3:
The hospital/HCE has plans for fire
And non-fire emergencies within the facilities.
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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

IND 17: The hospital has provisions for i. Early detection, ii.
Containment and iii. Abatement of fire and non-fire
emergencies.

Emergency Fire Plan:

Overview:
The fire emergency plan focuses on early detection, containment, and
abatement of fire emergencies, involving various responsible personnel.
Early Detection:
On detecting fire (e.g., smoke), an alarm will be raised through shouting "Fire!
Fire!"
Electricity supply will be switched off.
Doors and windows shall be closed.
Containment:
Trained staff will use fire extinguishers, water, and sand to combat the fire.
Doors and windows shall remain closed.
Gas cylinders, if present, will be removed immediately.
Abatement:
If the situation persists, additional staff will throw sand and use fire
extinguishers.
In critical cases, Rescue 1122/fire brigade will be called for help.
Equipment:
Sand and water buckets in each section.
Fire extinguishers.
Staff trained for emergencies.
Leadership and Communication:
Team leader oversees fire-fighting efforts.
Fire-fighting kits (helmet, goggles, mask, gloves, and shoes) are available.
Regular fire drills are conducted.
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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

Patient Evacuation:
Patients evacuated through designated exits.
Special counter outside the emergency department facilitates patients.
Medical Superintendent coordinates and monitors evacuation.
Non-Fire Emergencies: Earthquake After Earthquake:
List of Emergencies: Management:
During
Earthquake:
 Earthquake  Seek safe  Check for structural damage
 Civil disorders areas under and hazards.
tables or
 Terrorist attack desks.
 Administer first aid for
 Invasion of insects  Avoid injuries.
 Hysteric fits dangerous  Evacuate if necessary, taking
 Anti-social behavior areas near emergency supplies.
 Staff disorders windows or  Use torch for utilities; do not
objects that
 Hazardous material can fall.
use matches or switches.
spillage  Remain in  Stay away from power lines.
 Structural collapse protected  Listen to emergency
 Falls or collisions places until instructions on a battery-
 Patient falls shaking stops. powered radio.
 Anticipate  Avoid using phones and
 Bursting pipelines aftershocks.
 Sudden flooding vehicles unless necessary.

SOPs for the management of sudden flooding to clogging of

pipelines and heavy rains:
Pre-Emergency Preparation:
Display an emergency contact list prominently, including the administrator's
contact, hospital's landline number, and security in-charge.
Regularly inspect and maintain drainage systems and pipelines to minimize
the risk of clogging.
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Ensure electrical outlets and appliances are positioned above the expected
flooding level.
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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

During rainy and monsoon seasons, check daily weather forecasts to allow
sufficient time for potential flooding event preparation.
Install sandbags as a protective measure.
Emergency Response:
Call for help and inform relevant emergency contacts, including the medical
superintendent.
Promptly shift all patients to a safe location.
Shut off electricity, gas, and water supply from main sources to prevent
accidents and further damage.
Only qualified personnel with proper safety gear should handle emergency
situations.
Evaluate the extent of the issue and identify potential hazards before
initiating recovery actions.
Clear clogged pipelines using plumbing tools or seek assistance from
professional plumbers for effective drainage.
Set up industrial fans and dehumidifiers to facilitate drying and prevent mold
growth.
Remove damaged belongings promptly to salvage any salvageable items.
Disinfect and clean the affected area to prevent the growth of mold and
bacteria.
Arrange for a professional inspection of relevant systems to ensure safety and
functionality.

SOPs for the Management of hysteric fits of the patients or its

relative:
The following SOPs are designed to provide guidance on how to respond to
and manage hysteric
Fits displayed by patients or their relatives in a controlled and compassionate
manner. The
Primary goal should be to ensure the safety of everyone involved to maintain
a supportive
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MSDS Reference Manual for Al-Shifa Hospital and Kidney Stone Centre Cat II- B

 Stay calm when faced with a hysteric fit; don't get upset.
 Keep everyone safe during the fit; make a safe space.
 Provide personal space for the person having the fit; be ready to offer
support.
 Use clear and simple language to communicate.
 Avoid arguments; try to understand their feelings.
 Listen actively without interrupting; show empathy and understanding.
 Use calming techniques like deep breathing or reassurance.
 Once the fits stop, promptly move the person to the emergency department.

IND 18: The hospital has a documented safe exit (evacuation)

plan in case of fire and non-fire emergencies.

**Fire Emergency Evacuation Plan - Al-Shifa Hospital and Kidney

Stone Centre**
Emergency Exit Layout:
Each department has a designated emergency exit at the back, ensuring
unobstructed escape routes during a fire.
Fire Exit Signs are strategically placed for visibility.
Safety Measures:
Emergency exits are clearly marked, and obstructions are consistently kept
away for unimpeded access.
The hospital has established communication with civil and police authorities,
Rescue 1122, and the Fire Brigade for necessary support during emergencies.
Emergency Exit System:
The lighting source is reasonably reliable, typically from public utility electric
service.
Emergency lighting facilities maintain specified illumination for at least one
hour in case of normal lighting failure.
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"EXIT" Signs:
Signs are sized for readability from a distance of 15-20 meters.
Corridors, hallways, and aisles maintain a minimum width of 2.4 meters.
Accessibility Measures:
Ramps are available for emergency access, particularly to the ground floor.
Stairways are wide, made of concrete, and equipped with secure railings for
safety.
Evacuation Priority:
Children:
Given first priority during evacuation.
Mothers, attendants, duty nurses, ward servants, Ayas, or fit patients assist
in carrying children.
Newborns and children in incubators are carried wrapped in blankets.
Patients:
Mobile patients guided to appropriate exits.
Non-mobile patients transported using wheelchairs or stretchers based on
their condition.
Staff:
Evacuate last to ensure everyone else's safety.
Avoid unnecessary delays during evacuation.
Training report for the emergency exit plan is attached. See annexure 2.7
IND 19: Staff members are trained for their role in case of such
emergencies.
All the staff of hospital is trained for any fire and non-fire emergencies.
Training report and pictures are attached. See annexure 2.8
IND 20: Simulation exercise is held at least once in a year.
Simulation exercise is held biannually and all the staff of the hospital is trained
about this.
Report is attached. See annexure 2.9
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