FACILITY MANAGEMENT AND SAFETY

(FMS)
• safe and secure environment for patients, their families, staff and visitors
• proactive risk mitigations
• regular facility inspection rounds
• safe water, electricity, medical gases and vacuum systems
• medical and utility equipment management
• plans for emergencies within the facilities
• no-smoking area and manages hazardous materials in a safe manner
• measures on being energy efficient
FACILITY MANAGEMENT AND SAFETY (FMS)
Safe and secure environment
• Safety Committee
• Safety plan and policies
• Safety devices are installed and inspected periodically
• Non-smoking area
• Hazard Identification and Risk Analysis (HIRA) in both
clinical & non clinical area
• Safety education trainings to staff (fire safety,
HAZMAT)
• Facility safety inspections - at least twice in a year in patient
care areas and at least once in a year in non-patient care
areas
– grab bars, bed rails, sign posting, safety belts on stretchers and wheel
chairs, alarms both visual and auditory where applicable, warning signs
like radiation or biohazard, call bells, fire-safety devices, etc.
– Provisions are made available for physically challenged/vulnerable
person as per regulatory requirement example special toilet for
physically challenged
• Inspection reports – documented, preventive and corrective
actions
FACILITY MANAGEMENT AND SAFETY (FMS)
Safety for all
• Up-to-date drawings maintained that detail the site layout, floor plans and
fire escape routes
• Provision of space as per National Building Code, etc.
• Exit signs in local language
• Potable water and electricity are available round the clock
• Alternate sources (tested regularly) for electricity and water provided as
backup for any failure/shortage
• Documented operational and maintenance (preventive and breakdown)
plan
• Maintenance staff is contactable round the clock for emergency repairs -
PPE provided
• TAT of response
 FACILITY MANAGEMENT AND SAFETY (FMS)
Maintenance plans
• Equipments are inventoried and proper logs maintained
• Operated by qualified/experienced and trained personnel
• Maintenance plans for
– water management
– electrical systems
– heating, ventilation and air-conditioning
• A documented procedure for equipment replacement and disposal
(Condemnation committee)
• Energy Conservation - energy efficient lighting in a phased manner,
rain water harvesting, increase usage of solar power, recycling
where possible
Indian Green Building Council (IGBC)
LEED rating system | U.S. Green Building Council
GRIHA Council - Green Rating for Integrated Habitat Assessment
 FACILITY MANAGEMENT AND SAFETY (FMS)
Bio-medical equipment
• Inventoried and proper logs maintained
• Operated by qualified and trained personnel
• Periodically inspected and calibrated
• Documented operational and maintenance (preventive and
breakdown) plan
– DG, Chiller, AHU, FCU, Steam sterilizer, etc.
– RO plant of dialysis unit - water shall be tested for endotoxin levels every
month to ensure that levels should conform to national and/or
international guidelines
– Regular checking of pH, TDS, hardness etc.
• A documented procedure for equipment replacement and disposal
• Clinical staff trained on biomedical equipment
FACILITY MANAGEMENT AND SAFETY (FMS)
Medical gases, vacuum and compressed air
• A good reference is HTM 02-01 or NFPA‘s Medical Gas and
Vacuum Systems Installation Handbook (NFPA's new NFPA 99C
solution)
• Proper signage is kept for used, full, empty cylinders as per
statutory requirements under the provisions of Indian
Explosives Act, Gas Cylinder rules and Static and Mobile
Pressure Vessel (unfired) rules.
• Safety during handling, storing, distribution and use
• Maintenance plan
• Alarm units
• Alternate sources
• Check alternate sources regularly
FACILITY MANAGEMENT AND SAFETY (FMS)
Emergencies
• Fire detection and suppression systems
• Documented safe exit plan in case of fire and non-fire
emergencies
• Staff trainings
• Mock drills - at least twice in a year
• Maintenance plan for fire related equipment
FACILITY MANAGEMENT AND SAFETY (FMS)

Community emergencies, epidemics and other disasters

• Identify potential emergencies
• Document disaster management plan
• Provision for availability of medical supplies, equipment and
materials
• Staff trainings
• Mock drills - at least twice in a year
FACILITY MANAGEMENT AND SAFETY (FMS
Organization has plan for Non-Fire Emergencies
i. terrorist attack,
ii. invasion of swarms of insects and pests,
iii. earthquake,
iv. invasion of stray animals,
v. hysteric fits of patients and/or relatives,
vi. civil disorders effecting the organisation,
vii. anti-social behaviour by patients/relatives,
viii. temperamental disorders of staff causing deterioration in patient care,
ix. Spillage of hazardous (acids, mercury, etc.), infected materials (used
gloves, syringes, tubing, sharps, etc.) medical wastes (blood, pus,
amniotic fluid, vomits, etc.),
x. building or structural collapse,
xi. fall or slips (from height or on floor) or collision of personnel in passageway,
xii. fall of patient from bed,
xiii. bursting of pipelines,
xiv. sudden flooding of areas like basements due to clogging in pipelines,
xv. sudden failure of supply of electricity, gas, vacuum, etc., and
xvi. bursting of boilers and/or autoclaves.
FACILITY MANAGEMENT AND SAFETY (FMS)

HAZMAT
• Identify hazardous materials
• SOPs for sorting, labelling, handling, storage, transporting and
disposal of hazardous material
• Requisite regulatory requirements are met in respect of
radioactive materials
• Staff trainings for managing spills
 HUMAN RESOURCE MANAGEMENT
(HRM)

(a) Human resource planning, recruiting and socialisation of the new employees.
(b) Training and development relates to the performance in the present and
future anticipated jobs. The employees are provided with opportunities to
advance personally as well as professionally.
(c) Motivation relates to job design, performance appraisal and discipline.
(d) Maintenance relates to safety and health of the employees.
 HUMAN RESOURCE MANAGEMENT (HRM)

Planning
• Supports the organization's current and future ability to meet
the care, treatment and service needs of the patient
• Maintains an adequate number and mix of staff
• Well defined job descriptions and job specifications
• Criminal/negligence background check
 HUMAN RESOURCE MANAGEMENT (HRM)

Staff orientation
• Documented SOP for recruitment
• Induction training (maintain attendance record)
– Mission, vision
– Employee rights and responsibilities
– Patient rights and responsibilities
– Service standards
– Occupational safety
 HUMAN RESOURCE MANAGEMENT (HRM)

Appraisal system
• Documented system
• Pre determined criteria
• Pre defined time intervals
Disciplinary and grievance-handling
• SOP on grievance handling
• Staff made aware
• Action taken documented
 HUMAN RESOURCE MANAGEMENT (HRM)

Health needs
• Pre-employment medical examination is
conducted on all the employees
• Health problems of the employees are taken
care of in accordance with the organization’s
policy
• Annual staff health checks
• Occupational risks covered
 HUMAN RESOURCE MANAGEMENT (HRM)

Personnel files
• ID number
• Update the file
– Education, registration, training and experience
– In-service training and education records
– Disciplinary, background and health status
– Appraisal
 HUMAN RESOURCE MANAGEMENT (HRM)

Credentialing and privileging (Docs and nurses)

• Privileges to admit and care for patients in
consonance with education, registration,
training and experience
• Medical professionals admit and care for
patients as per their privileging
• Privileges made known to all staff
 INFORMATION MANAGEMENT SYSTEM (IMS)
Medical Records
• Documented procedures exist for storing and retrieving data
• Complete and accurate medical record for every patient
• Every medical record has a unique identifier
• Organisation policy identifies those authorized to make entries in medical
record
• Entry in the medical record is named, signed, dated and timed
• The author of the entry can be identified
• The contents of medical record are identified and documented
• The record provides a complete, up-to-date and chronological account of
patient care
• Provision is made for 24-hour availability of the patient's record to
healthcare providers to ensure continuity of care
 INFORMATION MANAGEMENT SYSTEM (IMS)

• Operative and other procedures performed are

incorporated in the medical record
• When patient is transferred to another hospital, the
medical record contains the date of transfer, the reason
for the transfer and the name of the receiving hospital
• Copy of discharge summary duly signed by appropriate
and qualified personnel
• In case of death, copy of the death certificate
• Whenever a clinical autopsy is carried out, the medical
record contains a copy of the report of the same
 INFORMATION MANAGEMENT SYSTEM (IMS)

Confidentiality, integrity and security of records

• Safeguarding against loss, destruction and tampering
• Effective process of monitoring compliance
• Patient health information not disclosed without the
patient’s authorization
• Documented procedure exists on how to respond to
patients/ physicians and other public agencies
requests for access to information in the medical
record in accordance with the local and national law.
 INFORMATION MANAGEMENT SYSTEM (IMS)

• Retention periods – documented

• Destruction procedure