0% found this document useful (0 votes)
513 views30 pagesFMS
Uploaded by
Abdullah AbdullahCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
0% found this document useful (0 votes)
513 views30 pagesFMS
Uploaded by
Abdullah AbdullahCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
- Overview
- Standards, Intents, and Measurable Elements
- Education
- Appendix
- References
Facility Management
and Safety (FMS)
Overview
Health cae organizations work co provide safe, functional, and supportive facilis for patent, Families,
staff, and visitors. To reach this goal, the physical facility, medical and other equipment, and people must be
cffectively managed, In paccular, management must strive to
reduce and control hazards and risks
prevent acidents and injuries; and
* maintain safe conditions.
Effective management inclides malkiisciplinay planning, education, and monitoring as follows:
‘The leaders plan the space, equipment, and resources nesded to safely and effectively support the
linical sevices provided.
+ Allsaffare educated about the facility, how to reduce risks, and how to monitor and 0 report
situations that pose risk.
+ Performance criteria ae used co evaluate importanc systems and to identify needed improvements
+ Comprehensive, faity-wide risk assessments are developed and monitored on each ofthe failiey
management and safery programs when needed.
Witten progeams are developed and include the following eight areas, when appropriate to the failty and
activities ofthe organization:
Tr Sofny—The degree to which the organizations buildings, constuction arts, grounds, and equipment
do not pose a hazard or risk to patients, staf, oF visitors.
2. Security—Protection from loss, destruction, tampering, or unauthorized accessor use.
3, Hazardous matcrals and waste—Handling, storage, and use of radioactive and other materials are
controlled, and hazardous waste is safely disposed.
4, Fire safety—Conducting ongoing assessment of risks to enhance protection of property and occupants
from fire and smoke.
5. Medical equipment—Equipment is selected, maintained, and used in a manner to reduce risks.
6. Utility systems—Electrcal, water, and other utility systems are maintained to minimize the risks of
operating failures
7. Emergency management—Risks are identified and response to epidemics, disisters, and emergencies
is planned and effective, inchuding the evaluation of che structural integrity of patient care
8. Construction and renovation—Risks to patients, staff, and vistors are identified and assessed during
the construction, renovation, demolition, and other maintenance activities
‘When the organization has nonhospital entities within the patient care facilities to be surveyed (such as
an independently owned coffee shop or gift shop), the organization hasan obligation to ensure chat these
independent entities comply withthe following failcy management and safety programs:
+ Safety and security programs
+ Hazardous materials programs
+ Emergency management programs
+ Fire safery programs
241
4
a
FS
g
Pretec _Jonsr Cowasiow Irenrion Accatorrarow Srannasos rox Hosocrass 7 Ebro
and Safety (FMS)
Laws, regulations, and inspections by local authorities determine in large part how a facility is designed, used
and maintained. All organizations, regardless of size and resources, must comply with these requirements as
part of their responsibilities co their patients, Familie, staff, and visitors.
(Organizations are requited to comply with laws and regulations, including building and lite codes. They
are knowledgeable about the details of the physical facilites they occupy by performing regular facility
inspections. They proactively gather data and carry out strategies to reduce risks and to enhance the patient
Note: Some standards requize the hospital to have a written policy, procedure, program, or other written docu-
sent for specific processes. Those standards are indicated by a ® icon ater the standard vex.
Standards
‘The following is a list of all standards for this function. They are presented here for your convenience without
theie intent statements or measurable elements. For more information about these standards, please see the
next section in this chapter, Standards, Intents, and Measurable Elements
Leadership and Planning
‘The hospital complies with relevant laws, regulations, building and fire safety codes, and facility
inspection requirements,
FMS.2 A qulified individual oversees the facility management and safery
risks in the care environment.
sure to reduce and control
Risk Assessment and Monitoring
FMS.3 The hospital develops and documents a comprehensive risk assessment based on facility
management and safety risks identified throughout the organization, prioritizes the risks, establishes
goals, and implements improvements to reduce and eliminate risks
FMS8.4 Data are collected and analyzed fiom cach of the facility management and safety programs to
reduce risks in the environment, track progress on goals and improvements, and support planning,
for eplacing and upgrading facilities, systems, and equipment.
Safety
FMS.5__ The hospital develops and implements a program to provide a safe physical facility through
inspection and planning to reduce risks. ©
Security
FMS.6 The hospital develops and implements a program to provide a secure environment for patents
families, staff and vistors. ©
Hazardous Materials and Waste
FMS.7 The hospital develops and implements a program for the management of hazardous materials and
waste. ®
FMS.7.4 The hospitals program forthe management of hazardous materials and waste includes
the inventory, handling, storage, and use of hazardous materia.
FMS.7.2 The hospitals progeam for the management of hazardous materials and waste includes
the types, handling, storage, and disposal of hazardous waste. ©
242 Fxcuary Manaceusur ano Suce7v (FMS)
Fire Safety
FMS.8 The hospital exablishes and implement a program for fie safety that includes an ongoing
assessment of risks and compliance with national and local codes, laws, and regulations for fire
safey. ®
FMS.8.4 The fre safety programm includes the early detection, suppression, and containment of
fire and smoke. ®
FMS.8.2 The fresafey program includes measures to ensure safe exit from the facility when fre
and non-fire emergencies occur. ®
FMS.8.3 All fice safety equipment and systems, including devices related to early detection,
alarm notification, and suppression, are inspected, tested, and maintained. ©
FMS.8.4 The hospital involves stalin regular exercises to evaluat che fire safery program. ©
FMS.8.5 The fire safety program includes limiting smoking by staff and patients to designated
nnon-patient care areas of the facility. ©
Medical Equipment
FMS.9 The hospital develops and implements a program for the management of medical equipment
throughout the organization,
FMS.9.1 The medical equipment program inchides inspection, testing, preventive maintenance,
and documenting the results. ©
FMS.9.2 The hospital has a proces for monitoring and ating on medical equipment hazard
notices, recall, reportable incidents, problems, and flutes. ©
Utility Systems
FMS.40 The hospital develops and implements a program for she management of utility systems throughout
the organization,
FMS.10.4. The uilty systems program includes inspection, testing, and maintenance to ensure
that utlitis operate effectively and eficintly co meet the needs of patients, staf, and
visitors. ©
FMS.10.2 The hospital uly systems program ensures that essential utilis, including power.
water and medical gases, are available at ll eimes and alternative sources for essential
utilities are established and tested. ®
FMS.10.3. Designated individuals or authorities monitor water quality regularly
FMS.10.3-1 Quality of water used in hemodialysis is tested for chemical, bacterial,
and endotoxin contaminants, and processes for hemodialysis services
follow professional sandards for infection prevention and control. ®
Emergency and Disaster Management
FMS.41 The hospital develops, maintains, and tests an emergency management program to respond 10
intemal and excernal emergencies and disasters that have the potential of occurring within the
hospital and community. ®
Construction and Renovation
FMS.A2 When planning for construction, renovation, and demolition projects, or maintenance activites
that affect patient care, the organization conducts a preconstruction risk assessment. © E
Jour Coynassion Iurenvarena Aceneomarion Savoanos fon Hosrras, Pry Ebirion
and Safety (FMS)
Education
FMS.13 Siaffand others are trained and knowledgeable abous the hospital’ facility management and safety
programs and their roles in ensuring a safe and effective facilicy
Standards, Intents, and Measurable Elements
Leadership and Planning
Standard FMS.1
‘The hospital complies with relevant laws, regulations, building and fire safety codes, and facility inspection
requirements,
Intent of FMS.1
Laws, regulations, nd inspections by national and local authorities determine in large part how a facilicy
is designed, used, and maintained. All hospitals, regardless of size and resources, must comply with these
requirements as part of their responsibilities to their patients, families, staf, and visitors. Such requirements
ray difler depending on the facility's age and location and other factors. For example, many building
conscruction codes and fire safety codes, such as for sprinkler systems, apply only to new construction
Hospitals begin by complying with laws and regulations.
Some hospitals are located inside larger, multiuse buildings, such as high-rise office buildings and shopping
‘malls, and may lease or rene the space in which they provide cat, treatment, and services. In these
circumstances, itis necessary for hospital leadership co communicate with the property owner to ensure that
the building complies with relevant laws, regulations, codes, and other requirements. In addition, hospital
leadership communicates and collaborates with the property owner regarding shared building systems and
building-related issues not under the hospital's control. Ics important to understand expectations and who is
responsible for maintaining these ystems. Shared systems and building issues may include security, fre safety
(for example, fire alarms, fire suppression systems), emergency exis, maintenance of wilites (for example,
ventilation, water quality), and other building issues. Is important for hospital leadership co have access to
documents managed by the property owner, such as maintenance records and inspection reports relevant to the
hospitals facilities.
Hospital leadership and the hospital’ facility management and safety structure are responsible for
+ knowing whar national and local laws, regulations, building and fice safety codes, and ocher
requirements, such as licenses and permits, apply o the hospitals facilities;
+ implementing the applicable requirements or approved alternative requirements
* maintaining and documenting compliance with local and national laws, regulations, building and fre
safety codes, inspection reports, and other Facility requirements; and
+ planning and budgeting for the necessary replacement or upgrading of facilities, systems, and
equipment ro meet applicable requirements ora identified by monitoring daa or to meet applicable
requirements and providing evidence of progress toward implementing the improvements. (Ado see
GLD.1.1 and GLD.2)
‘When the hospital has been cited for not meeting requirements, hospital leadership takes responsibility for
planning and meeting the requirements in the prescribed time frame.
‘The hospital documents its building and fire safery laws, regulations, and codes and any corrective actions
taken co address citations from external facility inspections and reports by completing the “Laws and
Regulations Worksheet” and "External Auditing Body Recommendation Worksheet” in the Joint Commision
International Hospital Survey Process Guide or provides the same information in a different form or document
244 Faencrv Moise avo Satery (FMS)
Measurable Elements of FMS.1
D1. Hospital leadership and the facility managemene and safety structure understand and implement the
national and local laws, regulations, building and fre safety codes, and other requirements applicable
to the hospital’ facilities.
(2, Hospital leadership and the facility management and safety structure document corrective actions
taken co meet the conditions of external icility reports oF citations from inspections by national and
local authorities
3. Hospital leadership plans and budgets for replacing or upgrading facilities, systems, and equipment
needed ro mect applicable requirements and for the continued operation of a sae, secure, and effec-
tive facility
4, Hospital leadership approves and allocates budgeted resources ot implements alternative strategies to
reduce risks until the resources can be allocated.
5, When the hospital is located inside a multiuse building, hospital leadership obtains evidence of com:
pliance with relevant laws, regulations, codes, facility inspection reports, utility maintenance require-
ments, and other requirements related to shared systems and building issues
Standard FMS.2
A qualified individual oversees the facility management and safety structure to reduce and control risks in the
Intent of FMS.2
Hospitals work to provide safe, Functional, and supportive facilities for patients, Families, staf, and visitors. To
reach this goal, the physical facility, equipment, medical equipment, and people must be effectively managed.
Jn particular, management mast strive co
+ reduce and control hazards and risks
+ prevent accidents and injuries: and
+ maintain safe conditions
Effective management includes mulidisciplinary planning, education, and monitoring a follows:
‘+ Hospital leadership plans the space, medical equipment, technology, and resources needed to safely
and effectively support the clinical and nonclinical services provided.
+ Allscaffare educated about the facility, how to reduce risks, and how to monitor and to report
situations that pose tsk
+ Performance criteria are used to evaluate important systems and to identify needed improvements
Hospital leadership identifies an individual qualified by taining and experience ro oversee che facility
management and safety structure, which includes coordinating and managing risk assessment and risk
reduction activities in ehe physical envionment. (Ado see GLD.9) Training and experience may include, but is
not limited to, risk management, facility management, and hospital operations. The individual who oversees
the structure may be a member of leadership, a leader in charge of one of more of the facility management and
safety programs, or another designated individual. All facility management and safety programs report to this
individual, who is responsible for integrating and coordinating the activities and functions of the overall facility
‘management and safety structure. In a small hospital, onc individual may be assigned part-time to oversee
the structure Ina larger hospital, several engineers or other specially trained individuals may be assigned to
manage one or mote facility management and safety programs under the direction ofthe individual who is
responsible for the overall structure.
Es
2
a
245
Pu
eect ns CConsusson Ivrennarionas Accespranion Stanoanos rox Hosea, 7 Eoriov
The facilcy management and safety structure must be managed effectively and in a consistent and continuous
‘manner. The individual who oversees the facility management and safety steuctute is responsible for ensuring
the following:
a) Recommendations for space, medical equipment, technology, and other resources to support the
facility management and safety structure ae provided to hospital leadership.
) Facility management and safety programs are planned and developed for the following: safer, security,
hhazatdous materials and waste, ftesufecy, medical equipment, utility systems, emergency and disaster
‘management and construction and renovation
©) The facility management and safety programs are c
)_Sraffand others ate tained on the program.
©) The programs are evaluated and monitored.
f) “The programs are reviewed and revised at least annually, or more frequently if needed (for example,
swhen there are changes to requirements in the country’s laws and regulations; changes to the hospital’
facilities, systems, or equipment; and so on).
cand fully implemented.
Depending on the hospital’ size ane complexity, a facility safetylenvironmental risk committee or some
other mechanism may be formed to support the individual responsible forthe facility management and
safety sccuctute. For example, this commictee could coordinate activities of the facility management and
safety programs, such as completing rsk assessment activites, analyzing monitoring data, and implementing
facility improvements. Whatever the mechanism chosen by the hospital to support the individual responsible
for the facility management and safety scructure, a multdisciplinary team should be considered, and include
represcntatives from the various facility management and safety programs as well as leadership, infection
prevention and control, aboracory and radiation safety programs, laser safety, housekeeping services, and the
duality and patient safety program, among others.
‘When independent business entities are present within the organization, the hospital hasan obligation co
censure that these entities comply with relevant facility management and safeey programs. Independent business
cents ate independently owned businesses occupying space within the hospital; for example, coffe shops,
sift shops, and banks
Measurable Elements of FMS.2
1. Oversight and direction ofthe facility management and safety structure is assigned to an individual
qualified by experience and training, and evidence of the experience and training is documented,
D2. The qualified individual is responsible for elements 2) through f) ofthe intent.
3. The qualified individual is responsible for coordinating and managing risk assessment and risk ceduc-
tion activities forthe facility management and safety structure
4, When independent business entities are present within the organization, the entities comply with the
facility management and safety programs, as applicable.
Risk Assessment and Monitoring
Standard FMS.3
“The hospital develops and documents a comprehensive rsk assessment based on facility management and
safety risks identified throughout the organization, priorities the risks, establishes goals, and implements
improvements to reduce and eliminate risks.
&
3
Fe
and Safety (FMS)
or ucrury Maxacenenr an Sarery (EMS) N
Intent of FMS.3
Risk assessment identifies and evaluates potential failures and sources of errors in a proces and includes
prioritizing areas for improvement based on the actual or potential impact of care, treatment, ot services
provided.
“The hospital develops and documents a comprehensive, facilty-wide risk assessment, atleast annually, chat
integrates all eight facility management and safety programs to maximize safety to patients, patients family
staff, and visitors. The eight programs are as follows:
a) Safety
b) Security
Hazardous materials and waste
d) Fire safety
©) Medical equipment
1) Utility systems
g) Emergency and disaster management
h) Construction and renovation
The hospital priorities che integrated risks. Goals are established and improvements are implemented to
reduce and eliminate the risks. The goals and improvements are monitored for effectiveness, including,
progressing and sustained improvement. Changes may be required to goals and improvements based on
successes and challenges identified in monitoring data. (Abo see GLD.5)
(Note: Refer to the standards inthis chapter for requirements related to risk assessment activities for each program,
Measurable Elements of FMS.3
1, The risl assessments from all eight facility management and safety programs listed as a) through H) in
the intent are integrated to develop and document 2 comprehensive, fclicy-wide risk assessment, at
least annually.
o
“The hospital prioritizes the sks, identifies goals and improvements, and implements improvements
to reduce and eliminate risk.
3. The hospital evaluates the effectiveness ofthe improvements, and based on he results, the hospital
updates the applicable ficlty management and safety programs.
Standard FMS.4
‘Data are collected and analyzed from each ofthe facility management and safety programs to reduce risks
in the environment, track progres on goals and improvement, and suppor planning for replacing and
upgrading facilities, systems, and equipment.
Intent of FMS.4
Monitoring each ofthe facility management and safery programs through data collection and analysis,
provides information that helps the hospital reduce rsks, track progress on goals, make decisions on system
;provements, and plan for upgrading or replacing medical equipment, technology, and utility systems.
“The monitoring data for the facility management and safery programs are documented and integrated into
the hospitals quality and patient safety program. The individual who oversees the facility management and
safery structure submies reports of the monitoring data and goals to hospital leadership at least quarterly. This
individual submits the risk assessment and planned and implemented improvements to hospital leadership at
least annually.
a
a
Hospital leadership provides an annual report co the governing entity on che effectiveness ofthe facility
management and safety programs. (Abo see GLDA and GLD.4.1) The annual report includes
247
Ly
prt 5
Fe
rl
Jour Couassa Irewusrious Acceeuroanion Stanoasos rox Hoswrits 7 Eoiiow
and Safety (FMS)
+ the results of the comprehensive risk assessment, including priorities
+ goals, monitoring data, improvements, and any challenges from the past year; and
+ goals, planned improvements, and anticipated challenges for the coming year.
Measurable Elements of FMS.4
1. Monitoring data ae collected and analyze for cach of the facility management and safety programs
and used to reduce risks in the environment and support planning for replacing or upgrading faili-
tis, ystems, and equipment.
2. Monitoring data For the facility management and safety programs are documented and integrated
Jno the hospitals qualiey and patient safery program.
3. Theindividual who oversees the facility management and safety structure provides monitoring data
reports that address the effectiveness of each program and progress on goals to hospital leadership on
a quarterly bass, and leadership rakes ation,
D4, ‘The individual who overses the facility management and safety structure provides the comprehen-
sive, facility-wide risk assessment and planned and implemented improvements to hospital leadership
av lease annually.
5. Hospital leadership provides an annual report co the governing entity on the effectiveness ofthe facil-
ity management and safey programs, and the governing entity takes action,
Safety
Standard FMS.5
‘The hospital develops and implements a program to provide a safe physical facility through inspection and
planning to reduce risks. ©
Intent of FMS.5
Safety refers to ensuring thatthe building, property, medical and information technology, equipment, and
systems do not pose a physical risk to patients, families, staff, and visitors. Prevention and planning are
essential to creating a safe and supportive patient care facility. Effective planning requires the hospital to be
aware of all the risks present inthe Facility. The goal are to prevent accidents and injuries and ro maineain safe
and secure conditions for patients, staff, and others, such a
trainees, and students
smilies, contractors, vendors, voluntees, visitors,
“The hospital develops and implements a written safety program. (Als see PCC.1.5; AOPS.3: AOR6.2:
COR3.5; COR4; COPA.1; and PCL.2) As part of che safety program, the hospital conducts and documents,
an ongoing inspection of its physical facilities. The results of the inspection are reviewed and addressed
ina documented risk assessment, a least anally, co identify areas in which safety risks and potential for
harm exist. The risk assessment also considers a review of processes and an evaluation of new and planned
services that may pose safety risks. Ic is important to involve a multidisciplinary team when conducting safety
inspections in the hospital. Examples of safety risks that pose a potential for injury ot harm include sharp and
broken furniture, broken windows, wate leaks in the ceiling, ergonomic risks (for example risks to staff when
‘moving patients or heavy objects), and fll risks (for example, due to uneven ot slippery floors or missing
handrails
Conducting regular rounds to inspect for safety risks, and the annual safety rsk assessment, help the hospital
‘identify, prioritize, plan for, and carry out improvement. Prioritizing and planning also includes budgeting for
longer-term facility, system, and equipment upgrading or replacement.
248 Frensry Miocene avo Sarery (EMS)
Measurable Elements of FMS.5
D1. ‘The hospital develops and implements a written program 10 provide a safe physical faci.
D2, Thehospital asa documented, current, accurate inspection of is physical facilis,
D3, ‘The eesulesfeom the facility inspection ace reviewed and addressed in a safety risk assessment chat
isconducted and documented annually, and safety risks are identified and prioritized from the risk
4, The hospital identifies goals, implements improvements, and monitors data to ensure chat safety risks
ate reduced or eliminated.
eee
Security
Se ee eee eager egg eee SSS
Standard FMS.6
‘The hospital develops and implements a program o provide a secure environment for paciens, families, staf,
and visitors. ©
Intent of FMS.6
Security eers to protecting the organization's property and the patient, families, visitors, and staff from harm
or loss, (Ali see PCC.1.4 and COP3.5) Examples of vulnerabilities and threats related to security rsks include
‘workplace violence, infant abduction, theft, and unlocked unsecured access to restricted areas in the hospital
Securigy incidents can be caused by individuals from either outside or inside the hospital
The hospital develops and implements a written security program to ensure that everyone in the hospital is
protected from pecsonal harm and loss or damage to property. As part of the security program the hospital
‘conducts and documents a risk assessment, a least annually, co identity areas in which security risks exist. The
tisk assessment also considers a review of processes and an evaluation of new and planned services that may
pose security risks
Staff, students, wainees, contract workers, volunteers, vendors, individuals associated with independent
business entities, and others, as determined by the hospital, are identified by badges (temporary or permanent)
‘or another form of identification. Others, such as families and visitors in the hospital, may be identified
depending on hospital policy and laws and regulations.
Restricted areas such asthe pharmacy, newborn nursery, and operating theatres must be secure and monitored.
(Alo see MMU.3.1) Children, elderly adults, and vulnerable patients not able to protect themselves or signal
for help must be protected from harm. In addition, remote or isolated areas of the facility and grounds may
require the use of security cameras.
Measurable Elements of FMS.6
(1. The hospital develops and implements a written program to provide a secure environment
D2. A security risk assessment is conducted and documented annually throughout che facility and secu-
tity risks ate identified and prioritized from che rsk assessment.
3. The security program idemtifisall security rs areas and restricted areas and ensures they are moni-
tored and kepe secu
D4, The security program ensures char al staff. students,tainees, contract workers, volunteers, vendor.
and individuals asocated with independent business entices ace iden.
D5, The hospital identifies goals and implements improvements in che security program, and monitors
data to ensure that security risks are reduced or eliminated.
249
Es
E
EL
Stet ie! s
Jour Consuson Ivrenuarowns Accresrranion Sranasos ron Hosts, Ze Eoiion
ay
=
rf
————SSSSSSSSSSSSSSSSSSSSSseFeseseees
Hazardous Materials and Waste
Standard FMS.7
“The hospital develops and implements a program forthe management of hazardous materials and waste. ©
Standard FMS.7.1
“The hospitals program for the management of hazardous materials and wast includes the inventory handling,
srorge, and use of hazardous materials. ©
Standard FMS.7.2
The hospitals program for the management of harardous materials and waste includes the ype, handling,
storage, and disposl of harardous waste. ©
Intent of FMS.7 Through FMS.7.2
“The hospital develops and implements a written program for the management of hazardous materials and
‘waste that includes identifying and safely controlling these materials and waste throughout the facility. (Adi see
AOPS.3; AOPS.6; MMU. 3; and PCL8) As part of the hazardous materials and waste program, the hospical
conducts and documents risk asesvmnent, atleast annually to identify areas in which risks exist The tsk
assessment also considers a review of processes and an evaluation of new and planned services that may increa
risk related to hazardous materials and waste,
“The hospital identifies and develops an inventory of its hazardous materials. The hospital start by
doing a thorough search forall areas within the organization where hazardous materials may be located.
Documentation from this search should include information about the type ofeach hazardous material being
stored, the quantities (or example, approximate or average) and the location(s) inthe organization. This
documentation should also address maximum quantities allowed for storing the hazardous material in one
location/area. For example, ifthe material is highly flammable oF toxic, there are limits on the quantities of the
‘material cha ean be stored in one location. An inventory of hazardous materials i created and updated, at leas
annually, ro reflect changes in the hazardous materials used and stored in the organization.
Hazardous materials can be categorized by the following:
+ Chemicals (for example, chemicals used for cleaning, disinfection, sterilization, water treatment,
pathology, hand hygiene, and others)
+ Cyrotoxic drugs
+ Radiozetive material
+ Medical gases
The hospital abo establishes the ypes of hazardous waste generated by the organization and how they are
‘identified (for example, color-coded and labeled waste bags/bins).
‘The following are categories of hazardous waste:
Infectious
Sharps
Pathological and anatomical
Pharmaceutical
CChemicalsfheavy metals)pressurized containers
Genotoxicleytoroxic
Radioactive material
250 Fxcurry Masacenenr ano Sarery (PMS)
The hospitals hazardous materials and waste program addresses hazardous materials and hazardous waste and
include processes for
+ the inventory of hazardous materials and waste that includes the type, the location(s), and the
{quanitics (for example, approximate or average in each location);
+ updating the inventory of hazardous materials at lease annually;
+ safe handling, storage, and use of hazardous matcrals
+ proper and clear labeling of hazardous materials that is consistent with information from the safety
daa sheets (SDS);
+ establishing and identifying categories of hazardous wastes
+ safe handling and storage of hazardous waste;
+ tracking quantity of and proper disposal of hazardous waste in accordance with local ws and
regulations:
+ proper protective equipment and proceduces for spills and exposures;
+ reporting and investigation of spills, exposures, and other incidents; and
+ documentation, inclading any permits, licenses, or other regulatory requirements
Information regarding procedures for handling or working with hazardous materials and waste in a safe
‘manner must be immediately available at all imes and includes information about the physical data of the
acral (such as its boiling point, ashpoine, and the like), its toxicity, whac effects using the hazardous
‘material may have on health, identification of proper storage and disposal ater use, che type of protective
equipment requited during use, and spll-handling procedures, which include the required firs aid for any type
of exposure, Many manufacturers provide this information in the form of SDS.
In the event of a hazardous materials spl, che hospital has procedures for responding to and managing spills
and exposures, Procedures include having spill kits available where nceded with the appropriate personal
protective equipment and spill control materials forthe potential type and sizeof spill. Procedures also address
hhow to report spills and exposures.
Hospitals implement procedures for responding to 2 hazardous material exposure, including initial frst aid,
obiaining appropriate medical care, reporting incidents, and so on. Exposure ro a hazardous material requites
immediate access to the appropriate first aid In some cases, such as with an exposure to a corrosive or caustic
‘chemical, access to an eyewash station may be necessary for immediate and continuous ushing to prevent of
minimize injury. An eyewash sation is designed to Aush both eyes simultaneously for 15 continuous minutes
ata flow rate of 1.5 lites per minute (04 gallons per minute). However, an eyewash station may not be
needed in all cases of hazardous material exposures. Hospitals should conduct a risk assessment to identify
where inthe organization eyewash stations are required, taking into account the physical properties ofthe
hazardous chemicals used, how these chemicals are used by staf o perform their work activities, and staff’
tse of personal procective equipment. Alternatives to an eyewash station may be appropriate depending on the
types of risks and potential for exposures. For example, personal cyewash bottles may be appropriate in areas
where exposure to a mild irritant isa tisk, of where individuals could use the bottles for immediate Bushing,
as they make their way to a proper eyewash station or get co an area for medical attention, Hospitals that have
eyewash stations installed must ensure proper maintenance, including a weekly flush and annual preventive
Measurable Elements of FMS.7
1. The hospital develops and implements a written program for the management of hazardous materials
and waste
2 Abazardous materials and waste risk assessment i conducted and documented annually throughout
the facility, and risks related 0 hazardous materials and wast are identified and prioritized from the
risk assessment.
3, The hospital identifies goals, implements improvements and monitors data to ensute chat risks
related to hazardous materials and waste are reduced or eliminated.
251
re
ae / Jour Const erenaion Acceeorraion Stans rot Ho
Tene Cea?
ry
o
Eomow
Measurable Elements of FMS.7.1
1, The hazardous materials and waste program identifies the ype, quantities, and locations of hazardous
materials and has a complete inventory, which is updated at least annually o relect changes in the
hazardous materials used and stored in the organization.
2, Thehazardous materials and waste program establishes and implements procedutes for safe handling,
storage, and use of hazardous materials
3, The hazardous materials and waste program establishes and implement the proper protective equip-
ment required during handling and use of hazardous materials.
D4, The hazardous materials and waste program establishes and implements proper and clear labeling of
hazardous materials that is consistent with information from the safety data sheets (SDS).
D5, The hazardous materials and waste program establishes and implements procedures for the manage
ment of spills and exposures, including the use of proper protective equipment and reporting of spills
and exposures.
6. Information about the hazardous materials related co safe handling, spill-handling procedures, and
procedures for managing exposutes are up to date and available a all times.
Measurable Elements of FMS.7.2
11. Thehazardous materials and waste program establishes the types of hazardous waste generated by the
hospital and how they are identified.
2 The hazardous materials and waste program establishes and implements procedures and the proper
protective equipment required for safe handling and storage of hazardous wast.
D3, When requited by local laws and regulations, the hazardous materials and waste program documents
the quantities of hazardous waste generated by the hospital
—— eee
Fire Safety
——
Standard FMS.8
The hospital establishes and implements a program for fre safery that includes an ongoing asessment of risks
and compliance with national and local codes, laws, and regulations for fie safety. ©
Intent of FMS.8
Hospitals most be vigilant about fre safety, as ie i an ever-present rsk in che health care environment. To
protect all occupants ofthe hospital’ facilites from fire and smoke, the hospital develops and implements a
writen program for fie safety. (Abo see PCC.1.5) The fire safery program aso addresses non-fire emergencies
for example, a toxic gis lak, which can pose a threat to occupants and require evacuation.
‘An ongoing assessment of compliance with the country’ codes, hws, and regulations related to fire safery i
important for identifying and minimizing risks. The hospital performs and documents an ongoing fire safety
risk assessment chat inchides the followings
2) Fire separations
1) _ Smoke separations/compartments
6) Hazardous areas (and spaces above the ceilings in those areas) such as soiled linen rooms, sash
collection rooms, and oxygen storage rooms
d) Fire exits
6) _ Kitchen grease producing cooking devices
252 ) Laundry and crash chutes
Emergency power systems and equipment
hh) Medical gas and vacuum system components
|) Storage and handling of potenially flammable macerials (for example, flammable liquids,
combustible gases, and oxidizing medical gases such as oxygen and nitrous oxide)
})_Procedues and precautions prevent and manage surgical fires
1) Fite hazards related to construction, renovation, or demolition projects
Risks are identified from the ongoing assessment. For example, risks may include equipment, systems, of ther
features for fie safety that are damaged, obstructed, nonfunctional, or need ro be removed. Risks may also be
identified from construction projects, hazardous storage conditions, equipment and system breakdowns, or
necessary maintenance that impacts fie safety systems, among other reasons.
When risks are identified, they ate immediately addressed and cortecced (for example, through repair, removal,
replacement, or other means). When the risks cannot be addressed immediately, the hospital has a process for
identifying when interim measures should be implemented, An interim measure(s) may be necessary when
the planned improvement to address the fre safety risk cannot be implemented right away. The purpose of
implementing interim measures isto ensure the safery ofthe building’ occupants duting times when features
and systems for fire safety are defective, compromised, or inoperable due to construction, maintenance, or 3
breakdown or repair. The type of and need for an interim measure(s) will depend on the type and scope of
the fire safety risk and the amount of time until the planned improvement to fully address th risk will be
implemented.
“The fie safety program includes criteria for evaluating when and co what extent interim measures should be
implemented
‘Examples of interim measures include posting signs to identify alternative exits: inspecting enitsfexit routes on
a daily basis in the affected area: providing temporary but equivalent fire alarm and detection systems when 2
‘ystem is impaired; providing additional firefighting equipments increasing fire safety surveillance of buildings,
grounds and exuipmen and providing nal tng of staff on the use of firefighting equipment
among other interim measures.
‘The hospital considers the risk posed to patients, staf, and others when determining che plan and time frame
for implementing improvements and/or interim measures. The ongoing risk assessment and time frame for
implementing interim measures and improvements is documented,
Note: A list of additional interim measures can be found in the Appendix atthe end of the "Facility
Management and Safety” (FMS) chapter.
Measurable Elements of FMS.8
1. The hospital develops and implements a written program for fire safery to protect all occupants of the
hospital’ facilites From fie, smoke, and non-fire emergencies.
2 The hospital performs and documents an ongoing fire safety risk asessment related to atleast a)
through k) in the intent, and fie safety risks are identified and prioritized from the risk assessment.
D3, The fire safety program includes implementing interim measures, when necessary, to ensure that
the safety ofthe hospitals patients, staf, and visitors is maintained when fire safety risks cannot be
immediately addressed
OQ 4 The hospital identifies goals, implements improvements, and monitors data to ensute that Gre safety
Fisks ate reduced or eliminate.
rv Manacewenr ao Saver (FMS)
rere
rots _Jowr Conus Iwrewvariona. AccReorario Stayoanos ror Hosprus, 7 Ebon
a
a
a
———
Standard FMS.8.1
“The fire safety progam includes the carly detection, suppression, and containment of re and smoke. ®
Standard FMS.8.2
“Te fie safety progam includes measures o ensure safe exit from the facility when fire and non-fre
emergencies occur. ®
Intent of FMS.8.1 and FMS.8.2
Every hospital needs to plan how it will keep its occupants safe in case of fire, smoke, and non-fire emergencies
Healthcare facility structure and design can help preven, detect, and suppress fires and provide safe ext fom
the facility. The hospitals program for fre saery addresses
+ early warning, early detection, and notification systems, such as smoke detectors, fte alarms, and fre
patrols:
+ suppression mechanisms, such as water hoses, fie extinguishers, chemical suppression systems, and
sprinkler systems:
+ containment of fire and smoke, including fire separations and smoke compartments, when required
by local laws and regulations; features for containment of fire and smoke are maintained to ensure
their effectiveness; and
+ safe and unobstructed access to exits in the event ofa fire or non-fire emergency, including clear exit
signage that is understandable to the hospital's occupants (for example, with a pictogram and/or
language(s] chat the majority of occupants understand) and emergency lighting
Features such as these give patients, staf, and visitors adequate time ro safely exit the facility or reach a safe
location within the facility in the event of fire, smoke, or non-fire emergencies. These features are effective no
‘matter what the age, size, oF consteuetion of the facility
Measurable Elements of FMS.8.1
D1. The fie safety program includes equipment/ystems forthe exely detection and alarm notification of
fire and smoke
D2, The fire safety program includes equipment/systems for the suppression of fire.
3, When required by local laws and regulations, the fire safety program includes containment of fire and
smoke, and these features are maintained ro ensure effectiveness and safery.
Measurable Elements of FMS.8.2
D1. The ie safery program inchudes the safe exi from the facility through fiee and unobstructed access
woaiits
D2 Thefie safety program includes clearly visible ext signage that is understandable tothe hospital’
cccupants
3, Thefire safety program includes lighting for emergency exit corridors and stale
a
Standard FMS.8.3
Ail fite safety equipment and systems, including devices related to early detection, alarm notification, and
suppression, are inspected, tested, and maintained. ©
254 Ensry Mavaceuenr ant Saree (FMS)
Intent of FMS.8.3
‘The hospital’ fre safety program identifies the frequency of inspecting, testing, and maintaining fire protection
and safety systems, consistent with requirements, Fire safety equipment and systems in hospitals include, bue
are not limited co, the following:
+ Heat and smoke detectors
Fire alarms
Fire pumps
Seandpipe systems
Sprinklers
Fire suppression systems
Fire hoses
Portable fire extinguishers
Fie doors and assemblies (including sliding and roll down doors)
‘Automatic shutdown deviees for air handling systeras
‘Automatic smoke management systems
The hospital inspects, tests, and maintains all ie safety equipment and systems within is building(s),
including equipment for ealy detection and suppression of fire and smoke. Activities and freq
inspection, testing, and maintenance are consistene with manufacturers recommendations. When local codes,
laws, and regulations include requirements for inspection, testing, and maintenance offre safety equipment
and systems, the hospital follows the more stringent requitements, whether those are the manufacturers
recommendations or the local codes, laws, and regulations
Any deficiencies identified, such as impaired or nonfunctioning systems and equipment, ae immediately
corrected. When corrections cannot be immediatly carvied out, interim measures are implemented to reduce
fire risk and ensure safety of patients, staff, and vistors until deficiencies can be fully corrected. The results of
all inspections, testing, and maintenance are documented, including corrections and interim measures that are
implemented.
Note: A list of interim measures can be found in the Appendix atthe end of the “Facility Management and
Safety” (FMS) chapter.
Measurable Elements of FMS.8.3
G1. All fice safety equipment and systems, including those for smoke and fire detection and suppression,
are inspected, tested, and maintained according to manufacturers’ recommendations or as required
by local codes, ws, and regulations, whichever sets the more stringent requirement.
2 Inspection, esting, and maintenance of all fre safety equipment and systems are documented,
inclading results and corcective actions.
3, Any deficiencies identified in fire safety equipment and systems are immediatly corrected, o interim
measures are implemented to reduce fie rsk unl deficiencies can be fully corrected
Standard FMS.8.4
“The hospital involves staff in regular exercises co evaluae the fire safety progeam. ®
Intent of FMS.8.4
“The hospital’ fire safery program identifies
+ the lan for reporting and responding toa fie emergency;
+ the plan for safely evacuating the facility in the event of fie, smoke, or non-fite emergencies;
+ the process for testing all portions of the fire safety program during each 12-month period:
(Creat
STM 8
Jour Cousin fren mow Acceeorreron Sunoanos ron Hoss, Pra Eomoy
and Safety (FMS)
+ the responsibilities of different staff members during a fire emergency:
+ thenecessary education of staf to effectively protect and evacuate patients when an emergency occuts
and
+ the participation of staff members in at least one fire safety exercise per year. (Abo see FMS.13)
Exercises to evaluate the fre safety program can be accomplished in multiple ways. For example, to ensure that
staff know what vo do, how to exit, and where to assemble (the “assembly points"), che hospital may choose
to conduct evacuation exercises during various shifts, including nights and weekends. (Evacuation exercises in
areas such asthe intensive care unit, operating theatre, or on high Roors of the building may provide additional
insights but are nor mandatory,) Note: Evacuation exercises to evaluate the fire safety program should not
involve patient.
Another example of an exercise to evaluate the fie safety program includes assigning a “fire marshal” to each
unit and having him ot her randomly quiz che staff about what they would do ifa fre occurred on their unit,
The staff can be asked specific questions, such as, “Whereis the oxygen shutofl valve? Ifyou have to shut off
the oxygen valve, how do you take care of patients who need oxygen? Where are the fire extinguishers on your
unit located? How do you report afte? How do you protect the patients during afte? Ifyou need to evacuate
patients, what is your process?” Staff should be able to respond correctly to these questions. ‘The fire marshal
should keep a record of those who participated. Other examples of exercises include computer-based teaching
and testing or a written test for staf to take relating tothe fire safety program,
‘Whatever the exercise chosen to evaluate the fire safery program, staff should be knowledgeable of the program
and be able 10 describe how to bring patients ro safety. Staff who do not pass are reeducated and retested,
Measurable Elements of FMS.8.4
D1. Stat from all shifts, including the night shift and weekends, annually participate in an exercise to
evaluate the fire safety program,
1 2. Sua are knowledgeable ofthe fire safety program and can describe how to bring patient to safer.
A 3. Results of exercises co evaluate the fie safery program ate documented, and staff who do not pass are
reeducated and retested on the ie safery program
OO
Standard FMS.8.5
The ie safety program includes limiting smoking by staff and patients to designated non-patent care areas of
the Fly.
Intent of FMS.8.5
“The fire safety program addresses limiting smoking and
+ applies roll patients, families, staff, and vistors
+ eliminates smoking in the hospital’ facilities or minimally limits smoking to designated non-patient
care areas that are ventilated to the outside; and
*+ prohibits smoking in all areas under construction or renovation.
‘Smoking includes, but is not limiced to, the use of cigarettes, cigars, pipes, hookahs, electronic cigarettes,
(including e-cigarettes and vaping devices), and other ignition sources for smoking.
“The fre safety programm that addresses limiting smoking identifies any exceptions related to patients, such as the
medical or psychiatric reasons a patient may be permitted to smoke, and those individuals permitted to grant
such an exception. When an exception is made, the patient smokes in a designated, nontreatment area, away
from other patients Measurable Elements of FMS.8.5
1. The fire safety program addresses eliminating or limiting smoking within the hospital Facility.
C2 The program applies to patients, Families, visitors, and stall:
G3. The program identifies who may grant patient exceptions for smoking and when those exceptions
apply.
Q 4, Smoking is prohibited inal areas under construction or renovation
Medical Equipment
Standard FMS.9
“The hospital develops and implements a program for the manages
of medical equipment throughout the
organization,
Standard FMS.9.1
‘The medical equipment program inchudes inspection, testing, preventive maintenance, and documenting the
results. ®
Intent of FMS.9 and FMS.9.1
The hospital develops and implements a written program for the management of medical equipment
throughout the hospital. As part of the medical equipment program, the hospital conducts and documents
a risk assessment, at least annually, ro identify areas in which medical equipment risks exist. To ensure chat
‘medical equipment is available for use and functioning properly, che hospital performs and documents
+ an inventory of medical equipment;
*+ regular inspections of medical equipments
+ testing of medical equipment according to its use and manufacturer’ requirements; and
+ performance of preventive maintenance.
Qualified individuals provide these services. Medical equipment is inspected and tested when niew and then on
an ongoing basis, according to the equipment age, use, and manufacturers instructions. Inspections, testing
results, and any maintenance are documented. This helps ensute the coutinuity ofthe maintenance process and
helps when doing capital planning for replacements, upgrades, and other changes. (Also see AORS.5; AOP..4;
COP3.3; COPS: and COPA.1)
Measurable Elements of FMS.9
1. The hospital develops and implements a written program for the management of medical equipment
throughout che hospical
C2. A medical equipment risk assessment is conducted and documented annually throughout the hospi-
tal, and medical equipment risks are identified and prioritized from the risk assessment.
3. The hospital identifies goals, implements improvements, and monitors data to ensure that medical
equipment risks ae reduced or liminate,
257 cian
7 Jones Cousion bvsessarionar Accarbrinion Stanoanos roe Hostras, Pr Borrow
and Safety (FMS)
Measurable Elements of FMS.9.1
(21, The medical equipment program addresses hospital-owned and nonhospital-owned medical equip-
‘meat in the organization, such as equipment that is leased, rented, brought in by physicians and
‘other health care practitioners, brought in by patients, and so on.
a
C3. Medical equipments inspected and tested when new and according to age, use and manufactures?
recommendations thereafter.
‘The medical equipment program includes an inventory of all medical equipment.
D4, The medical equipment program includes preventive maintenance and calibration as applicable.
ess
Standard FMS.9.2
The hospital has a process for monitoring and acting on medical equipment hazard notices, recalls reportable
incidents, problems, and fires. ©
Intent of FMS.9.2
“The hospital has a system in place for monitoring and acting on medical equipment hazard notices, recalls,
reportable incidents, problems, and failures sent by the manufacturer, supplier, or regulatory agency: Some
countries require reporting of any medical equipmenc that has been involved in a death, serious injury, oF
illness. Hospitals must identify and comply withthe laws and regulations pertaining co reporting of medical
equipment incidents. The hospital conducts a root cause analysis in response ro any sentinel events The
‘medical equipment management program addreses the use of any medical equipment witha reported problem
or failure, or that isthe subject oFa hazard notice or is under recall. (Abo see ASC.7.4)
Measurable Elements of FMS.9.2
1. The hospital has a process for monitoring and acting on medical equipment and implantable device
hazard notices, recalls, reportable incidents, problems, and failures
2 The hospital eports any deaths, serious injuries, oF illness that ae a result of medical equipment
‘through the hospital’ incident and adverse event reporting process
G3. The medical equipment management program addresses the use of any medical equipment with a
reported problem or flure, or that is the subject of a hazard notice oi under real.
——
Utility Systems
es
Standard FMS.10
“The hospital develops and implements a program for the management of utility systems throughout the
organization,
Standard FMS.10.1
“The utility systems program includes inspection, restin
4. Actions are taken and documented when water quality is found to be unsafe.
G5. Dental unit waterlines are treated and tested according to manufacturer's guidelines, and ereatments
and testing are documented
Measurable Elements of FMS.10.3.1
C1. Hemodialysis services in the hospital follow industry standards and professional guidelines for main-
taining water quality and implementing infection prevention and control measure.
(2. Water used in hemodialysis is tested monthly for bacterial growth and endotoxins and tested annu-
ally for chemical contaminants. The testing results are documented.
3, The hospital performs routine disinfection of the hemodialysis water distribution system,
4. The hospital conducts esting on all hemodialysis machines annually, including machines not in use,
and testing results are documented.
5. The hospital establishes and implements procedures for reprocessing dialyzes, inclading, as applica-
ble, Frequency for reusing/replacing dialyzers and processes for cleaning and testing dialyzes.
262 Facrry May
Emergency and Disaster Management
Standard FMS.11
‘The hospital develops, maintains, and tests an emergency management program (o respond to internal and
external emergencies and disasters that have the potential of occurring within the hospital and community. ©
Intent of FMS.11
‘Community emergencies and disasters may directly involve the hospital, such as damage to pat
asa result ofan earthquake, tsunami, or terrorist attack that keeps staff from coming to work.
and respond effectively to emergencies and disasters, the hospital develops and implements an emergency and
clsaster management program. The development of the program begins by identifying the types of emergencies
and disasters that ae likely to occur in the hospitals region (for example, earthquakes, yphoons, floods,
landslides, explosions, or others) and the impact these emergencies and disasters would have on the hospital
For example, a hurricane or tsunami is more likely o occur in areas where the ocean is near; however, facility
damage or mass casualties asa resule of war ora terrorist attack could potentially occur in any hospital
plan, prepare,
Hospitals play a sgnificanc role in the community during emergencies and disasters. In order for hospitals to
maintain operations during and after emergencies and disasters, itis important ro evaluate and identify the
seructural and nonstructural limitations ofthe hospital’ buildings. Determining how buildings will respond
to the emergencies and disasters that are likely to occur inthe region isan important aspect in developing
evacuation plans and identifying priority areas for building improvements
‘An evaluation of structural elements includes the type of building design and materials as well s components
of the building’ load-bearing system, including the foundation, columns, beams, walls, floor slabs, and so
oon. The building’ location is aso considered part ofthe structural elements (for example, risks related 10
proximity co other buildings, location in a hazard zone such asa floodplain, and other issues). An evaluation
of nonstructural elements includes architectural elements that are not load-bearing (such as the roof, ceilings,
windows, and doors): emergency access and exit routes to and from the hospital; critical systems (such as
clectricity, plumbing, waste management, fire protection); medical and laboratory equipment and other
nonstructural elements that are crucial for the safe operation of the hospital An evaluation of structural and
nonstructural elements allows the hospital to identify vulnerabilities and develop plans for addressing these
‘vulnerabilities and improving hospital safety and preparedness.
Ivis just as important to identify the probable effects of an emergency or disaster a itis to identify the types of
‘emergencies and disasters likely co occur. (lio see PCI.12.2 and MOI.13) This helps in planning the strategies
that are needed in the event thac che hospital experiences an emergency ot disaster. For example, what is the
likelihood that a natural disaster, such as an earthquake, will affect water and power? Could an earthquake
prevent staff from responding to the disaster, cither because roads are blocked or because they or theit family
‘members ate alo victims ofthe event? In such situations, staff responsibilities for their families and/or personal
safety may make it difficult or impossible co be at the hospital responding to the emergency ot disaster.
Hospitals need to identify and plan for other resources when staff may not be able to come to the hospital ©
provide and support patient care during an emergency or disaster.
Jn addition, hospitals need to idemtfy their role within che community. For example, what resources will the
hospital be expected to provide to the community in the event that an emergency or disaster occurs, and what
communication methods will be used within the community?
“The hospitals emergency and disaster management program provides processes for
a) determining the type, likelihood, and consequences of hazards, cheats, and events
b) identifying the structural and nonstructural vulnerabilities of the hospita’s patient care environments
and how the hospital will perform in the event of an emergency or disaster:
263
cer ano Serer (FMS)
Reet
(sw4) 7 Jour Counsion beremvarionas AcceeDIriow Stanuagas tox Ho
FS
iris
and Safety (FMS)
as 70 Eurron
©) planning for alternative sources of power and water in emergencies and disasters; (ho se FMS.10.2)
d) determining the hospitals role in such events;
©) determining communication strategies for events
6) managing resources during events, including alternative sources
8) managing clinical activities during an event, including alternative care sites;
h) identifying and assigning staf roles and responsibilities during an event (including contact staff,
vendors, and others identified by the hospital); (Ado see FMS.13) and
i) managing emergencies and disasters when personal responsibilities of staff confict withthe hospital’
responsibility for providing patient car. (Abo see MOI.13)
The emergency and disaster management program is rested by
‘+ an annual est of the fall program internally or as part of a community-wide test or
+ testing of critical elements c) through i) ofthe program during the yea.
Note: Letter ) is part of requirements for testing alternative sources of utilities in FMS. 10.2,
If che hospital experiences an actual emergency or disaster, activates its program, and debricfs properly
afterward, this situation represents the equivalent ro an annual test,
Measurable Elements of FMS.11
C11. The hospital develops, evaluates, and maintains a written emergeney and disaster management pro-
gram that identifies its response to likely emergencies and disasters, including items a) through i) in
the intent.
2. The hospital has identified the major incernal and excernal emergencies andlor disasters such 2s com-
munity emergencies, and natural or other disasters that pose significant risks of occurring, taking into
consideration the hospital's geographic location.
D3, The hospital identifies the probable impact har each type of disaster will have on all aspects of care
and services.
4, The entire program, oF at least critical elements ¢) through i) of the program, is tested annually.
‘Ac che conclusion of every test, debriefing of the rest is conducted.
ooo
66, Follow-up actions identified fiom testing and debriefing ae developed and implemented.
Construction and Renovation
Standard FMS.12
‘When planning for construction, renovation. and demolition projets, or maintenance activities that affect
patient car, the organization conducts a preconstruction rsk assessment. ©
Intent of FMS.12
Construction, renovation, demolition, and maintenance activities in a hospital can have an impact on everyone
in the organization; however, patients may suffer the greatest impact. For example, the noise and vibration
associated with these activities can affect patients’ comfort level, and dust and odors can change air quality,
which may pose a threat to a patient’ respiratory status, The risks to patients, staff, visitors, independent
business entities, and others in che hospital will vty depending on the extent of the construction, renovation,
demolition, or maintenance activity and its impact on patient car, infrastructure, and utilities, For example,
maintenance activity that involves medical gases may impact patient care; however, resurfacing the staf parking
Jot may have no impact on patent care.
264 car Maxacessens ao Ser (EMS) S.
In order to asses the risks associated witha consteuction, renovation, or demolition project, ora maintenance
activity that afects patient cate, che hospital brings relevant departments together, including, as needed,
representatives from project design, project management, facilities engineering, facility secutty/safery, infection
prevention and contol, fie safety, housekeeping, information cechnology services, and clinical departments,
and services
Risks ate evaluated by conclcting a preconstruction risk assessment, also known as PCRA. The tsk assessmene
is used to comprehensively evaluate risks in order to develop plans and implement preventive measures that
will minimize the impact the project will have on the quality and safer of patient care, For example, measures
to reduce fire risk and ensure safe exit are implemented when fire safey risks are identified. Required ateas of
the preconstruction risk asessment include
a) air quality
b) infection prevention and control; (Aio see PCI.11)
) utilities
A) noise;
«) vibration;
) hazardous materials and wast
8) fire safery
hy security:
i) emergency procedures, including alternate pathways/exits and access to emergency services; and
i) other hazards that affect cate, eeatment, and services
In addition, the hospital ensures that contractor compliance is monitored, enforced, and documented. As part
‘of the risk assessment, patient risk of infection from construction is evaluated through an infection control risk
assessment, aso known as ICRA.
Measurable Elements of FMS.12
1. When planning for construction, renovation, or demolition projects, or maintenance activities chat
affect patient care, the hospital conduets a preconstruction risk assessment (PCRA) for atleast a)
through j) in the intent.
12, The hospital takes action based on its assessment to minimize risks during construction, renovation,
id demolition projects, and maintenance activites that affect patient care,
3, The hospital ensures that contractor compliance is monitored, enforced, and documented,
ee
Education
ee
Standard FMS.13
Staff and others are trained and knowledgeable about the hospitals facility management and safety programs
and their roles ip ensuring a safe and effective fail
Intent of FMS.13
Sia are the hospitals primary source of contact with patients families, and visitors. Thus, they need to
be educated and trained to catry out cei roles in identifying and reducing risks, protecting others and
themselves, and creating a safe and secute facility. (Abo see FMS.8.4 and FMS.11)
Each hospital must decide the type and level of taining for staff and then implement and document a program
for che training, ‘The training program can include group instruction, online educational modules, printed
‘educational materials, a component of new staff orientation, and/or some other mechanism that meets the
hospital's needs. Training is provided to all sta¥ on al shifts on an annual basis and addresses all facility
265
Fa
& Jost Couasion leremuaronat Acceeorrarion Stans ron Hossiats, 7a Eoin
‘managemenc and safety programs. Training includes instruction on che processes for reporting potential risks
and reporting incidents and injuries. The taining program involves testing staff knowledge. Staff are trained
and tested on emergency procedures, including fte safety procedures. As applicable o the staff member’ role
and responsibilities, raining and testing address hazardous materials and response hazards, such as the
spill oF a hazardous chemical, and the use of medical equipment that may pose a risk o patients and staf
Knowledge can be tested through a variety of means, such as individual or group demonstrations, the staging
‘of mock events such as an epidemic io the communiey, the use of writen or computer tests, or other means
suitable to the knowledge being cested. The hospital documents who was tested and the results of the vesting
Measurable Elements of FMS.13
G11. Allstaf receive annual training and testing on each facility management and safety program
‘o ensue they can safely and effectively carry out their responsibilities, and esting results are
documented.
2. Training on the facility management and safety programs includes vendors, contract works, volun-
teers, students, trainees, and others,
determined by the hospital.
applicable to the individuals’ roles and responsibilities, and as
3. Staffcan describe and/or demonstrate thet roles in response to a fire
4, Staffcan describe and/or demonstrate actions 10 eliminate, minimize, or eeport safer, security, and
other risks
5. Stafcan describe and/or demonstrate precautions and procedures for handling and managing
‘medical gases and hazardous materials and waste, as applicable tothe staf member role and
responsibilities
1 6. Staff can describe and/or demonstrate procedures for and their roles in internal and community
emergencies and disasters, Fuser Masacesn ano Surry (FMS)
Appendix
Interim Measures
Taterim measures are actions taken to ensure the safety ofthe building’ occupants during times when features
and systems for fire safety ate defective, compromised, of inoperable de to construction, maintenance, ot
a breakdown or repair. When fre safery risks cannos be immediately addressed and corrected, the hospital
identifies and plans for improvements to address the risks. Interim measures may need o be implemented t0
ensure the safery of occupants unl improvements or repaies can be completed. The hospital determines when
and to what extent interim measures willbe implemented.
‘See FMS.8 and FMS.8.3 for requirements related to interim measures
‘The following are examples of interim measures:
1, The hospital initiates a fire watch, which involves a trained individual(s) pateolling the areas of the
building affected by the impairment/ie safety risk to look for evidence of smoke, fir, or other
abnormal conditions. For example, fire watch is initiated when a fie alarm system is ou of service
more than 4 out of 24 hours, ora sprinkler system is out of service more than 10 hours in a 24-hour
period,
2. The hospial poss signs identifying the location of alternative exits to everyone in the affected area
‘of the hospital (for example, when normal exic pathways andlor exit doors are not accessible or not
functional due to construction, maintenance activities, and so on).
3. The hospital inspects exits in affected areas on a daily basis
4, The hospital provides temporary but equivalent fire alarm and detection systems for use when a fire
system is impaired,
The hospital provides additional firefighting equipment.
6. The hospital uses temporary construction partitions that are smoke-tight or made of noncombustible
or limited-combustible material that will noc concribuce co the development or spread of ire
7. The hospital inereases surveillance of buildin
construction and storage areas
8. The hospital enforces storage, housekeeping, and debris-removal practices that reduce che building’
flammable and combustible fire load co the lowest feasible level
9. ‘The hospital provides additional training to salTon the use of Firefighting equipment.
10, ‘The hospital conducts addivional fie salery exercises with staf
1, The hospital inspeets and tests temporary ir systems monthly,
12, The hospital conducts education to promote awareness of fire safety-related building deficiencies,
impairments, construction hazards, and temporary measures implemented to maintain fire safety
13, The hospital provides additional training to staf wo compensate for increased risks duc to impaired
seruetaral or compartmental fre safety features
14, Other interim measures, as determined by the hospital and appropriate to the fte safety risk,
grounds, and equipment, giving special attention to
Q
&
fe
rettete ns z
/_ Jour Comussin Ieremvarionas Accasotnarion Srastutos rom Hosts, 71 EosTion
References
Leadership and Planning
‘American Sociry for Healthcare Engineering. Tal Fatty
‘Management. Accessed Oct 28, 2019, heigl isashe.or
reestool shen
‘Carponan JR, Grane MA. Design Tht Cares Planning Health
Facilities for Patients and Vitor, 3d ed, New York: Wiley,
2016.
(Charney FJ. How risk management focus can improve che
physical environment. Heath Facil Manage Epub 2018 Ape
4, Accessed Jan 5, 2020. reps ww hfnmagazinecom)
les 3313-how-avsk-management-focus-ca-improveshe
phvsicaL environment
Risk Assessment and Monitoring
Agency for Heahcare Research and Quality. Health Care
Facly Design Safe RBk Assenmen Tol. Sep 2017
Acree Jan, 2020, hupsifeonvarggosipaensaen!
setinghorpiel cout aes el,
Bahe NJ Sten Say Engincering and Rik Aesment:
‘Pracica Approach, 2 ed 2017. Boca Raton, FL: CRC
Pres, 2007
Safety
Center for Health Design. Designing for Baten Safe
Developing Meio t Ines Patent Safry Concert the
asia Proce: joseph A, eal. 2012. Accesed Jan 5, 2020
opens healehesign orgie defulfle/chdé6
ahwarepor Gina pt
Grant MP. Heatheare and commercial constuction: The
rol of inspections within health andsfey interventions
in dynamic workplaces and associations with safety climate
(PD diss), Harvard LH. Chan School of Public Health,
2016. Accessed Jan 5, 2020. hupdashharvard ed!
bistteam/handlet/27201742/GRANT.DISSERTA.
Security
ALBashawy M, et a Workplace volnceroward emergency
epartment staf i Jordanian opal: Acros sectional
sua. J Nir Re, 2015 Mar23(:75-81. buy.
sxg/101097/000000000000007
Blando JD, era Hospital security director background,
epinions, andthe implementation of security programs
rural of Apple Scary Rear 2017120) 497-51.
fuupsoi om 10.1080/19361600,
Bland JD. eal. Workplace violence and hospital sci
programs Reglaory compliance, program benchmarks,
innovate seateies. Melee Prt Manage, 2017,3(0):89=
105
Sem RD. Appropriate ment of program for preventing
oknce aguas belbeae tf J Heal Prot Manage
20173344447
268
ECRI Institute. Healthcare Construction and Design
Resource Center. Accessed Jan 5, 2020, hips /sonesiose
ssarcheults/pasesdesigns20and%20construction.
COlmsed RN. Prevention by design: Construction and
renoxtion of health care fils for patient sulery
and infection prevention Inficr Dis Clin North Am.
2016:30(3)-713-728,
Saunders I, ta. International benchmarking for
performance improvement in constuction safety and health
‘Benchmarking: An Inerntional Journal. 2016;23(4):916-936.
inal and Laboratory Standart Inset, Harmonized
“Terminology Database. 2019. Accessed Jon 5, 2020 pill,
hudchiorg
Ready US Deparment of Homiland Security. Rbk
Assessment. Acces Ja 5, 2020 psn ced gst
siskeasesment
US Department of Labor, Occupational Safty and Health
Administration. Work Safer in Hospitals: Caring for Our
Caregivers: Accessed Jan 5, 2020, huis /ssn.osba goss
hhospitasindecstanding_ problem. hem
‘World Health Organization. Safe Hospital and Health
Facies. 2017, Acessed Jan 5, 2020. hush int
‘baclichguidansesufchosptalsien.
York TW, MacAlister D. Hoyptal and Healthcare Security 6th
ed, Oxford, UK: Butterworth-Heinemann, 2015,
Zakaria H, etal. A systematic literate review of security
perimeter in hospital faci. Open Inreraronal Journal of
Informa. 208:(6 104-129. ceed an 5,202, hl fameworks for managing healthcare waste: A case stuly
ofthe National Health Servic in London. Safe. 2015
CCaniato M, TadorT, Vasari M International governance
structures for health-care waste management: A systematic
review af siete Iinerature J Environ Manage, 2015 Apr
15:153:93-107,
Uniced Nations (UN). Globally Harmonised Stem of Clas
{fiaion ard Labelling of Chemical (GHS), 80h ed. New York
UN, 2019,
US Centers for Disease Contil and Prevention, Case
Definition: Caustic of Carrsive Agent. Apr 4, 2018.
Accessed Jan 5, 2020, ups! /emergency.cdegov/agenl
caustiseasede a,
Fire Safety
Anesthesia Patient Safry Foundation, Prevention and
‘Management of Operating Room Fires Video, 2010. Accessed
Jan 5, 2020, psn apf org resources
Bongiowann set. Ixpementton of het practices or
smergency response and revvery a lrg hospital: A ie
emergency case sy Sf Se 2017 Ju6:121-13. hep
loLog/ 0.10168 2017.05016
Devito PM, Zamora R, Ciechillo M, Fire in the OR “All
hands-on deck!" J Clin Case Rep. 2017:7(9):10001023,
Accessed Jan 3, 2020, ups semantcsholarong/ 72d
Gb 4e25h2csel207820ce4346587308 pl
Medical Equipment
Kutor Jk Agede P, All RH. Maincenance practice, causes of
failure and rik assesment of diagnostic medical equipment
Journal of Biomedical Engineering and Medical Device
2017:2(1):1000123. Aecesed Jan 5, 2020, huis uon
longdom orgopen-acessmaiatensnee-pratcecaus-
oP fallue-and-sk-asessmentof diagnostic ip:
2475.7586-1000123,
Utility Systems
lenolino M, Mancini B, Cristino S. Industrial coling rower
disinfection eatment vo preven Legionella sp. In] Environ
‘es Public Heal, 2017 Sep 26:00: £1125.
Kenamoti H, Weber DJ, Ruta WA. Healhcate outbreaks
associated wit «water mero and infection prevention
strategies. Clin nfer Dis. 2016 Jur 1362(11) 1423-14835.
Lorena N. Cia features of emergency power generators.
Health Feil Manage, Ep 2015 Sep 2. Accessed Ja 5, 2020
bupf/wwew fimmagarine comn/arike712-rtal- fe
{uicsofemerency-power generator.
acusry Maxscrusyr ayo Sar (FMS)
US Centers for Dissase Control and Prevention, National
Institute for Occupational Safery and Health, Peer Review
Agend:: NIOSH List af Hazardous Drugs in Healthcare
Setings 2019, Oct 25,2017. Accessed Jan 5, 2020, hips
wuss govdniosb/teview/pectisiPharcnug?018-p hem
Us Deparement of Labor, Occupational Safety and Health
Adminisration, OSHA Brie Hazard Communication
Standaed: Safety Data Sheets, Acened un 5, 2020. icp!
ences 3
World Heath Organization. Heath Care Waste Feb 8, 2018,
‘Acces Jan 5, 2020, hp /onwooin/medacentiel
faasheew/E2SAens
‘World Health Organization, Saf Management of Wastes rom
Healh-Care Artvtc, ad ed Charter Yet aly editors
2014. Accessed Jan 5, 2020. hngps/svsha.inlvsbiscea
10665 /85349/1/9789241548364 
