اختبار ادارة السلامة والمرافق

King Salman Hospital - Facility Management & Safety (FMS) Overview

• Total number of FMS Standards: 39
• Total number of Sub-Standards assessed by FMS Surveyor: 350 (15% of total)
• Sub-Standards assessed by FMS Surveyor in the FMS Domain: 171
• Sub-Standards FMS Surveyor Sharing with others: 143
• Sub-Standards assessed by FMS Surveyor outside the FMS Domain: 36

Example of a Standard Scored by FMS Surveyor

• FM.21: The hospital has an effective fire alarm system.
• FMS.21.1: A fire alarm system that is functional and regularly inspected as per civil defense guidelines.
• FMS.21.2: Fire alarm system testing results are documented.
• FMS.21.3: The fire alarm system has preventive maintenance.
• FMS.21.4: Elevators are connected to the fire alarm system.

Example of a Standard Scored by More Than One Surveyor

• LD.26: The department head develops an organizational chart for the department.
• LD.26.1: Each department has an organizational chart that clearly displays all sections/divisions, titles (or names), lines of authority, accountability, and reporting relationships.
• LD.26.2: The organizational chart is signed by the department head and approved by the hospital management.
• LD.26.3: The organizational chart is communicated to the staff working in the department.

Example of a Standard Assessed by FMS Surveyor Outside His/Her Domain

• RS.3: All equipment and machines in the respiratory care services are operated within manufacturers' specifications and maintained free of defects.
• RS.3.1: All equipment and machines are operated within manufacturers' specifications.
• RS.3.2: The periodical preventive maintenance is developed and implemented in accordance with manufacturers' instructions.
• RS.3.3: All maintenance and repair records are maintained for future reference and inspection.

NHS 3rd Edition - ESR Standards

• FMS.9: The hospital ensures all occupants are safe from radiation hazards.
• FMS.32: The hospital ensures proper maintenance of the medical gas system.
• FMS.21: The hospital has an effective fire alarm system.
• FMS.22: The hospital has a fire suppression system in the required areas.
• FMS.23: There are fire exits that are properly located in the hospital.
• FMS.24: The hospital and its occupants are safe from fire and smoke.

NHS 3rd Edition - Assessment Activities

• Total number of assessment activities: 4291
• FMS Assessment Activities: 335

Surveyor Load/Specialty

• FMS: 8%
• LD: 14%
• LB: 17%
• PH: 12%
• IC: 15%
• NR: 15%
• MD: 19%

FMS Assessment Activities

• Document Review
• Medical Record Review (N/A)
• Personnel Files Review
• Observation
• Leadership Interview
• Unit Visit Interview
• Unit Visit Documented Evidence

Weight of Each Assessment Category

• Interview: 8%
• Unit Visit Interview: 12%
• Documented Evidence: 16%
• Document Review: 27%
• Personnel File Review: 9%
• Medical Record Review: 0%
• Observation: 37%

Types of Documents

• Policy & Procedures
• Plans
• Meeting Minutes
• Programs
• Charts (Organization, Improvement)
• Records
• Reports
• Forms
• Guidelines
• Licenses & Certifications

Compliance Checklist

• Approval
• Content
• Serve the purpose
• Validity
• Applicability
• Accessibility
• Implementation
• Format
• Multidisciplinary

Multidisciplinary - New Medical Equipment Policy & Procedures

• Definition: New
• Owner: Biomedical Engineering
• Applicability: Physicians, Nursing, Security

Policy & Procedures

• Legal Document
• Not Time Related
• Coverage
• Awareness
• Master Policy

FMS Standards Overview

• FMS.1 - FMS.10 - Facility Safety
• FMS.11 - FMS.13 - Security
• FMS.14 - FMS.15 - Hazardous Materials
• FMS.16 - FMS.17 - Emergency Preparedness and Plans
• FMS.18 - FMS.24 - Fire Safety
• FMS.25 - FMS.27 - Medical Equipment
• FMS.28 - FMS.39 - Utility Systems

How to Implement Safety

• Hospital leadership provides support & resources aligned with regulatory requirements.
• Hospital has plans to manage safety of the environment.
• Staff is educated on their responsibilities (commencing at orientation, continuing regularly).
• Hospital collects & analyzes data to determine plan effectiveness and facilitate quality improvement.

Who is Responsible for Safety?

• All Staff is responsible for ensuring their own safety.
• All Staff is responsible for reporting any safety violations.

When to Implement Safety

• Safety comes first
• Implement safety on a daily basis

Main Eight (8) Plans/Topics in the FMS Chapter

• Facility Safety
• Security
• Life/Fire Safety
• Emergency Preparedness (Internal)
• Emergency Preparedness (External)
• Hazardous Materials & Waste Disposal
• Medical Equipment
• Utilities

FMS and Leadership

• Hospital leaders establish and support a Facility Management and Safety program.
• Hospital leaders support the program to acquire the essential equipment.
• The program has a budget for necessary upgrades or replacements.
• Orientation program for all new hires.

Staff Motivation

• Motivating staff with financial or emotional gestures.
• Important for hospital leaders to appreciate hard-working staff to ensure compliance with safety policies and procedures.

Effective Communication

• Effective communication creates a healthy environment for safety.
• Facilitates identifying, reporting, and mitigating safety issues.

Utilizing Technology for Communication

• Technology improves communication during emergencies.
• Example systems: BMS, Overhead Paging, PA system, Security/Safety Walkie-Talkie, 2-way radio.

Infrastructure

• Infrastructure refers to the fundamental facilities, utilities, and systems.
• Example items: Power distribution systems, water distribution system, hospital buildings, medical equipment, pavements and roads.

Infrastructure (Additional details)

• Saudi Building Code is crucial for complying with safety requirements.
• Safety needs to be integrated into engineering drawings.
• Leaders need to ensure safety standards are met, especially in older buildings.

Organizational Culture

• Leaders are role models for their employees, infecting them with a safety-first culture (Safety is Everyone's Responsibility).
• How to achieve this:
  • Conduct Leadership safety rounds
  • Encourage staff to report hazards and risks
  • Chair safety committees
  • Empower safety departments
  • Authorize intervention in unsafe practices.

Continuous Training

• Training for teaching/developing skills and knowledge.
• Related to specific competencies.
• Improve capability, capacity, productivity, and performance
• Examples: Emergency codes, hazardous materials handling, evacuation procedures, equipment operation, violent behavior, child kidnap/bomb threats.

اختبر معلوماتك حول المفاهيم الأساسية لإدارة السلامة ومعايير إدارة السلامة. يغطي هذا الاختبار أنشطة التقييم ومسؤوليات أصحاب المصلحة واستراتيجيات إدارة المخاطر والسيناريوهات الاستباقية في إدارة السلامة.