Adhiparasakthi Dental College - Facility Management | PDF

ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01...

ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 1 of 41 FMS/ 01/03 03/05/2023 1.0 PURPOSE: 1.1 To provide a system and method to provide safe and secure environment 1.2 To provide environment and facilities operate to ensure safety of patients, their families, staff and visitors 2.0 SCOPE: 2.1 Hospital wide 3.0 RESPONSIBILITY: 3.1 Safety Committee 3.2 Maintenance Manager 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 FMS : Facility Management and Safety 4.3 EDP : Electronic Data Processing 4.4 HIS : Hospital Information System 4.5 CA : Corrective Action 4.6 PA : Preventive Action 4.7 APDCH : Adhiparasakthi Dental College & Hospital 4.8 MAPIMS : Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Providers PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 2 of 41 FMS/ 01/03 03/05/2023 Third, January 2023./FMS 5.2 FMS.1: The DHSP has a system in place to provide a safe and secure environment. FMS.3: The DHSP's environment and facilities operate to ensure safety of patients, their families, staff and visitors. FMS 1: The DHSP has a no – smoking policy 6.0 POLICY: 6.1 Safety Policy: 6.1.1 The hospital aims to provide a safe facility for all its occupants. 6.1.2 This shall be accomplished by a Facility management and Safety Committee, which shall oversee all aspects of Facility Safety: 6.1.3 Preventive and breakdown maintenance Schedule are monitored and carried out by the Maintenance department, Electrician, and House Keeping Supervisor. 6.1.4 Drawings (site layout, floor plan and fire escape route) shall be maintained in each floor in a visible manner. 6.1.5 Fire escape is marked in each area with green board. 6.1.6 Internal and external sign posting in the organization shall be maintained in a language understood by patient, families and community – responsibility House Keeping Executive. 6.1.7 A comprehensive safety inspection shall be done twice a year in patient care areas and once a year in other areas by Site Engineer and Electrical Contractor. 6.1.8 A report shall be generated after each inspection by maintenance manager which shall be discussed in Facility Management and Safety Committee Meeting and shall form the basis for safety. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 3 of 41 FMS/ 01/03 03/05/2023 6.1.9 corrective and preventive action 6.1.10 Response times are monitored from time of reporting to time of inspection and time of implementation of corrective actions. 6.1.11 A complaint attendance register shall be maintained to indicate the date and time of receipt of complaint, allotment of job and completion of job. 6.2 Safety committee: The Safety Committee shall conduct Hazard Identification and Risk Analysis (HIRA) and accordingly take necessary steps to eliminate or reduce such hazards and associated risks. The committee shall comprise of the following members: 6.2.1 Correspondent 6.2.2 Principal 6.2.3 Administrative manager 6.2.4 Maintenance Manager 6.2.5 Facility management and safety team - Incharge 6.3 Patient-safety devices: Patient-safety devices shall be installed across the organization and inspected periodically. The devices are: 6.3.1 Grab-bars 6.3.2 Sign postings 6.3.3 Safety belts on stretchers and wheelchairs 6.3.4 Alarms – both visual and auditory 6.3.5 Warning signs – radiation or biohazard 6.3.6 Call bells 6.3.7 Fire safety devices 6.4 No-Smoking Area: APDCH shall be a declared No Smoking Area depicting the same. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 4 of 41 FMS/ 01/03 03/05/2023 6.5 Facility Inspection Rounds: 6.5.1 Facility inspection rounds shall be conducted by Safety Committee to ensure safety at least twice in a year. 6.5.2 Potential risks enlisted as a common safety hazard checklist are identified during the rounds. 6.5.3 The finding of the rounds is documented and the CAPA measures are taken to rectify the faults. A before and after evidence shall be maintained to document the work done. 7.0 PROCEDURE: 7.1 Building Safety: 7.1.1 A set of safety instructions have been set at APDCH Hospitals, to ensure a safe environment for the patient, visitors and employees of the hospital. The following are the set of safety instructions which shall be followed by the engineer and other staff: 7.1.2 Sufficient lighting and air circulation shall be provided in all the areas of the hospital; False ceiling materials used are non-combustible; 7.1.3 The slope and drainage are properly connected so as to avoid any seepages/leakages in the building; 7.1.4 Stock of combustible /flammable materials shall be stored in the designated area; 7.1.5 Inside the hospital antiskid tiles and appropriate signage are used for safety of patients, visitors and employees. 7.2 Up-to-date drawings: 7.2.1 There shall be a designated individual who maintains the up-to-date drawings of the site layout, floor plans and fire-escape routes. 7.2.2 There shall be separate rate civil, electrical, plumbing, HVAC and piped medical PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 5 of 41 FMS/ 01/03 03/05/2023 7.2.3 gas drawings. 7.2.4 There shall be internal and external sign postings in the organization in bi- lingual so that it is easily understood by patients, families and community. 7.3 Maintenance Team: 7.3.1 There are designated individuals responsible for the maintenance of all the facilities. 7.3.2 The hospital has a regular maintenance team comprising of Maintenance In- Charge, electricians, plumbers, masons, carpenters, metal fabricators, painters, sanitary workers and gardeners. 7.3.3 These people are placed directly under the control of administration manager. 7.3.4 As a part of routine maintenance all patient rooms and its furniture are repainted and refurnished regularly. 7.3.5 The overhead water storage tank is inspected and cleaned regularly and water sample tested. The bathrooms and toilets and plumbing are checked and maintained. 7.3.6 All electrical points and fittings are rechecked for defects and promptly repaired. 7.3.7 This is an ongoing process done every six months or sometimes earlier if the necessity arises. 7.3.8 The repainting of the general areas, masonry work, and floor maintenance are done on a regular basis. 7.3.9 Electricians and plumbers are present on all duty hours a day. 7.3.10 They are also responsible for the preventive maintenance work. 7.3.11 The electricians are also responsible for the maintenance of the back-up generators of the hospital through Maintenance Contractor. 7.3.12 The working and maintenance of the affluent Sewage Treatment Plant and the heavy duty water pumps are the responsibility of the duty electricians and PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 6 of 41 FMS/ 01/03 03/05/2023 7.3.13 plumbers. 7.3.14 Any complaints in the plumbing are attended to promptly by the plumbers who are also assigned the duty of undertaking the repairs of the existing water lines. 7.3.15 The large septic tanks are placed concealed underground with the soak pits placed away at safe distances from the fresh water source. 7.3.16 Special care is taken to prevent stagnation of water and prevent the control of mosquitoes. 7.3.17 The hospital has people responsible for maintenance work. 7.3.18 In the event of breakdown of power and water supply or problems related to medical gas, vacuum, and compressed air supply, the maintenance team acts promptly to rectify it. 7.3.19 The hospital has its dedicated electric transformer and serviced by Electrical Contractor on a regular basis. 7.3.20 The filtering system of the Sewage Water Treatment is checked from time to time and the maintenance work is done. 7.3.21 This is regularly inspected by the authorities and certified. 7.3.22 Special care is taken to see that prompt action is taken in the event of electrical failures or breakdowns. 7.3.23 The operation of the three generators which cater to the needs of the whole hospital is the responsibility of the duty electricians. 7.3.24 The uninterrupted supply of running water is the responsibility of duty plumbers who also rectifies faults and does emergency repair works 7.3.25 In case of break down in supply, authorized water transporting agency is contacted. 7.3.26 The hospital has g t 1 lift. Annual maintenance contracts are there for this lift. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 7 of 41 FMS/ 01/03 03/05/2023 7.4 Biomedical Waste Management: 7.4.1 Bio medical waste management is outsourced. 7.4.2 Chlorinated Plastics and hospital wastes are not burnt in the incinerator, taking into consideration the environment safety and keeping compliance with the Pollution Control Board norms 7.4.3 An MOU agreement is signed between APDCH & MAPIMS for collection of segregated biomedical waste management 7.4.4 Certificate on this is procured by hospital are recorded 7.4.5 The waste water treatment plant is proposed in accordance with the Pollution Control Board norms. 7.5 Hospital Information System: 7.5.1 There are designated people / technicians to maintain the computer systems and the hard ware. 7.5.2 A computer technician is on all working hours call to rectify faults of the computer hardware and networking. 7.5.3 The computer software system is on an annual maintenance contract. 7.5.4 The computer software provider is responsible for any trouble shooting or up - grading of the software and his representative is available on call all working hours to rectify any problems which may arise. 7.5.5 The software is under annual maintenance contract. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 8 of 41 FMS/ 01/03 08/05/2023 7.6 Telephone Systems: 7.6.1 The Maintenance Department takes care of the general telephone, intercom and extension lines 7.6.2 Internet connections are available in the designated areas administration section. 7.6.3 All the maintenance staff of the hospital is contactable by mobile systems. The services of the duty electricians and plumbers who work in shifts are available on all working hours a day PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 1 of 41 FMS/ 02 03/05/2023 The Organization's Environment and Facilities Operate in a Planned Manner and Promote Environment-Friendly Measures 1. Purpose 1.1. To establish and maintain a well-organized, safe, and environment-friendly campus at Adhiparasakthi Dental College. 1.2. To ensure compliance with NABH 3rd edition standards and national environmental regulations. 1.3. To enhance the health and safety of patients, staff, students, and visitors. 1.4. To promote sustainable practices through waste management, energy conservation, and water management. 2. Scope 2.1. This manual applies to all departments, staff, students, and facilities within Adhiparasakthi Dental College. 2.2. Includes administrative and clinical areas, laboratories, storage facilities, and common areas. 2.3. Covers practices related to environmental management, including waste management, water conservation, energy efficiency, and pollution control. 3. Responsibility 3.1. Chief Administrator: 3.1.1. Ensure compliance with environmental policies and regulations. 3.1.2. Oversee the implementation of sustainable practices. 3.2. Facility Manager: 3.2.1. Monitor and maintain the physical environment in accordance with policies. 3.2.2. Implement and supervise waste management, water, and energy-saving initiatives. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 2 of 41 FMS/ 02 03/05/2023 3.3. Housekeeping Supervisor: 3.3.1. Maintain cleanliness and hygiene standards as per the policy. 3.3.2. Ensure proper segregation, collection, and disposal of waste. 3.4. All Staff and Students: 3.4.1. Comply with the environment-friendly measures and policies. 3.4.2. Report any discrepancies or areas of concern to the respective supervisors. 4. Abbreviations 4.1. NABH: National Accreditation Board for Hospitals & Healthcare Providers 4.2. SOP: Standard Operating Procedure 4.3. EHS: Environmental Health and Safety 4.4. EMS: Environmental Management System 4.5. MSDS: Material Safety Data Sheet 5. References 5.1. NABH 3rd Edition Standards for Dental Healthcare Facilities 5.2. Environmental Protection Act, 1986 5.3. Water (Prevention and Control of Pollution) Act, 1974 5.4. Hazardous Waste Management Rules, 2016 5.5. Ministry of Environment, Forest and Climate Change (MoEF&CC) Guidelines 6. Policy 6.1. Adhiparasakthi Dental College commits to maintaining a safe, healthy, and sustainable environment. 6.2. Implement a comprehensive Environmental Management System (EMS) to ensure compliance with NABH standards. 6.3. Regular monitoring and evaluation of environmental performance, including waste PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 3 of 41 FMS/ 02 03/05/2023 management, water conservation, and energy efficiency. 6.4. Promote awareness and training on sustainable practices among staff and students. 7. Procedure 7.1. Waste Management 7.1.1. Segregation of Waste at Source: We ensure waste is segregated into three categories at the point of generation: biodegradable, non-biodegradable, and hazardous waste. Use clearly labeled, color-coded bins to facilitate segregation: o Green: Biodegradable waste (food waste, garden waste). o Blue: Recyclable waste (paper, plastic, glass). o Red: Hazardous waste (biomedical waste, chemicals, sharps). Provide training to all staff and students on proper waste segregation practices. 7.1.2. Collection and Temporary Storage: We designate specific collection times for different types of waste to avoid cross- contamination. Waste collection staff wear appropriate personal protective equipment (PPE) such as gloves, masks, and aprons. Temporarily store segregated waste in a dedicated storage area away from clinical areas to minimize risks. 7.1.3. Waste Disposal: We partner with government-authorized vendors for the disposal of biomedical and hazardous waste, adhering to local regulations. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 4 of 41 FMS/ 02 03/05/2023 Non-hazardous waste will be transported to municipal facilities or recycling centers, while biodegradable waste should be composted or disposed of appropriately. Maintain records of all waste disposal activities, including type, quantity, date, and vendor details. 7.1.4. Audit and Compliance: Conduct quarterly audits of waste management practices to identify gaps and improve processes. Ensure compliance with the relevant waste management rules (e.g., Biomedical Waste Management Rules, 2016). Regularly update waste management SOPs based on audit findings and regulatory changes. Process Flow for Waste Management: Waste Generation ➜ Segregation at Source ➜ Collection ➜ Temporary Storage ➜ Authorized Disposal ➜ Record Maintenance ➜ Quarterly Audit 7.2. Water Management 7.2.1. Installation of Water-Efficient Fixtures: The institution Use water-efficient fixtures such as low-flow faucets, aerators, and dual- flush toilets throughout the campus. Regularly inspect and maintain fixtures to prevent leaks and ensure efficiency. 7.2.2. Leak Detection and Repair: Conduct periodical checks for leaks in pipes, tanks, and fixtures. Establish a quick response team to repair leaks within 24 hours of detection. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 5 of 41 FMS/ 02 03/05/2023 Monitor water consumption using meters to identify unusual spikes, which could indicate hidden leaks. 7.2.3. Water Conservation Awareness: Implement awareness programs for staff and students about the importance of water conservation. Display signage in restrooms, kitchens, and common areas promoting water-saving practices. 7.2.4. Rainwater Harvesting: Install rainwater harvesting systems to capture and store rainwater for non-potable uses such as gardening and cleaning. Regularly clean and maintain the rainwater harvesting system to ensure effective water collection. 7.2.5. Monitoring and Evaluation: Set up a water management committee responsible for monitoring water use and evaluating conservation strategies. Review water consumption data monthly and adjust strategies accordingly to meet conservation goals. Process Flow for Water Management: Water Use ➜ Leak Detection and Repair ➜ Conservation Practices ➜ Rainwater Harvesting ➜ Monitoring and Evaluation 7.3. Energy Efficiency 7.3.1. Installation of Energy-Efficient Lighting and Equipment: PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 6 of 41 FMS/ 02 03/05/2023 Replace incandescent bulbs with LED lights throughout the campus. Install motion sensors in low-traffic areas to automatically switch off lights when not in use. Utilize energy-efficient equipment, such as Energy Star-rated appliances in laboratories, clinics, and administrative areas. 7.3.2. Regular Maintenance of Electrical Systems: Conduct monthly inspections of electrical systems to identify and fix faults or inefficiencies. Maintain air conditioning units, fans, and other electrical equipment regularly to ensure optimal performance. 7.3.3. Maximizing Natural Light and Ventilation: Design buildings and rooms to maximize natural light and ventilation, reducing the need for artificial lighting and air conditioning. Encourage the use of blinds and shades to regulate indoor temperatures naturally. 7.3.4. Energy Monitoring System: Implement a system to monitor and track energy consumption across the campus. Analyze data regularly to identify areas for improvement and reduce overall energy usage. Set annual energy-saving targets and develop strategies to achieve them. 7.3.5. Awareness and Training Programs: Conduct training programs for staff and students on energy-saving practices, such as turning off lights and equipment when not in use. Promote an energy-conscious culture across the campus through campaigns and activities. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 7 of 41 FMS/ 02 03/05/2023 Process Flow for Energy Efficiency: Energy Use ➜ Installation of Efficient Equipment ➜ Regular Maintenance ➜ Monitoring Consumption ➜ Training and Awareness ➜ Implementation of Reduction Measures 7.4. Pollution Control 7.4.1. Air Pollution Control Measures: Ensure that all ventilation systems are well-maintained to minimize indoor air pollution. Reduce the use of volatile organic compounds (VOCs) in cleaning agents, paints, and other materials. Plant trees and create green spaces around the campus to improve air quality. 7.4.2. Water and Soil Pollution Control: Ensure proper handling, storage, and disposal of hazardous chemicals as per MSDS guidelines. Install spill containment measures in areas where chemicals are used or stored. Regularly inspect drainage systems to prevent contamination of local water sources. 7.4.3. Noise Pollution Control: Implement soundproofing measures in high-noise areas such as mechanical rooms or labs. Limit construction or maintenance activities during teaching hours to minimize disruption. 7.4.4. Training and Awareness on Pollution Control: Provide regular training to staff and students on pollution control measures and environmental best practices. Display informational posters on pollution control practices throughout the campus. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 8 of 41 FMS/ 02 03/05/2023 7.4.5 Regular Monitoring and Reporting: Conduct regular monitoring of air, water, and noise pollution levels. Prepare and submit reports to relevant authorities as required by law. Review and update pollution control policies and procedures annually. Process Flow for Pollution Control: Pollution Source Identification ➜ Preventive Measures ➜ Safe Storage ➜ Training Management of Hazardous materials : 1.0 PURPOSE: To provide guidelines and instructions for safe handling of all the hazardous Chemicals used inside the hospital. 2.0 SCOPE: 2.1 Hospital – wide 3.0 RESPONSIBILITY: 3.1 All hospital staff 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 FMS : Facility Management and Safety 4.3 CA : Corrective Action 4.4 PA : Preventive Action 5.0 REFERENCE: 5.1 NABH: Accreditation standards for Dental Health Care Service PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 9 of 41 FMS/ 02 03/05/2023 5.2 The organization has a plan for management of hazardous materials. 6.0 POLICY: 6.1 This policy is applicable to all the users who store hazardous materials in the department and if there are any spillages they are requested to follow the following guidelines. Departmental heads are responsible for educating staff on the hazardous materials and documents are maintained for the same. 7.0 PROCEDURE: 7.1 Four major varieties of spills involving the hazardous materials at different circumstances, they can be grouped in to the following categories: 7.1.1 Chemical hazardous materials. 7.1.2 Infectious hazardous materials. 7.1.3 Radioactive hazardous materials. 7.1.4 Mercury spills 7.1.5 Chemotherapeutic materials 7.2 Chemotherapeutic hazardous material spills: 7.2.1 Wear appropriate personal protective equipment while cleaning the spills. Clean the spill area with the spill kit and all the staff must be aware of the location of the spill kit. Absorb the liquid with tissue paper. Discard the tissue paper towels in the black colour bag. If broken glass pieces / sharps are present clean with the scoop. Discard the broken glass and sharps to chemotherapy sharp container and wipe down the area with isopropyl alcohol or bleach. Once the spill is cleaned, remove the gloves, gown and discard in the black bag. Tie the waste bag and label the bag as Hazardous material spill. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 10 of 41 FMS/ 02 03/05/2023 7.2.2 Report the spill to the Safety officer: 7.2.2.1 Name of the hospital: 7.2.2.2 Location of the spill: 7.2.2.3 Date and time of occurrence: 7.2.2.4 Summary of the spill: 7.2.2.5 Signature of the person reporting: 7.3 Chemical Hazardous spills: 7.3.1 Wear personnel protective equipment. 7.3.2 Evacuate the people in the spill area. 7.3.3 Minor Spills: 7.3.3.1 Determine the type of materials involved in spills. 7.3.3.2 Put on appropriate personal protective materials. 7.3.3.3 Apply suitable absorbent materials i.e paper towel. 7.3.3.4 Dispose the waste in the appropriate biomedical waste bin. 7.3.3.5 Call the house keeping staff and wash it with plain water. 7.3.3.6 Report the spill to the hospital safety officer. 7.3.4 Major spills: 7.3.4.1 Evacuate the people those who are there in the spill area. 7.3.4.2 Restrict the entry in to that area. 7.3.4.3 Clean the area with the available spill kit. 7.3.4.4 Use appropriate personnel protective measures at the time of PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 11 of 41 FMS/ 02 03/05/2023 7.3.4.5 Avoid breathing vapours from spills. 7.3.4.6 Collect the residue and place it in the waste bag. 7.3.4.7 Record the details of the materials involved in spills. 7.4 Infectious Hazardous material spills: 7.4.1 A spill kit is to be maintained which is easily accessible. 7.4.2 The spill kit will include (minimum): 7.4.2.1 One set of liquid impermeable, disposable overalls or impervious gown, boots; 7.4.2.2 Gloves; 7.4.2.3 Shoe covers; 7.4.2.4 Protective eyewear: goggles, face shields, etc.; 7.4.2.5 Red disposable infectious/bio hazardous waste bags; 7.4.2.6 Disinfection solution; 7.4.2.7 Absorbent material paper towels; 7.4.2.8 Scoop and brush. 7.4.3 For Management of Infectious Material: 7.4.3.1 Put caution board and cordon off the area. Open windows and Doors, switch off the AC/Fan (if available). 7.4.3.2 Remove all jewellery from hands and wrists. Wear PPE (Mask, cap, apron, goggle, disposable shoe covers, rubber or chemical resistant glove) and remove any broken pieces of glass or sharp objects PREPARED BY VERIFIED BY APPROVED BY  FMS COORDINATOR PRINCIPAL CORRESPONDENT ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 12 of 41 FMS/ 02 03/05/2023 7.4.3.4 Cover it with a piece of paper or absorbent cloth 7.4.3.5 Pour 0.1% Sodium Hypochlorite on the spill. For Minor Spill (less than 30ml ) Waitfor 5 minutes (or) For Major Spill ( more than 30ml ) wait for 10-20 minutes 7.4.3.6 Wipe the area in a circular manner & put the collected material in the yellow cover. Mop the area with Bacillocid Special Solution 7.4.3.7 Send incident report form to Quality Manager 7.4.3.8 Hands will be washed after spill cleanup. 7.4.3.9 Report should include: 7.4.3.9.1 exact location of the spill, and names of all employees involved; 7.4.3.9.2 date, time, and a short, detailed summary of the spill; 7.4.3.10 This information will be logged as a hazardous material incident. 7.4.4 For Management of Mercury Spills: 7.4.4.1 Put caution board and cordon off the area. Open windows and Doors, switch off the AC/Fan (if available). 7.4.4.2 Remove all jewellery from hands and wrists. Wear PPE (Mask, cap, apron, goggle, disposable shoe covers, rubber or chemical resistant glove) and remove any broken pieces of glass or sharp objects 7.4.4.3 Locate all mercury beads and collect with the cardboard sheets/ universal clean- up pads. Aspirate the mercury with the help of a syringe 7.4.4.4 Secure it in an air-tight container with Distilled water 3/4th filled PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 13 of 41 FMS/ 02 03/05/2023 7.4.4.5 Use sticky tape to collect smaller hard-to-get beads 7.4.4.6 Use VYTAC Mercury Immobilizer (MIS) which neutralizes liquid mercury into a solid amalgam which makes it easier to scoop up the leftover contents 7.4.4.7 Place all broken glass pieces (if any) and mercury contaminated materials, including PPE’s used, into a leak proof plastic bag 7.4.4.8 Use Torch Light for locating left over shiny mercury beads if any 7.4.4.9 Label the plastic bag as Mercury Waste with bio hazard sticker 7.4.4.10 Send incident report form to Quality Manager 7.5 Sorting, Labelling, Storage and Transportation of hazardous Materials: Hazardous materials should never be disposed of down the drain or in regular trash. Workers should be trained on emergency procedures and accidental spill for the materials that they work with. Spill kits should be available for such emergencies; all cleanup materials should be handled as hazardous waste. Hazardous materials should not be mixed up with other waste. All the hazardous materials should be stored in the leak proof /corrosion free container and sealed properly. All hazardous materials should not be kept on the floor or in the corridor. The sealed containers should be labelled with the name and hazard class of the waste along with the words ‘Hazardous Waste’ and the date it was generated PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 01 of 41 FMS/ 04 03/05/2023 1.0 PURPOSE: 1.1 To provide guidelines for ensuring safety of Patients, Visitors and Hospital staff through maintenance of hospital equipment. 2.0 SCOPE: 2.1 Hospital wide 3.0 RESPONSIBILITY: 3.1 Admin manager 3.2 Maintenance Manager 3.3 General maintenance manager 3.4 Biomedical Engineer 3.5 Safety Committee 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 FMS : Facility Management and Safety 4.3 EDP : Electronic Data Processing 4.4 HIS : Hospital Information System 4.5 CA : Corrective Action 4.6 PA : Preventive Action PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 02 of 41 FMS/ 04 03/05/2023 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Providers, Third edition, 2023 5.2 The DHSP has a program for “support service equipment” management 6.0 POLICY: 6.1 Qualified and trained personnel: 6.1.1 There shall be qualified and trained personnel to operate and maintain equipment and utility systems 6.1.2 There shall be personnel on -call for all working hours. 6.1.3 Equipment planning: 6.1.4 The equipment planning shall be done based on the future requirements of the organization in accordance with its services and strategic plans. 6.1.5 The plans shall be reviewed periodically or as and when required. 6.2 Equipment selection: 6.2.1 All equipment shall be selected, rented, updated and upgraded by collaborative process. 6.2.2 There shall be involvement of the end-users, management, finance and engineering departments in the selection of equipment. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 03 of 41 FMS/ 04 03/05/2023 6.3 Equipment management: 6.3.1 All equipment shall be inventoried, and proper logs maintained in the HIS. 6.3.2 All equipment shall be allotted asset tags. 6.3.3 Wherever applicable, the relevant quality conformance certificates along with the manufacturer’s factory test certificate shall be retained as a part of the documentation for every equipment. 6.4 Equipment Maintenance: 6.4.1 Routine maintenance: 6.4.1.1 Periodic maintenance shall be done by the designated maintenance staff as per the check list (Daily, weekly and monthly) basis. 6.4.1.2 Details of repair status shall be maintained by the maintenance department in HIS portal. 6.4.1.3 All the equipment is identified by the identification equipment code affixed on the equipment 6.4.2 Break Down Maintenance: 6.4.2.1 Any breakdown call should be attended in less than 6.4.2.2 All the breakdown calls shall be notified to the maintenance department by raising ticket and informing the Maintenance tracer or complaint Management through HIS 6.4.2.3 All minor breakdowns related directly to patient comfort should be immediately on rounds itself. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 04 of 41 FMS/ 04 03/05/2023 6.4.2.4 Maintenance staff shall analyse the nature of work to be done for rectifying the problem. 6.4.2.5 Details of breakdown repairs call shall be documented in HIS. 6.4.2.6 All down calls will be termed accomplished only offer verification from the In- charge of the concerned department in HIS portal. 6.4.2.7 The Supervisor shall maintain the details of work in the maintenance logbook. 6.4.3 Preventive maintenance: 6.4.3.1 Maintenance manager shall prepare and maintain a maintenance plan as per the list of available equipment. 6.4.3.2 Based on the preventive maintenance plan scheduled work is done on a regular basis. 6.4.3.3 The details of preventive maintenance plan maintained in the service register. 6.4.3.4 Periodic checking of the building shall be done periodically by the designated staff for peeling of paints from walls, cracks, seepages etc. and should be in writing be given. 6.4.3.5 All repair working shall be attained in 2 hrs. 6.4.3.6 On failure of above the reason should be explained to the admin manager / Maintenance in charge on the same day. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 05 of 41 FMS/ 04 03/05/2023 6.5 Water Management: 6.6.1 All water storage tanks shall be cleaned and treated periodically, at regular intervals. 6.6.2 The RO plant shall be tested regularly and undergo maintenance every 6 months. 6.6 Electrical System Maintenance: 6.6.3 All electrical systems, transformers, Low Tension and / or High- Tension panels and lifts shall be covered under the periodic maintenance plan by the engineering department. 6.7 Heating, Ventilation, Air Conditioning (HVAC) Maintenance: 6.7.1 All elements of HVAC – chiller plant, air handling units (AHUs), Fan Coil Unit (FCU) and air- conditioners shall be covered under the periodic maintenance plan of the engineering department. 6.8 Equipment replacement and disposal: 6.8.1 All equipment to be condemned or disposed shall be routed through the Purchase & Condemnation Committee PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 1 of 41 FMS/ 05 03/05/2023 The organisation has a programme for Medical Gases, Vacuum, and Compressed Air 1. Purpose 1.1 Objective 1.1.1 To ensure the safe and effective management of medical gases, vacuum, and compressed air at Adhiparasakthi Dental College and Hospital. 1.1.2 To maintain continuous availability, safety, and quality of medical gases, vacuum, and compressed air. 1.1.3 To comply with NABH 3rd edition standards and other regulatory requirements. 2. Scope 2.1 Applicability 2.1.1 This manual applies to all areas of the hospital using medical gases, vacuum, and compressed air, including operating rooms, ICUs, emergency rooms, patient wards, dental units, and laboratories. 2.1.2 It is applicable to all personnel involved in the management, usage, and maintenance of medical gas and compressed air systems. 3. Responsibility 3.1 Roles and Responsibilities 3.1.1 Chief Medical Officer (CMO): Oversees the entire medical gases and compressed air program and ensures compliance with standards. 3.1.2 Biomedical Engineering Department (BME): Responsible for the maintenance, repair, spare part replacement, and servicing of the medical gas and compressed air systems, including equipment checks and repairs. 3.1.3 Nursing Staff: Responsible for monitoring and reporting any issues with medical gases, vacuum, or compressed air systems. 3.1.4 Housekeeping Staff: Ensures cleanliness around medical gas and compressed air storage areas and checks for any leaks or damages. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 2 of 41 FMS/ 05 03/05/2023 3.1.5 Facility Management Team: Responsible for the procurement, storage, safe handling, and distribution of medical gas cylinders and compressed air systems. 4. Abbreviation 4.1 Key Abbreviations 4.1.1 MG – Medical Gases 4.1.2 VAC – Vacuum System 4.1.3 CA – Compressed Air 4.1.4 BME – Biomedical Engineering 5. Reference 5.1 Key References 5.1.1 NABH 3rd Edition Standards, Chapter on Medical Gases, Vacuum, and Compressed Air. 5.1.2 Manufacturer guidelines for medical gas and compressed air equipment. 5.1.3 WHO guidelines on the use and management of medical gases and compressed air. 5.1.4 Local and national regulatory guidelines for medical gas and compressed air safety. 6. Policy 6.1 Policy Statement 6.1.1 Adhiparasakthi Dental College and Hospital is committed to the safe management, storage, distribution, and use of medical gases, vacuum, and compressed air to ensure patient safety and compliance with NABH standards. 6.1.2 All personnel involved in handling medical gases, vacuum, and compressed air shall receive appropriate training and adhere to the established procedures. 6.1.3 The hospital shall ensure regular maintenance, checks, and repair of all equipment and systems related to medical gases, vacuum, and compressed air, including the replacement of spare parts when necessary. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 3 of 41 FMS/ 05 03/05/2023 7. Procedure 7.1 Handling and Storage of Medical Gases and Compressed Air 7.1.1 Medical gases and compressed air shall be stored in designated, secure, and well-ventilated areas. 7.1.2 Cylinders must be stored upright and secured with chains or straps to prevent tipping. 7.1.3 Empty and full cylinders should be stored separately and clearly labelled. 7.1.4 Compressed air systems must be inspected regularly to ensure there are no leaks or potential hazards. 7.2 Maintenance, Repair, and Spare Replacement 7.2.1 The Biomedical Engineering Department shall conduct weekly inspections of medical gas and compressed air outlets, pipes, and associated equipment. 7.2.2 Any defects, leaks, or equipment malfunctions detected during the weekly inspections must be reported immediately, and corrective actions should be taken promptly. 7.2.3 Maintenance logs must be maintained, detailing the dates of inspections, findings, actions taken, and parts replaced. 7.2.4 Spare parts inventory for medical gas and compressed air systems should be regularly updated, ensuring all critical components are available for immediate replacement. 7.3 Weekly Checklist and Safety Checks 7.3.1 A weekly checklist must be completed by the Biomedical Engineering Department to verify the following: Proper functioning of all medical gas outlets and compressed air systems. Absence of leaks in pipes, valves, and connections. Appropriate pressure levels in the compressed air systems. Availability and condition of spare parts for emergency repairs. 7.3.2 All checklists must be reviewed by the Chief Medical Officer (CMO) to ensure compliance and safety. 7.4 DHSP Procedures for Medical Gases Safety 7.4.1 The Dental Hospital Safety Program (DHSP) procedures include: PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 4 of 41 FMS/ 05 03/05/2023 Safety measures at all levels, including proper labeling, storage, and handling of medical gases and compressed air. Use of appropriate personal protective equipment (PPE) while handling gases. Ensuring that all storage areas are well-ventilated and free from potential ignition sources. 7.5 Written Guidance for Safe Handling 7.5.1 Written guidance governs the handling, storage, distribution, and use of medical gases in a safe manner, which includes: Clear instructions for the handling and use of medical gas cylinders. Guidelines for storage conditions to prevent contamination or accidental release. Procedures for monitoring gas levels, pressure, and ensuring secure connections. 7.6 Alternate Sources for Medical Gases, Vacuum, and Compressed Air 7.6.1 Alternate sources are provided to ensure continuity in case of failure: Oxygen cylinders are available in the emergency cart and throughout the hospital. Nitrous oxide is available in the pedodontics department. Backup vacuum pumps and portable compressed air units are on standby for emergency use. 7.7 Testing of Alternate Sources The Biomedical Engineering Department regularly tests the functioning of these alternate sources: Testing is conducted monthly to verify the readiness and functionality of all backup systems. Results of tests are documented, and any issues are resolved immediately. 7.8 Maintenance Plan for Centralized Compressed Air Supply 7.8.1 If a centralized compressed air supply system is installed, a maintenance plan shall include: Regular inspection of compressors, air dryers, filters, and distribution lines. Weekly checks for leaks, pressure stability, and proper operation of the control system. Annual servicing by certified technicians to ensure compliance with safety standards. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 5 of 41 FMS/ 05 03/05/2023 7.9 Training and Competency 7.9.1 All relevant staff must undergo training on the safe handling and usage of medical gases, vacuum, and compressed air. 7.9.2 Training sessions shall be conducted annually, with additional refresher courses as needed. 7.9.3 Training records must be maintained, documenting the date, content, and attendees of each session. 7.10 Process Flow for Medical Gas and Compressed Air Management 7.10.1 Procurement 7.10.1.1 Medical gases and compressed air supplies are procured based on usage rates and safety stock levels. 7.10.2 Storage 7.10.2.1 Medical gases and compressed air systems are stored in designated areas with appropriate safety measures in place. 7.10.3 Distribution 7.10.3.1 Medical gases and compressed air are distributed to different hospital departments based on their requirements. 7.10.4 Monitoring and Maintenance 7.10.4.1 Regular checks and maintenance are conducted to ensure all systems are functioning correctly. Weekly checklists are completed to verify system integrity. 7.10.5 Repair and Spare Replacement 7.10.5.1 The Biomedical Engineering Department handles all repairs and spare part replacements promptly to ensure continuous operation. 7.10.6 Emergency Response 7.10.6.1 In case of emergencies, established protocols are followed to ensure patient and staff safety. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 1 of 41 FMS/ 06 03/05/2023 1.0 PURPOSE: 1.1 To provide guidelines & document the plan for fire and non-fire emergencies from within the hospital. 2.0 SCOPE: 2.1 Hospital – wide 3.0 RESPONSIBILITY: 3.1 Maintenance Department 3.2 Hospital Safety Committee/ Code Red committee 4.0 ABBREVIATION: 4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers 4.2 FMS : Facility Management and Safety 4.3 CA : Corrective Action 4.4 PA : Preventive Action 5.0 REFERENCE: 5.1 NABH: Accreditation Standards for Dental Health Care Service Providers, Third Edition, January 2023/FMS 5.2 FMS.6: The DHSP has plans for fire and non- fire emergencies within the facilities 6.0 POLICY: 6.1 The hospital has a firefighting team drawn from the hospital staff. 6.2 They are given the necessary training to use firefighting equipment and given PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 2 of 41 FMS/ 06 03/05/2023 6.3 When the CODE RED is announced by the general alarm bell or Public Announcement system, the fire-fighting team will rush to the site of fire accident and on reaching the site will coordinate their action to extinguish the fire by the time the informed fire force arrives at the site. 6.4 The fire-fighting team will conduct the safe and organized evacuation of the people from the site in an orderly manner and without creating panic or confusion. 6.5 The fire drills shall be conducted twice a year 6.6 There is an established maintenance plan for all fire-fighting equipment. 7. PROCEDURE: 7.1 This hospital has provisions and facilities to combat any fire emergencies. All the floors of the hospital are provided with automatic water sprinklers systems controlled electronically and have access to firefighting equipment and water hoses at vantage points. High power pumps are installed to pump water in case of fire hazard. 7.2 The hospital has marked fire exits strategically located. The emergency exit routes are marked. Each patient room and common passages have marked directions of the exit routes to be used in the case of fire and other emergencies. Fire extinguishers and other firefighting equipment are provided in high-risk areas like the medical records room, pharmacy, store etc. 7.3 Besides the members of the ‘Fire Fighting Team’ other staffs both medical and non- medical are trained to react and combat in such emergencies, with the priority to protect the patients and valuable hospital equipment and assets. 7.4 The Fire Fighting Team organizes mock fire and emergency drills twice a year with the help and guidance from the local fire fighting force. All staff takes part the drill which gives emphasis of safe evacuation of the patients and occupants in the affected areas or hospital in general, as the fire fighting and containment activity is under progress. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 3 of 41 FMS/ 06 03/05/2023 7.5 Hospital Fire Fighting Team: 7.6 During Daytime [8:00 am to 6:00 pm]: 7.7 Fire Safety Protocol: 7.7.1 Fire risk areas in the Hospital are identified as given below: - Kitchen; Generator Room; Sub-station; Medical Gas storage room and medical record room. At these places, First Aid fire appliances are provided. In case of any fire incident the following action is to be taken: - Try to put it off; Shout for help in case not being able to put it off; if it is an electrical fire, inform general maintenance or cutting off the power supply. 7.7.2 In case of fire in the hospital building and surrounding areas following action is to be taken:- Immediately try to put it off; If not extinguished ,shout to help; Switch off the electrical supply; Shift the patient to safer places. If fire has not been extinguished, without panic direct the patients to safer locations through fire escape route. 7.7.3 Use fire escape route for going out of the hospital building (Fire /Emergency escape route is drawn and displayed at all floors important locations for information of patient and staff). 7.8 Fire Fighting Instructions: 7.8.1 The fire-fighting is an emergency requirement and this is called as CODE RED in this hospital it will be alerted through Public PREPARED BY VERIFIED BY APPROVED Announcement BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 4 of 41 FMS/ 06 03/05/2023 7.8.2 system/bell/fire alarm by dialling 111. 7.8.3 Fire accidents may occur any time. If these fire accidents are not attended immediately it can cause loss to life and property. In case a fire incident is noticed at this hospital area, the following action is to be taken:- 7.8.4 Try to put off electric equipment 7.8.5 Shout for help in case assistance is required. If unable to put off inform about the type of fire and location of fire. Security Supervisor will activate “Code Red” signal and assemble the firefighting team consisting of the following personnel on duty at this hospital. Security Supervisor will inform all the above personnel and reach the fire site without delay. If it is an electrical fire the electric supply should be switched off by informing duty electrician. Water will be used if it is confirmed as solid fire. If evacuation is required, the evacuation plan is to be activated. All inmates should move to the assembly point. The Security Supervisor will maintain a record of the fire accident by noting the date, time of call and time of dousing the fire and loss of life or property if any. If the fire is not controllable the matter to be informed to civil fire station for immediate help while informing give type of fire and correct location of fire. The firefighting team shall reach to the place of fire without delay and organize firefighting after getting this warning of “ Code Red ” 7.9 Fire Prevention Points: 7.9.1 Do not store inflammable materials like petrol, LPG, in the hospital building and rooms. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 5 of 41 FMS/ 06 03/05/2023 7.9.2 Do not use kerosene stove, burners, gas stoves in the hospital rooms and department. 7.9.3 The spirit lamp used in the laboratory should be placed in a safe place and put off after use. 7.9.4 Do not use the candles / oil lamp to light the rooms department. 7.9.5 Do not use the unauthorized electrical appliance in this hospital rooms and department. 7.9.6 Do not store the loose papers files and old record in card board boxes. 7.9.7 The old record room should be properly ventilated and electrical line protected against the fire. 7.9.8 All-important departments will be provided with the first aid fire appliance. 7.9.9 Do not leave the remains of used match stick, candles or cloth pieces etc in the floor area. 7.9.10 Extinguish and throw these items in dust bin only. 7.9.11 Put off electrical supply to the rooms in case any spark is noticed and inform duty electrician. 7.9.12 While refuelling the diesel tank of generator take fire precautions and do not bring any lighted material near to the refuelling point. 7.9.13 Put off all light fans and electrical equipment and remove the equipment connection from the plug while locking the room after the work PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 6 of 41 FMS/ 06 03/05/2023 7.10 Emergency Evacuation Plan /Emergency Exit: Ground Floor Occupants: 7.10.1 In the event of fire or other emergencies which warrant the evacuation of patients and duty personnel, please be guided by the following evacuation plan: 7.10.2 Alert all inmates one by one and room by room of the emergency without causing undue panic and commotion while informing the matter. 7.10.3 Evacuate all the patients first with the help of stretcher, trolleys or by the wheeled cots. 7.10.4 The only route to be used for evacuation of such patients should be the hospital Staircase. 7.10.5 The lifts should not be used in such situations. 7.10.6 Patients unable to walk should be evacuated one by one using wheelchairs. 7.10.7 Evacuation should be done in an orderly manner without causing confusion or panic. 7.10.8 These patients will be moved to departments on the other floors except the affected area. 7.10.9 The duty personnel will leave the emergency affected floor last after ensuring that all the patients, their personal belongings and medical documents are safely evacuated. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 7 of 41 FMS/ 06 03/05/2023 7.11 Fire Fighting Appliances Within The Hospital (Refer Annexure 1 And 2): 7.11.2 First aid appliances: -Foam extinguisher, powder compound extinguisher, CO 2 gas extinguisher. 7.11.3 Major fire appliances. 7.11.4 Water facilities within the corridors 7.12 Firefighting training 7.12.2 The Fire Fighting Team organizes mock fire and emergency drills twice a year with the help and guidance from the local fire fighting force. 7.12.3 All staff takes part in the drill which gives emphasis on the safe evacuation of the patients and occupants in the affected areas or hospital in general, as containment activity is under progress. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 8 of 41 FMS/ 06 03/05/2023 Annexure 1: FIRE PROCEDURE Dial 111 and announce CODE RED and in which department and floor the incident had happened. PULL-CALL-FIGHT – EVACUATE 7.12.3.1 REMOVE ANYONE IN DANGER area 7.12.3.2 PULL ALARM 7.12.3.3 CALL the hospital fire number and give them exact location, stating building, floor and room number 7.12.3.4 FIGHT FIRE. Isolate area, close nearby doors and windows. If safe to do so, shut off electrical appliances and oxygen. Turn off all lab experiments. Including all gases in the general area of the fire. Attempt to extinguish or control spread of fire with extinguisher, hose, wet blanket, etc. 7.12.3.5 EVACUATE - To the safest stairwell. Evacuation on patient floors only will be Nursing in charge PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 9 of 41 FMS/ 06 03/05/2023 7.12.3.6 KNOW Location of fire alarms on your floor KNOW “Fire Alarm Code” for your area (found at the pull-box station) KNOW Location and correct operation of fire extinguishing equipment The term "Code Red" is used within the hospital in place of the word "Fire". Do not use elevators during a "Code Red" PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – FACILITY MANAGEMENT AND SAFETY Doc No: APDH/NABH/ Issue Date: Version:03 Issue:01 Page 10 of 41 FMS/ 06 03/05/2023 Annexure 2: FIRE FIGHTING EQUIPMENTS & PROCEDURES Class Extinguisher Type of Fire Action Operation ABC Dry powder Ordinary Smothers – removes 02 combustible fire, Push toggle lever or pull pin. flammable liquid, Direct hose at base of fire. Squeeze handle. electrical Cover all burning surfaces. equipment BC Carbon Di oxide Flammable liquids, Smothers – removes 02 (red cylinder) electrical equipment Push toggle lever or pull pin. Direct hose at base of fire. Squeeze handle. Cover all burning surfaces. PREPARED BY VERIFIED BY APPROVED BY FMS COORDINATOR PRINCIPAL CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 1 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 DEPARTMENTAL MANUAL HUMAN RESOURCE DEPARTMENT MANUAL APDCH / DM / HRM/ 02 Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 2 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 AMENDMENT SHEET Sl. Section No Details of the Amendment Reasons Signature Signature No. & Page No of the of the preparatory approval authority authority Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 3 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 CONTROL OF THE MANUAL The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a readily identifiable and retrievable mode. The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as and when the amended versions are received. The HR Coordinator is responsible for issuing the amended copies to the copyholders, the copyholder should acknowledge the same and he /she should return the obsolete copies to the HOD. The amendment sheet, to be updated (as and when amendments received) and referred for details of amendments issued. The manual is reviewed once a year and is updated as relevant to the college/hospital policies and procedures. Review and amendment can happen also as corrective actions to the non conformities raised during the self-assessment or assessment audits by NABH. The authority over control of this manual is as follows: Preparation Approval Issue HR Coordinator Correspondent NABH Coordinator The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’, and the photocopies of the master copy for the distribution are considered as ‘Controlled Copy’. Distribution List of the Manual: S.No Designation 1 NABH Coordinator 2 Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 4 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 1.0 Introduction The process of hiring and developing employees so that they become more valuable to the organization 2.0 PURPOSE: 2.1 To recruit people who have a positive attitude towards patients & students themselves and other employees and who are able to give quality service. 2.2 To ensure that employees are selected, trained, promoted and treated on the basis of their relevant skills, talents and performance without any discrimination. 2.3 To provide a clean, safe, healthy, fearless and enjoyable working environment. 2.4 To motivate employees through performance appraisal and reward system. 2.5 To provide training and development for all the employees to enable them to achieve the highest level of skills possible. 3.0 SCOPE: The manual covers the following area of H.R functions such as: 3.1 Manpower planning 3.2 Recruitment and selection 3.3 Joining induction 3.4 Training & Development 3.5 Performance Appraisal 3.6 Employee grievance redressal & Disciplinary Procedure 3.7 Health Needs of the employees 3.8 Employee Separation 4.0 ABBREVIATIONS: 4.1 APDCH - Adhiparasakthi Dental College & College/hospital 4.2 NABH - National Accreditation Board for College/hospitals and Healthcare Providers 4.3 HRM - Human Resource Management Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 5 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.0 REFRENCES : 5.0 Accreditation Standards for Dental Health Care Service Providers, Third Edition, Feb 2023. S.No ChapterNo/ Relevant NABH Standard /Objective Element StandardNo 1 5/HRM1 The DHSP has a documented system of human resource planning (a-g) 2 5/HRM2 The organisation implements a dened process for staff recruitment. (a-d) 3 5/HRM3 Staff are provided induction training at the time of joining the organisation. (a-h) 4 5/HRM4 There is an ongoing program for professional training and development of the staff. (a-f) 5 5/HRM5 Staff are trained in safety and quality-related aspects. (a-g) 6 5/HRM6 An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process. (a-e)) 7 5/HRM7 Process for disciplinary and grievance handling is dened and implemented in the organisation (a-f ) 8 5/HRM8 The organisation promotes staff well-being and addresses their health and safety needs. (a-e) 9 5/HRM9 There is a documented personal record for each staff member (a-d) 10 5/HRM10 There is a process for credentialing of dental / medical professional, permitted To provide patient care without supervision (a-f) 11 5/HRM11 There is a process for collecting, verifying and evaluating the credentials of para- dental staff (a-e) 5.1 MANPOWERPLANNING: 5.1.1 PLANNING PROCEDURE The planning procedures involves,  Quality of the Personnel required for the Job  Quantity of the Personnel required for the Job 5.1.2 QUALITY OF THE PERSONNEL REQUIRED FOR THE JOB: Job Analysis is a tool for identifying quality personnel required for a particular job Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 6 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.1.3 MANPOWER PLANNING FOR DOCTORS: Man Power Planning for Doctors is done as per the DENTAL COUNCIL OF INDIA requirement. For all other staff the manpower planning is done according to College /hospital Policy as mentioned above. 5.1.4 DEPARTMENTS: All the Departments in the College / hospital are categorized into Departments. Those are  Human Resource  Administration  Accounts  Purchase & Stores  Facility & Management  Information Technology  Patient Care  Pharmacy  Medical Records  Hostel  Principal Office/ Dental  Library  Research  Nursing Services  Quality Assurance Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 7 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.1.5 JOBANALYSIS: DEFINITION: It is the process of identifying the content of a job in terms activities involved and attributes needed to perform the work and identifies major job requirements. Job Analysis includes:  Job Description  Job Specification Job Analysis will be done by the HR Department in coordination with concerned department In- charges/Headstodevelopdutiesandresponsibilitiesrequiredforaparticularjobandtheskillsetsrequired fromthepersonnel 5.1.6 JOBDESCRIPTION: DEFINITION: Abroad, general, and written statement of a specific job, based on the finding so job analysis. It generally includes roles & responsibilities, skills & qualifications, communications, documentation, attendance & grooming, training & education, safety precautions along with the job's designation of the person to whom the employee reports This will also helpful to identify the training needs and will help to evaluate the performance of the personnel 5.1.7 JOBSPECIFICATION: DEFINITION: A statement of employee characteristics and qualifications required for satisfactory performance of defined duties and tasks comprising a specific job or function It translates the job description into terms of the human qualifications which are required for a success full performance of a job. Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 8 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.1.8 QUANTITY OF THE PERSONNEL REQUIRED FOR THE JOB: The number of personnel required to accomplish a particular task is carried out through the following steps:  Existing Manpower Analysis  Man Power Forecasting 5.1.9 EXISTING MANPOWER ANALYSIS: The Manpower plan is reviewed whenever required (with Entry & Exit list) to ensure that adequate manpower is existing in each department and will help in identifying manpower requirement to avoid disturbance in the services of the college/hospital. 5.1.10 MANPOWER FORECASTING The future Manpower requirement is forecasted by the Top Management according to the expansion strategy of the Organization and by the Head of Department according to the addition of Services in the Department. 5.2.1 SELECTIONPROCESS Employee Selection is the process of putting right employee on right job. It is a procedure of matching organizational requirements with the skills and qualifications of people. 5.2.2 APPLICATION RECEIPT Received applications are being segregated based on their qualification and the post applied. The date and reference details have to be mentioned in the application Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 9 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.2.3 SCRUTINY OF APPLICATIONS It is HR Departments responsibility to scrutinize the applications and do short listi ng and then the short listed applications are handed over to the concerned department Heads /In-Charges to filter the prospective applicants to call for interview. 5.2.4 INTERVIEW The screened employee is called for interview. 5.2.5 INITIAL SCREENING:(I Round) Initial screening will be done by HR Department to evaluate the employee’s confidence level, attitude and body language to ascertain his/her interest towards the organization. 5.2.6 TECHNICAL INTERVIEW:(II Round) Once the HR round is completed and if the employee seems good then technical round will be conducted by the concerned department Head/ In-Charge. If needed written test will be conducted to evaluate the employee’s technical skills 5.2.7 ANTECEDENT HISTORY CHECK: Background verification will be done to the employee those who have successfully completed the technical round. It will be done by ringing up to the previous organization and information about the employee will be obtained over the phone or Background Verification form will be sent through mail if required by that. 5.2.8 CREDENTIALING VERIFICATION To check the credential of Doctors through Dental Council of India website / Dental Council of Indiaregistrationdetails.Ifthedetailsfurnishedbytheemployeearebogushis/heremploymentwillbecan celledwithoutanyfurthernotice. Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 10 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.2.9 JOINING PROCESS: At the time of joining the new joiners have to produce the following documents and information:  To fill the Employee Application Form that pertain the employee’s personal details.  Submission of his / her Experience Certificate (if any), Qualification Certificates, Training Certificates (if any), Address or ID Proof  Passport size photos to be produced (Four Nos.) From HR part:  Orientation about the college/hospital will be given- Mission, Vision Statements of the college/hospital, various specialties, Various Departments, Location and Functions, College/hospital Contact Details  New Joinees will be taken for College/hospital Rounds to familiarize various departments and Staff  Instructions will be given regarding Attendance (Registration of Entry and Exit at the Security point)  Special Class on Grooming Standards will be conducted to the New Joinees  Per anent Identity Card will be issued within a week.  Appointment order and job description will be issued by the Principal (Teaching) / Administrative Officer (Non Teaching) and a duplicate copy will be documented in the personal file with HR Department.  If the details furnished by the employee are bogus his/ her employment will be cancelled without any further notice Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 11 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.2.10 FINAL INTERVIEW: If the employee is short listed in the technical (second) round and their background check result are good they will be called for final round with Correspondent (Prior appointment will be fixed with Correspondent) and compensation & date of joining will be decided in this round. For Doctors and other key positions, final round will be conducted by the Correspondent. Salary will be fixed based on the following criterions:  Educational Qualification  Professional Qualification  Relevant Work Experience  Performance in the Interview  Internal comparison 5.2.11 OFFER LETTER After the Final Round of Interview, Offer Letter will be issued for the selected employee which is signed by the Correspondent. 5.2.12 PHYSICAL FITNESS TEST If the employee got selected, he/she will undergo Medical Test to know whether they are physically fit for the job. If not fit the offer will be turned down Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 12 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.3.0 INDUCTION 5.3.1 PROCEDURE: On the date of joining the new joinees will be given a brief introduction about the college/hospital A detailed orientation about the college/hospital will be conducted to new recruits every month. For that new joinees list to be prepared and a circular has to be sent to the concerned departments mentioning the orientation date, time and venue Induction Attendance sheet to be maintained and the attendees signature has to be obtained in the register Induction Feedback Forms will be collected & analyzed and to be documented in the Induction File At the end of the Induction Programme new recruits will be taken for College/hospital Rounds The new hires are sent to their respective departments where they will be oriented about their department policies and procedures 5.3.2 TOPICS COVERED IN INDUCTION PROGRAMME:  The college/hospital-Vision and Mission Statements, various Specialties  All Departments-Location and functions  HR policies:  Manpower Planning  New Joined Formalities Prepared by Verified by Approved by HR COORDINATOR AO CORRESPONDENT  ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL PROCESS MANUAL – DEPARTMENT OF HUMAN RESOURCE Issue Date: Page 12 of APDCH/DM/HRM/09 Version: 03 Issue:01 03/05/2023 30 5.4.0 TRAINING & DEVELOPMENT: PROCEDURE: 5.4.1 TRAINING NEEDS ANALYSIS: The training needs of each employee should be identified and Programmes should be developed that are best suited to their needs. This analysis specifically defines the gap between the current and the desired individual and organizational performances. Training Need Analysis is based on the following requirements  Performance problems  Organizational Goals and Objectives  Anticipated introduction of new system / equipment’s, task or technology a desire by the organization to benefit from a perceived opportunity  Changes in existing policies  Job Rotation/Change in Job Responsibility  Willingness of an individual employee based on the needs analysis training programs are classified as: Technical/ Professional Training Soft Skill Training Safety and Quality Related Training Once the training needs are identified and classified Training Calendar will be prepared for the whole year and the concerned department Heads/ In-Charges have to conduct technical training in the department and