King Salman Project 1- Introduction to FMS V4 PDF

‫‪1 of 54‬‬ ‫مشروع‬ ‫خطط تدريبية مكثفه لألمن والسالمة بمستشفى الملك سلمان‬ ‫التدريب على معايير السالمة وإدارة المرافق‬ ‫للمركز الوطني العتماد المنشآت الصحية‬  2 of 54 An Introduction to Facility Management & S...

‫‪1 of 54‬‬ ‫مشروع‬ ‫خطط تدريبية مكثفه لألمن والسالمة بمستشفى الملك سلمان‬ ‫التدريب على معايير السالمة وإدارة المرافق‬ ‫للمركز الوطني العتماد المنشآت الصحية‬  2 of 54 An Introduction to Facility Management & Safety (FMS) National Hospital Standards (NHS)  3 of 54 FMS Overview in the NHS 3rd Edition  NHS 3rd Edition 4 of 54 Total number of FMS Standards 39 Total number of Sub-Standards assessed by FMS Surveyor = 350 (15% of the total Sub Standards) Sub Standards assessed by FMS Surveyor in the FMS Domain = 171 Sub-Standards FMS Surveyor Sharing w/ others = 143 Sub Standards assessed by FMS Surveyor outside the FMS Domain = 36  NHS 3rd Edition 5 of 54 An example of a standard to be scored only by FMS surveyor☺ FM.21 The hospital has an effective fire alarm system. There is a fire alarm system that is functioning and regularly inspected as per civil defense FMS.21.1 guidelines. FMS.21.2 The fire alarm system testing results are documented. FMS.21.3 The fire alarm system has preventive maintenance. FMS.21.4 The elevators are connected to the fire alarm system.  NHS 3rd Edition 6 of 54 An example of a standard to be scored by more than one surveyor including FMS☺ LD.26 The department head develops an organizational chart for the department. Each department has an organizational chart that clearly displays all sections/divisions within LD.26.1 the department, titles (or names), lines of authority, accountability, and reporting relationships. The organizational chart is signed by the department head and approved by the hospital LD.26.2 management. LD.26.3 The organizational chart is communicated to the staff working in the department.  NHS 3rd Edition 7 of 54 An example of a standard to be assessed by FMS surveyor outside his domain☺ All equipment and machines in the respiratory care services are operated within RS.3 manufacturers’ specifications and maintained free of defects. RS.3.1 All equipment and machines are operated within manufacturers’specifications. The periodical preventive maintenance is developed and implemented in accordance with RS.3.2 manufacturers’instructions. RS.3.3 All maintenance and repair records are maintained for future reference and inspection.  NHS 3rd Edition 8 of 54 NHS 3rd edition has identified two FMS standards as an ESR based on their level of risk on patients: proximity of risk, probability of harm, severity of harm, and number of patients at risk  NHS 3rd Edition 9 of 54 Total number of assessment activities = 4291 FMS Assessment Activities = 335 Surveyor Load / Specialty 10 of 54 FMS LD 8% 14% LB 17% MD 19% PH 12% NR IC 15% 15%  FMS Assessment Activities 11 of 54 1. Document Review 2. Medical Record Review (N/A) 3. Personnel Files Review 4. Observation 5. Leadership Interview 6. Unit Visit Interview 7. Unit Visit Documented Evidence  12 of 54 Weight of each assessment category for FMS Surveyor Documented Evidence 16% Unit Visit Interview Document Review 12% 27% Interview 8% Medical Record Personnel File Review 9% Review 0% Observation 37% 13 of 54 Types of Documents 14 of 54 Policy & Procedures Plans Meeting Minutes Programs Charts ( Organization , Improvement ) Records Reports Forms Guidelines Licenses and Certifications  Compliance 15 of 54 Approval Content Serve the purpose Validity Applicability Accessibility Implementation Format Multidisciplinary  Multidisciplinary 16 of 54 New Medical Equipment Policy and Procedures Definition: New Owner: Biomedical Engineering Applicability: Physicians, Nursing, Security Policy & Procedures 17 of 54 Signatory Legal Document Wording Not Time Related People Coverage Processes Awareness Master Policy  Policy & Procedures Applicability Preparation Date Index Effective Dates Review Dates Purpose Definitions Policy Approvals  19 of 51 Procedures References Policy & Procedures Plans 20 of 54 Futuristic Approval Periodic Review Objectives Contingency Plans  S 21 of 54 S Specific M Measurable S.M.A.R.T. A Achievable R Realistic T Time-Bound Meeting Minutes 22 of 54 Continuity Attendance (Quorum) Effectiveness (Issues Resolves, Escalation) Frequency  23 of 54 Facility Management and Safety  24 of 54 Introduction Facility Management & Safety Facility Infrastructure [Interior, exterior, Facility management is at the Systems, utilities] center of occupant needs, business and communication processes, management and Processes [Facility Medical Services and Technology workflow technologies, and Plans] the physical infrastructure itself. (IFMA Definition). Occupants Safety management is an [Personnel, Patients, organizational function, which and Visitors] ensures that all safety risks have been identified, assessed and satisfactorily mitigated.  25 of 54 Facility Management A facility manager is expected to operate and maintain the facility in a manner that supports the goals and mission of the entire organization. In this way, the facility manager is able to: Provide safe, healthy and productive facility environments. Develop the lowest possible systems/component failure and highest possible reliability at the lowest overall total cost. Develop, recommend and manage facility operational planning requirements. Anticipate change and plan in advance for necessary adaptations. Hire, train, manage and assess the technical performance and occupant service performance of operation and maintenance (O&M) staff. Comply with all relevant international, national and local codes and regulations.  26 of 54 Safety Management A safety management must assume proactive strategy that includes identifying hazards before they materialize into incidents and taking the necessary actions to reduce the safety risks. Components of a proactive safety management strategy are: Clear-cut safety policy ensuring the senior management commitment to safety; Hazard identification and risk assessment using state-of-the-art risk assessment methods; Safety reporting systems used to collect, analyze and share operational safety related data; Competent investigation of safety occurrences with sole purpose of identifying systemic safety deficiencies; Safety monitoring and oversight aimed to asses safety performance and eliminate potential risk sources; Dedicated safety training for personnel Safety lesson dissemination and sharing best practices among operators and service providers; Building an organizational safety culture that promotes good safety practices and encourages safety communications in a non-punitive environment  27 of 54 How to implement ? The hospital leadership has to provide all necessary support and resources to improve safety in the work place in alignment with the regulatory requirements. The Hospital must have plans for managing the safety of the environment and must implement these plans. (Planning) Staff must be educated on their responsibilities. Education must commence at orientation and continues on a regular basis thereafter. (Training) The Hospital must collect and analyze data to determine the effectiveness of the plans and facilitate continuous quality improvement. (Monitoring)  28 of 54 Who is responsible? It is the responsibility of all staff to ensure their own safety! It is the responsibility of all staff to report any safety violation(s)  29 of 54 When to implement safety? Safety comes first! It should be implemented on day to day work.  30 of 54 Main Eight (8) plans/topics included in the F M S Chapter 1. Facility Safety 2. Security 3. Life/fire safety 4. Emergency Preparedness plans (Internal) 5. Emergency Preparedness plans (External) 6. Hazardous Materials and Waste disposal 7. Medical Equipment 8. Utilities  31 of 54 FMS Standards Overview [FMS.1 – [FMS.11 [FMS.14 [FMS.16 FMS.10] – – – FMS.13] FMS.15] FMS.17] Emergency Hazardous Security Preparedness Materials Facility Safety and Plans [FMS.18 [FMS.25 [FMS.28 – – – FMS.24] FMS.27] FMS.39] Fire Safety Medical Equipments Utility Systems  32 of 54 Leadership Role and Impact on Implementing FMS Standards  33 of 54 A safe, functional and effective environment for patients, staff, and other individuals is crucial to prevent or minimize risks in the environment of care. The hospital leadership has to provide all necessary support and resources to improve safety in the work place in alignment with the regulatory requirements.  34 of 54 10 Key Components of Leadership Commitment to Safety  35 of 51 Planning Communication Organization Qualified Budget Workforce Allocation Leadership Commitment to Safety Motivation Building Culture Safe Continuous Oversight Infrastructure Training  Planning 36 of 54 Implementing an effective Safety Management Program requires establishing flexible safety management plans with continuous monitoring and improvement. Such plans should have: 1. Clear scope (What does the plan cover?) 2. Tangible objectives (what do we want to achieve ? Or why do we have this plan ?) 3. Time-frame. (When ?) 4. Measurable goals and performance indicators (Are we doing well ? ) Examples: To train 100% of hospital staff on fire safety. To reduce hazardous medical waste by 20kg per day by end of 2024. Achieve 95% preventive maintenance completion of medical equipment by end of 2024.  Organization 37 of 54 Leaders should ensure effective communication throughout the hospital through creating clear organizational structures , setting roles and responsibilities and delegations. Examples: 1. FMS Organizational Charts. 2. Clear Job descriptions.  Oversight 38 of 54 This is achieved through: 1 Establishing multidisciplinary safety committee/s that meet regularly , to stand on safety issues and challenges and develop necessary action plans. 2 Monitor hospitals’ departments implementation and adherence to safety policies and procedures and provide safety consultations. 3 Follow up progress of safety management plans in achieving its planned objectives.  Safety Budget Allocation 39 of 54 One of the most challenges for an organization to comply with general safety requirements and CBAHI FMS standards is the lack of financial support to procure necessary safety equipments to ensure facility and occupants safety. Examples of safety program items that require financial support: 1. Procurement of fire extinguishers , fire blankets and first aid kits. 2. Contracts for maintenance of fire fighting and detection systems. 3. Installation of surveillance cameras and access control systems for security sensitive areas. 4. Procurement and installation of fire resistant doors. 5. Contracts for generator sand elevators maintenance and supply of medical gas systems. 6. Training of staff on fire fighting and safety measures.  40 of 54 Remember, one of CBAHI standards is: FMS.1: Hospital Leaders establish and support a Facility Management and Safety program. ▪ FMS.1.2 Hospital leaders support the facility management and safety program to acquire the necessary equipment. ▪ FMS.1.4 The program has a budget for the necessary upgrading or replacement as identified by monitoring data or to meet applicable laws and regulations.  Workforce Selection 41 of 54 Selecting experienced and qualified workforce is a key factor for organizations to achieve its goals and its safety management program in specific. having an effective safety management program.  42 of 54 CBAHI standards emphasize this as one of its FMS standards is: FMS.2 There is a qualified individual(s) responsible for directing and coordinating the facility management and safety program. FMS.2.1 The hospital has a facility management and safety program director who directs and coordinates all aspects of the facility management and safety program. FMS.2.2 The program director is qualified by education (e.g., bachelor’s degree in engineering science), training, and experience in healthcare facility management and safety. FMS.2.3 The program director is assisted by qualified staff (e.g., safety officer) as required, according to the size and complexity of the hospital services. FMS.2.4 The program director provides ongoing consultation to all departments.  Organizational Culture 43 of 54 Leaders are models for their employees. Therefore , it is important that they infect their employees with the culture of (safety First) and that (Safety is Everyone's responsibility) How to achieve this: 1. Conducting Leadership Safety Rounds. 2. Encourage staff to report hazards and risks. 3. Chair safety committees. 4. Empower Safety Departments. 5. Authorized to intervene in un-safe practices.  Continuous Training 44 of 54 Training is teaching, or developing in oneself or others, any skills and knowledge that relate to specific useful competencies. Training has specific goals of improving one's capability, capacity, productivity and performance. Examples of FMS required trainings: 1 Training on emergency codes. 2 Training on hazardous materials handling , transportation, storing and disposal using proper PPE. 3 Training staff on evacuation procedures. 4 Training staff on proper medical equipment operation based on manufacturer recommendations. 5 Training security personnel on dealing with violent behaviors , child kidnap cases and dealing with bomb threats.  45 of 54 FMS.1.5 There is an orientation program conducted for new hires on the FMS plans. FMS.16.4 There is an orientation on the external disaster plan for new hires with an annual update for all staff. FMS.19.5 The hospital ensures developing and scheduling staff training programs on the use of fire extinguishers. FMS.25.5 The hospital ensures that all maintenance works are conducted by qualified and trained staff. 45  Staff Motivation 46 of 54 Motivating staff can be financial and/or emotional gesture to make your staff feel appreciated. It is crucial for hospital leaders to motivate those champions that work hard to ensure compliance with the safety policies and procedures. Motivating staff keep them aligned with the organizations safety goals and objectives and drive them further to be engaged in the safety management program. Whats in it for me ?  Effective Communication 47 of 54 Effective communication creates a healthy environment for safety since it facilities identifying, reporting and mitigating safety issues.  48 of 54 Utilizing technology can improve communication when it comes to responding to emergencies. Examples of communication systems that can support FMS: BMS – Building Management System Overhead Paging System or PA System Security and Safety Walkie-Talkie or 2-way radio communication devices  Infrastructure 49 of 54 1-Infrastructure refers to the fundamental facilities , utilities & systems serving a hospital to sustain it operations. Examples: 1-Power distribution systems. 2-Water distribution system. 3-Hospital buildings. 4 -Medical equipments. 5 -Pavements and roads.  Infrastructure 50 of 54 Feasibility Legal Finance Hospital Commissioning Healthcare Planning Hard & Soft Facility Equipping Construction IT & Data Technology Architectural & Engineering Management Design 2. Availability of intact hospital infrastructure according to Saudi Building Code is an important factor to comply with healthcare facilities safety requirements. 3. Safety needs to be considered from the early design phases of engineering drawings. 4. Leaders struggle to comply with safety standards when it comes to old buildings.  51 of 54 FMS and Leadership: FMS.1 Hospital Leaders establish and support an FMS program FMS.1 Hospital Leaders establish and support an FMS program Intent All plans are established, approved, Valid, Comprehensive, appended with supporting documents (inspection reports, meeting minutes, invoices, etc.) Plans should be specific, measureable, achievable, resourced, and time-bound (SMART criteria)  52 of 54 FMS and Leadership: FMS.2 There is a qualified individual(s) responsible for directing and coordinating the facility management and safety program Intent Intent Safety Director/Officer and assistant team are qualified by education, professional development, certification. Evidence of communicating safety issues. List of departmental liaison safety officers is up-to-date, approved, and supported by communication, such as but not limited to letters, emails, etc.  53 of 54 FMS and Leadership: FMS.3 There is a multidisciplinary safety committee that provides oversight of the facility management and safety program Intent Approved and valid Terms of Reference Meeting minutes are documented, approved, and reflect the meeting sessions per year. Documented actions/recommendations based on meeting findings and analysis  54 of 54 MRS. DOROTHY WOLFE BROWN Company Quality & Accreditations Consultant, CBAHI Facility Management and Safety Surveyor.