CHAPTER 16.
FACILITY MANAGEMENT
Verification Standard
S. OPERATIONAL score Score
VERIFICATION CRITERIA
N STANDARDS
Met Unmet Met Unmet
1 Check availability of:
The hospital complies Hospital site Map,
1
with relevant laws,
regulations, and facility 2 Hospital Map/construction plan/ with update if modifications done,
inspection 3 License (by FMHACA)
requirements. Identity letter from relevant bodies for newly established hospitals (letters
4
for inauguration of the hospital )
1 View organization chart.
2 Check availability of general service director/coordinator
Designated hospital
Check customized departmental and individuals’ JD which includes
staff members are 3 functions in facility management and related activities
2 assigned for facility
maintenance and safety Confirm on organization chart that the hospital has assigned individuals for
functions. the following service categories each: masonry, plumbing, electrical
4 installation, landscape and garden, sewerage (optional for Primary hospitals, but
Plumbing and electrical service personnel mandatory).
Check FMx activities integrated with Annual plan and TOR of IPPS/CASH
The hospital grounds committee that includes regular inspection of hospital compounds to
1
are regularly inspected, ensure maintenance needs, safety and cleanliness
maintained to ensure Confirm inspection done as per the schedule and actions taken
3 Check general service manager working as IPPS/CASH, incidence,….
cleanliness of grounds 2
and safety of patients, committee member
visitors and staff. View patient and staff areas (garden, waiting areas etc) are tidy, clean and
3 free from hazards (e.g. free of discarded equipment or other materials),
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4 Check all walk ways are covered and safe for the transport of patients.
5 Check activities performed & adhered with the plan
Interview Head of Facility management head and observe that;
Potable water is 1 Alternative source of water exists as a backup (e.g. tank, well).
available 24 hours a Obtain documentary evidence that water sources are tested for safety at a
day and water sources 2 minimum every 3 months ( see sample submissions)
regularly tested to meet
4 essential patient care Check sample taken from main lines to the hospital entry, main and
3 alternate sources within hospital, different service areas,
and safety to the
hospital community Check that 4 reports and their corresponding actions taken based on the
(microbiological 4 results and recommendations
checks)
5 Check 5 randomly selected service areas for water availability
Interview Head of Facility management:
Confirm that an alternative power source is available (Generator, solar
1 panels,…).
Electrical services are Confirm that this is sufficient to provide power at least to essential patient
available 24 hours a 2 areas including wards, OR, emergency room, labor and delivery, laboratory,
day through regular or refrigerator rooms,………
5
alternate sources to Check the backup generator is automatic or started within 5 minutes.
3
meet essential patient
care. Check dedicated assigned personnel to ensure Generator functionality and
4 service continuity with sufficient diesels, battery to start up, and document
for regular maintenance)
5 Check 5 randomly selected areas for functional sockets & lighting
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View maintenance center:
The hospital has a
maintenance center with 1 Check availability of necessary PPEs for personnel
technical personnel, 2 Confirm that this has adequate space and is not crowded.
sufficient space and Confirm that the general maintenance workshop separated from the
adequate ventilation to 3
medical equipment workshop
6 conduct maintenance
Confirm that there are hand-washing facilities, facilities for cleaning and
and repair (e.g.,
4 disinfection equipment, a storage area, SOPs and necessary reference
electrical, water,
materials
sanitation, sewerage and
ventilation) and 5 Check staff skill mix (see standard 16 : 2 above) available on work
equipment. 6 Check ventilation and lighting of the room
Interview Head of Maintenance Department:
The maintenance center
has appropriate tools Stock of sufficient maintenance tools are available for all functions and
and testing equipment to 1 that routine calibration/testing is performed as required ( test for circuits,
perform repairs, as well switch leak, power,…)
7 Check availability of spare parts and spare inventory (paper and/or
as procedures to ensure 2
the routine calibration of computer based),
the testing equipment is Check Backup supplies’ with stock management for electric systems,
performed as required. 3 masonry, buildings (cement, paint, metal, wood, glass, …….)
The hospital conducts Interview Head of Maintenance Department and
regular preventive
maintenance for all
facilities and operating 1 Confirm that regular preventive maintenance is conducted.
systems (e.g., electrical, Confirm that maintenance logs exist for as a minimum: electrical systems,
8 2
water, sanitation, water and sewerage.
sewerage and
ventilation) to ensure View schedule of service areas and documentations for preventive
patient and staff safety 3 maintenance
and comfort.
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Check 5 randomly selected service areas in the previous month conducted
4 as per the schedule
Interview Head of Maintenance Department:
There is a notification 1 Confirm that a notification and work order system exists.
and work order system 2 Check data for;
for facility and operating No of work orders received
9 system (e.g., electrical,
No of completed work orders/actions taken
water, sanitation,
sewerage and No of incidents reported and equivalent actions taken (in separate file)
ventilation) repairs. View at least 5 recent work order requests then check equivalent reports
3
on corrective maintenance
View transport policy:
1 Check policy includes all areas of concern in EHSTG
Check vehicle service conducted according to the manufacture
2 recommendation
The hospital has a
transport policy for the View logs of two randomly selected hospital vehicles and confirm that
10 3 vehicle utilization complies with transport policy
use of and access to
hospital vehicles. Interview and check relevant staff (in the general service) adherence to the
4
policy
Check whether measures taken by regulatory bodies on drivers due to
5 violation of the transport policy prepared by the hospital
View policy:
The hospital has a Check policy includes (Visiting hour, traffic control, …..) and fixed visit
1 hrs posted at gate, wards with its implementation
11 policy addressing access
to the hospital premises. Visit wards and confirm that all attendants are wearing appropriate ID
2 badges (showing Wards and Bed No.)
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Observe all staffs, clients and vehicles searched/checked on entry and
3 exit at hospital check point
4 Check security training conducted at least annually and to new hire
Check prohibition policy and handover of weapons/sharps by the security
5 department
6 Check hospital prepare separate vehicle entrance and walking entrance
1 View fire safety plan that includes fire and evacuation drilling at least
biannually to the staffs(addressing topics in the guide line)
O Obtain documented evidence of most recent Fire Drill ( saved
Video, attendances, documents)
The hospital has a fire Check water hydrant hoses exist within the facility at least at potential fire
safety plan that 2 points(optional for primary hospitals)
12 addresses both the
3 Check Fire safety inspection done by authorized body ( optional for PH)
prevention and response
to fires. Check fire extinguishers filled and updated properly (as per production &
4 manufacturer recommendation)
See SOPs for Extinguishers utilization with possible contact address of all
5 stake holders (Police department, electric & water authority, Red – cross
society,…)
Check major incidence plan, MIP prepared and approved by SMT and
1 distributed at least to each service areas as reference
View safety and response plan for safety of all possible incidences are
The hospital has a plan 2 addressed (fire, buildings, sewerages, water sources, Epidemics, ..etc)
for responding to likely
13 incidences in the Check Roles and Responsibility of staffs and external stake holders
3 addressed in the MIP in response to disaster management
hospital or natural and
other disasters. Check implementation of the plan with incidence officer and General
4 service/Facility Management head
Check availability of alarm/command post and Check staff responses on
5 alarming
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Check disposal manual available for management of hazardous materials
6 in the hospital (Laboratory, Pharmacy, main Stores)
Check Hospital set biogas production system using hospital wastes to
7 minimize sewage and get energy power
14 Staff members are 1 Check training conducted annually and address:
trained and Operation of firefighting equipment
knowledgeable about Evacuation and practices
their roles in the plans
Responsibility/task sharing/ of each staffs
for fire safety, security,
hazardous materials, and Confirm that each one knows what action to take and their individual
emergencies. responsibility in the event of a fire and use of extinguisher( 5 staffs),
2
security threat or other emergency
TOTAL 64
Comments:
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