POLICIES & PROCEDURES ON FACILITY

Document Name :
MANAGEMENT AND SAFETY

E/ NABH / SGH /FMS/ 1 - 4

Document No. :

No. of Pages : 17

Date Created : 01/4/2017

Date of Imple mentation : 01/5/2017

Designation :
Prepared By : Name :
Signature :

Designation :
Approved By : Name :

Signature :
Designation : NABH Coordinator
Responsibility of Updating : Name :

Signature :
 AMENDMENT SHEET

S.No. Section Details of the amendment Reasons Signature of Signature

no & the of the
page no preparatory approval
authority authority
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.

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.

Administrative Manager 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 Administrative Manager.

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 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

Accreditation coordinator
Managing Director, Sigma Hospital
Administrative Manager

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 Accreditation Coordinator

2 Administrative Manager
 CONTENTS

S.No. Topics Page Number

1.0 Purpose 5

2.0 Scope 5

3.0 Responsibility 5

4.0 Abbreviations 5

5.0 Reference 5

6.0 Policy 6

7.0 Procedures 8
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1.0 PURPOSE:
1.1 To provide guidelines for ensuring safety of Patients, their Families, Staff and Visitors.

2.0 SCOPE:
2.1 Hospital wide

3.0 RESPONSIBILTY:
3.1 Administrative Head
3.2 General Manager
3.3 Security Head
3.4 Maintenance department Staff
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 HMIS : Hospital Management Information System
4.4 CA : Corrective Action
4.5 PA : Preventive Action

5.0 REFERENCE:
5.1 NABH: Pre Accreditation Entry Level Standards for Hospitals, First Edition, April 2014.
5.2 FMS.1.: The organization’s environment and facilities operate to ensure safety of patients, their
families, staff and visitors.
5.3 FMS.2.: The organization has a program for clinical and support service equipment
management.
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5.4 FMS.3.: The organization has provisions for safe water, electricity, medical gas and vacuum
systems.
5.5 FMS.4.: The organization has plans for fire and non- fire emergencies within the facilities.

6.0 POLICY:
6.1 Safety Policy:
a) The hospital aims to provide a safe facility for all its occupants.
b) This shall be accomplished by a Facility management and Safety Committee, which shall
oversee all aspects of Facility Safety:
c) Preventive and breakdown maintenance Schedule are monitored and carried out by the
Maintenance department, viz Biomedical Engineer, Site Engineer, Electrical Engineer &
Electrician, and House Keeping Supervisor.
d) Drawings (site layout, floor plan and fire escape route) shall be maintained in each floor
in a visible manner.
e) Fire escape route in the display of escape route drawing is marked in Red color.
f) Fire EXIT signage is provided in Green Color through self- illuminating stickers.
g) Internal and external sign posting in the organization shall be maintained in a language
understood by patient, families and community – responsibility House Keeping
Executive.
h) The provision of space shall be in accordance with the available literature on good
practices.
i) Space is provided for the proper functioning of the department.
j) 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.
k) A report shall be generated after each inspection by maintenance department in-charge
which shall be discussed in Facility Management and Safety Committee Meeting and
shall form the basis for safety.
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l) Records are maintained and monitored at the time of reporting for taking corrective and
preventive action.
m) Response times are monitored from time of reporting to time of inspection and time of
implementation of corrective actions.
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:
Chairman
Quality Manager
NABH coordinator
RMO
Anesthetist
Gynecologist
Safety officer

6.3 Patie nt-safety devices: Patient-safety devices shall be installed across the organization and
inspected periodically. The devices are:
a) Grab-bars
b) Bed-rails
c) Sign postings
d) Safety belts on stretchers and wheelchairs
e) Alarms – both visual and auditory
f) Warning signs – radiation or biohazard
g) Fire safety devices
6.4 Facility Ins pection Rounds:
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a) Facility inspection rounds shall be conducted by Safety Committee to ensure safety at

least twice in a year in patient care areas and at least once a year in non-patient care
areas.
b) Potential safety and security risks enlisted including hazardous materials checklist are
identified during the rounds.
c) The finding of the rounds are documented and the CA / PA measures are taken to rectify
the faults.
6.5 Safety Education for Staff:
a) All staff are educated about safety requirements – in both patient care areas and non-
patient care areas
b) There shall be regular safety training covering Fire safety, Hazardous materials, use of
Personal Protective Equipment, Bio-Medical waste Management, etc.

7.0 PROCEDURE:
7.1 The hospital adheres to the following applicable laws and regulations:
a) Bio- medical Waste Management and Handling Authorization
b) Registration With Local Authorities
c) X-ray (including portable and cath lab)
d) PNDT Act Registration
e) License for MTP
f) Pharmacy license

7.2 The hospital has identified Mr. Krishna Kumar in the Administration Department as the person
who will maintain a record of the above Licenses and regularly update their renewals.

7.3 Equipment planning:

a) The organization has a proper equipment planning system that takes in to account the
future requirements of the organization in accordance with its scope of services and
strategic plans.
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b) The plans shall be reviewed periodically or as and when required.

c) All equipments are selected, updated and upgraded by collaborative process.
d) There is involvement of the end-users, management, finance, engineering and biomedical
departments in the selection of equipments.

7.4 Equipment manage ment:

a) All equipments are inventoried and proper logs maintained in the Registers.
b) All equipments are allotted asset tags.
7.5 Equipment Maintenance:
a) Routine maintenance:
7.5.a.1 The Biomedical Engineer is responsible for the overall management and upkeep
of the Bio - medical equipments.
7.5.a.2 Designated staff is responsible for daily maintenance of equipments based on
daily monitoring checklist/Weekly monitoring /monthly monitoring.
7.5.a.3 Deficiency details are documented in equipment break down book and the same
is communicated to the chief biomedical engineer
b) Breakdown Maintenance:
7.5.b.1 All breakdown entries are made in the Registers.
7.5.b.2 The complaint is registered and complaint number is generated.
7.5.b.3 Bio medical engineer is assigned or directed to the site for rectification as per
first line service guidelines.
7.5.b.4 If it is minor break down, corrective actions are taken by the biomedical
engineer with the available spare parts in- house within 2-3 hours and the same
is documented in the breakdown register with the time of rectification details
and it is counter signed by the biomedical engineers who have performed the
tests.
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7.5.b.5 If the problem is not solved, the service engineer is put forward to the service
engineer depending upon the warranty/AMC and further plan of action is
decided.
7.5.b.6 Average down time depends on the type f breakdown
7.5.b.7 The details are updated in to the daily breakdown report and follow up is done.

c) Preventive maintenance:
7.5.c.1 The Biomedical Engineer prepares and maintains a maintenance plan as per
the list of available equipments.
7.5.c.2 The Preventive Maintenance of instrument having an AMC contract is done by
communicating with Bio-Medical engineer and company engineer.
7.5.c.3 A schedule is prepared by the biomedical department for preventive
maintenance as per the manufacturer recommendation.
7.5.c.4 All medical equipments undergo preventive maintenance at prescheduled
period.
7.5.c.5 The concerned department is informed about the schedule of the equipment for
preventive maintenance well in advance, so that they can keep the equipment
free for required time period.
7.5.c.6 The availability of necessary spares, consumables, tools and necessary
materials are ensured through standardization and /or advance planning,
through Stores and guidance by Head of Bio Medical Department.
7.5.c.7 After completion of maintenance (whether preventive or breakdown) the OK
report is taken from the user department and also an acknowledgment Is taken
from user department.

7.6 Calibration of Devices:

a) A list of all instrument /equipment/ devices requiring calibration is prepared and maintained.
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b) The list identifies the measurement instruments by name, type, serial number, location,
applicable calibration requirements, date of calibration done and calibration due date.
c) The calibration status is updated continuously.
d) Calibration certificate to be obtained from calibration agency with verification marked as
O.K. /Not O.K.
e) The same is kept with the biomedical department and copy is provided to the user department.
Sticker is displayed on the machine which shows the last calibration date and next due date.
7.7 The maintenance of piped gas, compressed air, and vacuum are looked after by the hospital
Maintenance team.
7.8 This team is responsible for the uninterrupted supply of piped medical gases, compressed air and
vacuum.
7.9 There is a maintenance plan for medical gas, compressed air, and vacuum installation.
7.10 The orders for replenishing the exhausted gas cylinders are done by the store.
7.11 All the faults and repairs of the gas and vacuum pipe lines are identified and rectified by them.
7.12 They are responsible for intimating the authorities about the deficiencies of gas supplies and the
quality of their services.
7.13 A log is maintained on the supply and installation of gases.
7.14 This hospital has provisions and facilities to combat any fire emergencies. All the floors of the
hospital is provided with adequate fire fighting equipments and fire alarms.
7.15 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 fire fighting equipments are
provided in high risk areas like the medical records room, pharmacy, store, etc.
7.16 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 equipments and assets.
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7.17 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.

7.18 Hospital Fire Fighting Team:

a) During Daytime [8:00 am to 5:00 pm]:
1. Mr.Gnanashankar S
2. Dr.Siddesh G
3. Mr. Venkatesh G V
4. Mr. Manjunatha R
5. Mr. Shivamurty A
6. Balaji Rao

b) During Night Time [5:00 pm to 8:00 am]:

1. Mr.Gnanashankar S
2. Night MOD
3. Mr. Manjunath R
4. Punith S
5. Lokesh A
6. Night security Staff

7.19 Fire Safety Protocol:

a) Fire Preventive Measures:
7.19.a.1 Fire risk areas in the Hospital are identified as given below:- Generator Room;
Substation; Medical Gas storage room and medical record room.
7.19.a.2 At these places, First Aid fire appliances are provided.
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7.19.a.3 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 Tel (Extn. 316) or cutting off the power supply.
7.19.a.4 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; Inform tele. nos. (Extn. 316) or (Extn: 316);
Shift the patient to safer places. If fire has not been extinguished, without panic
direct the patients to safer locations through fire escape route.
7.19.a.5 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).

7.20 Fire Fighting Instructions:

a) The fire- fighting is an emergency requirement and this is called as CODE RED in this
hospital it will be alerted through Public Announcement system/bell/fire alarm.
b) 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:-
7.20.b.1 Try to put off electric equipment.
7.20.b.2 Shout for help in case assistance is required. If unable to put off inform Tel. Ext.
No : 316 about the type of fire and location of fire. Security Supervisor will
activate “Code Red” signal and assemble the fire fighting 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. The Security Supervisor will maintain a
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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 fire fighting team shall reach to
the place of fire without delay and organize fire fighting after getting this
warning of “ Code Red ”

7.21 Fire Prevention Points:

a) Do not store inflammable materials like petrol, LPG, in the hospital building and rooms.
b) Do not use kerosene stove, burners, gas stoves in the hospital rooms and department.
c) The spirit lamp used in the laboratory should be placed in a safe place and put off after
use.
d) Do not use the candles / oil lamp to light the rooms department.
e) Do not store the loose papers files and old record in card board boxes.
f) The old record room should be properly ventilated and electrical line protected against
the fire.
g) All important departments will be provided with the first aid fire appliance.
h) Do not leave the remains of used match stick, candles or cloth pieces etc in the floor
area.
i) Extinguish and throw these items in dust bin only.
j) Put off electrical supply to the rooms in case any spark is noticed and inform duty
electrician.
k) While refueling the diesel tank of generate or take fire precautions and do not bring
any lighted material near to the refueling point.
l) Put off all light fans and electrical equipment and remove the equipment connection from
the plug while locking the room after the work.
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7.22 Eme rgency Evacuation Plan /Emergency Exit: Ground Floor Occupants: 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:
a) Alert all inmates one by one and room by room of the emergency situation without
causing undue panic and commotion while informing the matter.
b) Evacuate all the patients first with the help of stretcher, trolleys or by the wheeled cots.
c) The medical documents of the particular patient should be sent along as well.
d) The only route to be used for evacuation of such patients should be the hospital
Staircase.
e) The lifts should not be used in such situations.
f) Ambulatory of semi-ambulatory patients should be evacuated one by one using wheel
chairs.
g) The patient’s medical documents should be sent along.
h) Evacuation should be done in an orderly manner without causing confusion or panic.
i) These patients will occupy the vacant beds on the other floors except the affected area.
j) Casualty observation beds or crisis management beds on the ground floor shall also be
used.
k) 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.
7.23 Fire Fighting Training:
a) The Fire Fighting Team organizes mock fire and emergency drills twice a year with the
help and guidance from the local fire fighting force.
7.24 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.
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POLICY TO PREVENT CHILD/NEONATE ABDUCTION & ABUSE

Purpose
To prevent child/neonate Abduction & Abuse Hospital premises.

Scope
Hospital Premises

Responsibility:
Admin staff, NICU Staff, Security personnel, front office.

Policy:
Definition:
According to the world Health Organization “Child maltreatment, sometimes referred to as child abuse, neglect
and exploitation that results in actual or potential harm to the child’s health, development or dignity.
Within the broad definition, five subtypes can be distinguished
1. Physical abuse

2. Sexual abuse

3. Neglect and negligent treatment

4. Emotional abuse

5. Exploitation

 Protection of child abuse in Hospital

 Only qualified staff is allowed to work in hospital especially in NICU & Obstetric wards.

 Identification bands should be secured immediately after birth.

 Staff should be qualified and experienced in handling neonatal emergencies and care.

 Staff should be well trained and educated about teaching and training medical, social and legal aspects

of child abuse and neglect.

 Mother or in her absence a guardian is allowed to remain with the patient 24 hours.

 All the patients are tagged with their name, registration number, IPD number for their unique

identification number

 Special vigilance CCTV camera is installed to monitor all main areas of the hospital.
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 Security team is trained and active to counter any abduction case inside the hospital.

 Patient movement outside the ward is along with an identified responsible person.

 Hospital staff is made aware of the safety precaution to prevent abduction and abuse

 Parents are educated about looking after their children

 Inform the security immediately (246) in the event an infant or child cannot be located.

 A code has been assigned to report and activate security team for necessary action in case of any

abduction inside the hospital.

 Code ‘PINK’ is announced for activating and informing security team.

 All gates are closed and manned.

 All suspicious persons are checked and questioned if required.

 The entire hospital is thoroughly checked by the team by visiting designated areas.

 Police is to be informed after establishing the case of abduction.

Announce ment of Code “PINK”

 Whenever the code “PINK’ is to be declared the Manager on duty will make sure about all the required

arrangements needed.

 In case of any type of child physical /sexual abuse, safety committee members whom so available shall

be set up immediately to investigate/ review the occurrence/incident.