Presentation on Facility Related Areas which are critical for NABH Accreditation Perspective in Hospitals by Dr.B.Krishnamurthy

1. Designing Hospitals According To NABH Standards Dr. B. Krishnamurthy MD DA FRCA Director, Acute Care Services, Kaveri Hospitals, Chennai. Principal Assessor , NABH Lead Auditor, QMS Lead Auditor, EMS

2. The Peter Principle “In A Hierarchy Every Employee Tends To Rise To His Level Of Incompetence”

4. Comply With Relevant Rules And Regulations, Laws And Bye Laws And Facility Inspection Requirements.

6. Plan For Management Of “HAZMAT”.

7. Ensure the HCO Is A No Smoking Zone.

9. FMS Standards Summary

11. Objective Elements 43

12. To Get Full Accreditation

13. No Individual Standard

14. Should Have More Than One Zero

15. Average Score For The Individual Standard

16. Should Be More Than 5

17. The Overall Average Score For All The Standards

18. Must Exceed 7

19. Average Score For Individual Chapters

21. Space Requirements As Per IS 12433 ( Part 2 ): 2001

22. IS-12433-basic Requirement For Hospital Planning Up To 100 Beds.

24. Inter Bed Distance

25. 2.25 M From Centre To Centre

26. 1.2 M Edge To Edge.

27. 200 Mm Clearance At Head End

28. Easy Trolley Movement

29. Space For Bed Side Furniture For Patients.

31. Corridors 2400 Mm / 7.8 Feet

32. Doors Width 2 Meters

33. Staircase Width 6.6 Feet / 2 Meters

34. Fire Exit Doors 3.35 X 2 Feet Width And 7.5 Feet In Height, Two Leaf, 30 Meters Distance For Travel, Open Outwards.

35. Floor Indication Board 0.5m X 0.5mNational Building Code

37. Fire Zones

38. Types Of Construction

39. General Requirements

40. Life Safety

41. Fire Protection

42. Additional Occupancy - Wise Requirements

43. Annexures

44. C . For High Rise Buildings

48. Color Coding Of PipelinesIS 2379: 1990

49. Air Conditioning In OT - Standards

50. FMS Rounds Indicative list of things to look for: Entire building including terrace and basement Fire exits Diesel storage area Liquid oxygen plant Water treatment plant/RO plant Sewage treatment plant Gas manifold room Diesel Generator set (s) Vacuum and air compressor plant Gas pipelines Electrical yard/sub-station/receiving area Lift machine room (s) HVAC / Chiller plant

51. FMS Rounds Indicative list of things to look for: Signages Provision of space Patient and employee safety aspects Safety rails/Guard rails Blind corners Low ceiling Open wires Broken steps/ floor tiles Fire related Fire alarms Fire hoses and fire extinguishers Smoke detectors Adherence to statutory requirements Distance Safety Inspection reports Gas pipelines Cigarette and beedi stubs!!!

52. FMS Rounds Facility FMS 1 a, c • Various Statutory Requirements O Building O Fire O Diesel Storage O Liquid Oxygen And Storage Of Medical Cylinders. O Boiler O Electrical Inspectorate Reports. O ETP O DG Sets • Mechanism For Renewing Licenses

53. Rules, Regulations, Laws & By laws

55. Enlist All Laws & Regulations

56. Update As & When Needed

57. Identify Appropriate Individuals In HCO Responsible For Each Law & Regulations

59. FMS Rounds Facility FMS 2 a-g • Preventive And Break Down Maintenance Plan • Response Time • Up To Date Drawing, Layout, Escape Route • Signage • Provision Of Space • Designated Individual For Maintenance • Presence Of Staff Round The Clock For Emergency Repairs

60. Preventive MaintenanceDAILY/WEEKLY/FORTNIGHTLY/ MONTHLY/QUARTERLY/HALF YEARLY/ANNUALY

62. The HCO Maintains A Complaint Attendance Register.

63. Date And Receipt Of Complaint

64. Allotment Of Job

65. Completion Of Job

67. Floor Plans And

69. FMS Rounds Facility HIC 2 h • Validation of OT air-conditioning • Change of HEPA filter (s) FMS 9 d • Staff Interview

70. FMS Rounds Safety FMS 5 a-d Documented plan for handling fire and non-fire emergencies which includes exit plan Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction Mock drill schedule and record - Twice a year mock drill Smoke detectors, fire alarms, fire alarm control panel etc. (where applicable) Safety Manual

71. FMS Rounds Safety FMS 7 a-e Potential emergencies (Community emergencies, epidemics and disasters) identified Documented disaster management plan Provision of supplies Tested at least twice a year

73. Flood

74. Bomb Threats

75. Hostage Situations

76. Civil Disorders Like Strikes

77. Sudden Failure Of Electricity, Gas, Vacuum

78. Hazmat Spills

79. Building Collapse

80. Bursting Of Pipelines, Boilers or Autoclaves

81. Antisocial Behavior By Patients, Relatives, Staff

82. Hysteric Fits By Patients, Relatives, Staff

83. Temperamental Disorders Of Staff

85. Clear Line Of Authority

86. Establishment Of Command Nucleus

87. Alert Code

88. Information & Communication

89. Readymade Action Cards For Each Category Of Staff

90. Resource Earmarking & Availability

91. Training

96. Who Might Be Harmed And How ?

97. Probability

98. Severity

99. Impact

100. Risk Rating

101. Control Measure

102. What Are We Doing Now?