Hospital Environmental and Safety Services Manual

Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013
Service Std 2: Environmental and Safety Services Page 1
SERVICE STANDARD 2: Environmental and Safety Services
Standard No. Survey Item Hospital
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2.1 ORGANISATION AND MANAGEMENT
2.1.1 Each activity is organised and administered to provide
optimum support to the goals, objectives and values of the
Facility and to meet the needs of the Facility, patients, staff
and visitors.
2.1.1.1 Based on the complexity of the facilities, there are designated
committees on safety, health and environment issues with
clearly defined:
 Appointment of a Chairperson
 Terms of Reference
 Committee members
 Tenure of membership
 Frequency of meetings
2.1.1.2 Each designated committee ensures and documents the
following:
a) action plans indicating the persons responsible;
b) activities with input from patients, community, medical
practitioners, service staff, and in consultation with other
relevant services;
c) monitoring and compliance with Terms of Reference;
d) practice is consistent with professional standards,
guidelines and relevant legislation;
e) review and revise action plans as required, signed and
dated accordingly.
2.1.1.3 There is an organisation chart which:
a) represents the structure, function and reporting
relationships between the Person In Charge (PIC) and the
staff of the Environmental and Safety Services;
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b) is accessible to all staff;
c) includes off-site services if applicable;
d) is revised when there is a major change in any of the
following:
 organisation;
 functions;
 reporting relationships;
 goals and objectives;
 staffing patterns.
2.1.1.4 Regular committee meetings are held to discuss issues and
matters pertaining to the operations of the Environmental and
Safety Services and minutes are available and made accessible
to relevant staff.
2.1.1.5 There is documented evidence that where more than one
committee have interests in the issues of the Environmental
and Safety Services:
a) There is clear committee structure that shows line of
reporting.
b) There is coordination of the actions undertaken or
proposed by the committees.
c) Records are kept on actions taken to identify and correct
the cause of any problem.
2.1.1.6 The Head of Environmental and Safety Services is involved in
the planning, management and justification of the budget and
resource utilisation of the services.
2.1.1.7 The Head of the Environmental and Safety Services ensures
that the staff of Environmental and Safety Services complete
incident reports with evidence that these are discussed by the
services with learning objectives. These reports are forwarded
to the Person In Charge (PIC) of the Facility.

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2.1.1.8 There is documented evidence that Root Cause Analysis of all
incidents have been done and action taken to prevent
recurrence.
2.1.1.9 There are appropriate statistics and records maintained on the
provision of Environmental and Safety Services and there is
evidence that these are used for managing the services and
patient care purposes.
2.1.1.10 Where services are provided by an external source, there is a
written agreement between the external service provider and the
Facility stating the requirements for service delivery, including the
following:
a) formal lines of communication and responsibilities between
the external service provider and the Facility;
b) provision of adequate numbers of appropriately qualified
personnel to perform their duties;
c) participation, as appropriate, of the external service
provider in committees of the Facility;
d) arrangement for adequate pick up and delivery;
e) arrangements for after-hours and emergency services;
f) mechanisms for dealing with problems in service delivery;
g) adequate facilities and equipment for providing the
services at the Facility and at the site of the external
service;
h) involvement of the external service provider in safety and
quality improvement activities of the Facility, as
appropriate;
i) comply with the appropriate MSQH Standards of
Accreditation for Environmental and Safety Services.

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2.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT
2.2.1 The Environmental and Safety Services are directed by and
staffed with adequate numbers of appropriately qualified
staff as required under relevant regulations and statutory
requirements to achieve the objectives of the services.
2.2.1.1 The Head and staff of each service fulfil the educational
qualification, training, experience and certification required to
meet the demands of the various positions and to achieve the
objectives of the services. These requirements are documented.
2.2.1.2 The Head of Environmental and Safety Services has a letter of
appointment which delineates the authority, responsibilities and
accountabilities of the position.
2.2.1.3 The number of personnel and support staff with the appropriate
qualifications employed are sufficient to enable the services to
meet the documented purposes.
2.2.1.4 There is evidence that a structured orientation programme
where new staff are briefed on their services, operational
policies and relevant aspects of the Facility to prepare them for
their roles and responsibilities has been implemented.
2.2.1.5 There is documented evidence of implementation of a staff
development plan which provides the knowledge and skills
required for staff to maintain competency in their current
positions as the demands of the positions evolve.
2.2.1.6 There are continuing education activities for staff to pursue
professional interests and to prepare for current and future
changes in practice as evidenced by:
a) Records on staff education and development needs being
appraised and identified are available.
b) Records on continuing education activities for staff are
available.

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c) A programme for on-the-job training, in-service education,
and continuing education for all staff appropriate to their
work has been implemented. These should include:
i) additional training to staff in the execution of
procedures unique to special areas, such as the
operating rooms, obstetrical units, emergency
services, special care units, and isolation rooms;
ii) instructions on environmental control in the
prevention of healthcare associated infections and
the roles of the employee in this control;
iii) safety measures in hazardous areas such as the
central sterilising supply services, operating
theatres, kitchens, workshops, laundry, laboratories,
and radiation emission areas.

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2.3 POLICIES AND PROCEDURES
2.3.1 Documented policies and procedures reflect the current
knowledge and practice of Environmental and Safety
Services, and they are consistent with the objectives of
each service and relevant regulations and statutory
requirements.
2.3.1.1 There is an Environmental, Health and Safety Policy statement
that is displayed throughout the hospital. There are documented
specific policies and procedures to support the Environmental,
Health and Safety Policy statement.
2.3.1.2 There is documented evidence that policies and procedures are
developed in collaboration with staff, medical practitioners,
Management and where required with other external service
providers and with reference to relevant sources involved.
2.3.1.3 Policies and procedures are dated, authorised, signed and
reviewed at least once every three years and revised as
required.
2.3.1.4 There is evidence of staff acknowledgement that policies and
procedures including new and revised ones are communicated
to all staff.
2.3.1.5 There is evidence of compliance with policies and procedures.
2.3.1.6 Copies of policies and procedures, relevant Acts, Regulations,
By-Laws and statutory requirements are accessible to staff.
2.3.1.7 Current reference manuals, pamphlets, journals, and books as
well as information and scientific data from manufacturers
concerning their products are readily available for reference and
guidance.

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2.4 FACILITIES AND EQUIPMENT
2.4.1 Adequate facilities and equipment are available to enable
the Environmental and Safety Services to meet its goals,
objectives and ensure safety.
2.4.1.1 There is adequate and proper utilisation of space and
equipment to enable staff to carry out their professional and
administrative functions.
2.4.1.2 There is documented evidence that equipment complies with
relevant national/international standards, e.g. those set by
SIRIM Berhad (Standards and Industrial Research Institute of
Malaysia) and current statutory requirements.
2.4.1.3 There is evidence that the Facility has a comprehensive
maintenance programme such as predictive maintenance,
planned preventive maintenance and calibration activities, to
ensure the facilities and equipment are in good working order.
The maintenance programme and budget are reviewed.
2.4.1.4 There is evidence that specialised equipment is operated by
staff with appropriate qualification and privileged by the Facility.
2.4.1.5 There is evidence that provisions are made for the personal
comfort of staff and patient. This includes:
 clean and hygienic facilities;
 room temperatures are kept at comfortable levels and
adequately ventilated;
 steps taken for reduction of noise in patient and staff work
areas.

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2.5 SAFETY AND QUALITY IMPROVEMENT ACTIVITIES
2.5.1 The Head responsible for environmental and safety
activities ensures the provision of quality performance with
staff involvement in the continuous safety and quality
improvement activities of the Services.
2.5.1.1 There is evidence that the Head of the Service has in a written
document assigned responsibilities to appropriate
individuals/committees for safety and quality improvement
activities within the services.
2.5.1.2 There are documented plans for systematic safety and quality
improvement activities that include:
a) Planned activities
b) Data collection
c) Monitoring and evaluation of the performance
d) Action plan for improvement
e) Implementation of action plan
f) Re-evaluation for improvement
2.5.1.3 There are safety and quality improvement activities in place that
include tracking and trending of specific performance indicators
not limited to but at least two (2) of the following:
a) percentage of staff (includes all on-site outsourced service
providers) given orientation and training in Health and
Safety requirements
b) percentage of high level risks identified and corrected
2.5.1.4 There is evidence that feedback on results of safety and quality
improvement activities are regularly communicated to the staff.

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2.5.1.5 Records on safety and quality improvement activities are kept
and confidentiality of staff and patients is preserved.
2.5.1.6 There is documented evidence of safety and quality
improvement activities that address staff safety.

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2.6 SPECIAL REQUIREMENTS
2.6.1 Fire Safety
The Facility is constructed, equipped, operated and
maintained in a manner that ensures the safety of and
protects its patients, visitors, staff and property from fire.
2.6.1.1 Fire Safety : Building and Fire Alarm
a) There is evidence that all buildings comply with relevant
legislation relating to fire safety.
b) All fire alarm systems are integrated and linked to the
nearest fire station or fire station designated by fire
authorities.
2.6.1.2 There are documented reports of fire safety inspection by the
fire authorities (BOMBA) available. Fire inspection should be
performed within the last one year, and more recently in the
event of a major building renovation, development or service
alteration.
2.6.1.3 There is documented evidence of planned timetable for
compliance and implementation of recommendations made by
the fire authorities.
2.6.1.4 There is written evidence of approval from the appropriate
government and fire authorities for all new buildings, renovation
works and service alterations. Drawings and design calculations
to be endorsed by certified professional bodies.
2.6.1.5 There is evidence of automatic fire suppression systems (for
example, sprinkler, deluge or clean agent systems) installed
where required based on recommendations of the local fire
authority.
2.6.1.6 Fire fighting equipment (for example, fire extinguishers,
hydrants, hose reels, fire blankets) are located appropriately.

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2.6.1.7 Fire Safety : Systems and Equipment
a) All fire fighting systems and equipment are appropriate to
the type of fire most likely to occur in the area where they
are located;
b) There is documented evidence of regular testing and
maintenance of the systems being performed at least
annually.
2.6.1.8 There are approved fire detection and alarm systems (such as
smoke detectors or manual fire alarms) throughout the Facility
and are in working order.
2.6.1.9 There are clear signs for the location of fire fighting equipment.
„EXIT (KELUAR)‟ signs are prominently displayed at the main
corridors and exit doors in accordance with regulations.
2.6.1.10 There are adequate “No Smoking” signs displayed throughout
the Facility.
2.6.1.11 There are appropriate systems in the design and construction of
buildings to minimise the risk of the spread of fire and smoke.
(E.g. ventilation systems, compartmentalisation).
2.6.1.12 Doors to patient rooms and exit doors are not locked from the
inside except where specifically required (for example,
psychiatric units). In such cases, there are documented policies
and procedures to ensure adequate access and egress.
2.6.1.13 Fire Safety: Egress
a) There is adequate means of egress from all parts of the
building in compliance with requirements of local fire
authorities and building regulations.
b) There should be clear signs to indicate dead-end
corridors.

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2.6.1.14 Doorways, corridors, ramps, and stairways for egress in case of
fire are:
a) kept free of obstruction at all times;
b) wide enough for the evacuation of non-ambulatory
patients.
2.6.1.15 Fire and smoke doors which can be opened and closed
manually are kept closed at all times (no door stopper allowed)
except doors which are held open by electric hold-open devices
set to release upon activation of the fire detection system.
2.6.1.16 There is a letter of appointment for a designated fire safety
officer who is trained to be responsible for fire safety issues.
2.6.1.17 Fire Safety : Fire Evacuation Plan
a) Fire evacuation floor plan including assembly area
locations are displayed prominently in all areas.
b) The Facility has written fire emergency plans and
procedures which include:
i) the assignment of personnel to specific tasks and
responsibilities;
ii) instructions for the use of alarm systems and
signals;
iii) information concerning methods of fire containment;
iv) information concerning the location of fire fighting
equipment;
v) systems for notification of appropriate persons;
vi) specification of evacuation routes, assembly points,
and procedures;
vii) other provisions as the local situation dictates;
viii) emergency resuscitation e.g. Code Blue (adults),
Code Pink (children).
2.6.1.18 Fire Safety : Fire Drills
a) There are written reports on fire drills held regularly to
accommodate staff working at different times (day/night)

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and under varied conditions. These reports include
evaluations on all drills, and documentation of staff
attendances.
b) The drills ensure:
i) all staff are trained in fire procedures including fire
alarm or notification procedures, and are familiar
with the use and operation of the fire fighting
equipment available;
ii) all staff are aware of the method and route of
evacuation from their area;
iii) designated staff are trained to physically evacuate
non-ambulant patients;
iv) there is a written plan available throughout the
Facility detailing action to be taken in the event of
patients having to be moved.

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2.6.2 Safety Programmes
The management of the Facility promotes occupational
safety and health programmes that ensure a safe and
healthy environment for patients, staff and visitors.
2.6.2.1 Safety Programmes: Committee
a) There is a multidisciplinary committee(s) formed for the
purpose of implementing and maintaining a
comprehensive safety programme for patients, staff and
visitors and for monitoring and reporting on occupational
health matters.
b) Minutes of these committee meetings are available and
decisions made are implemented.
c) In a small Facility, safety matters may be dealt with as
items on the agenda in a committee whose terms of
reference encompass various aspects of safety and
patient care.
2.6.2.2 There is documented evidence that programmes for
occupational safety and health are being implemented in
accordance with statutory regulations.
2.6.2.3 There is documented evidence of planned safety activities that
monitor and evaluate the performance of safety programmes
which includes:
a) reporting of activities as required by law and regulation;
b) conducting risk management activities such as risk
assessment, risk registration and risk prevention has been
implemented, monitored and evaluated. The evidence
includes:
i) Data collection
ii) Monitoring and evaluation of the performance
iii) Action plan for improvement
iv) Implementation of action plan
v) Re-evaluation for improvement

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2.6.2.4 There are reports on regular safety inspections to monitor
compliance to indoor air quality, health surveillance and
hazardous and chemical risk assessment requirements
according to the Safety Programme.
2.6.2.5 The designated safety officer who is trained has a letter of
appointment which clearly delineates his authority,
responsibilities and accountabilities for safety related activities
2.6.2.6 There is evidence that all staff are familiar with safety
programmes.
2.6.2.7 There are written environmental, occupational safety and health
policies and procedures and implemented throughout the
Facility.
2.6.2.8 There are written safety procedures specific to potentially
hazardous areas, and for hazardous substances (for example,
central sterilising supply services, food services areas,
laundries, laboratories, operating suites, radiation emission
areas, special units, and workshops) and implemented
throughout the Facility.
2.6.2.9 There is evidence that special safety measures in the form of
policies and procedures, facilities and equipment have been
implemented for hazardous areas in accordance with applicable
standards and the requirements of national and local statutory
authorities.
2.6.2.10 There is evidence that personal protective clothing and
equipment are provided where required, and their usage
monitored.
2.6.2.11 All portable gas cylinders are stored, restrained, and secured in
accordance with applicable standards and the requirements of
national and local statutory authorities. The requirements are:
a) Oxygen and flammable gases are stored separately from
each other.

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b) Storage areas are ventilated, built of non-combustible
material, and secured as appropriate.
c) All full gas cylinders are restrained and stored in an upright
position.
d) Flammable anaesthetic gases are not used in piped
systems.
e) Storage areas are appropriately sign posted including “No
Smoking” signs in accordance with statutory requirements.
2.6.2.12 There is provision of emergency suction apparatus and medical
gas supplies in key areas such as operating suites, special care
units, emergency services etc.
2.6.2.13 Safety Programmes: Power Supply
a) There is evidence that the Facility has provision for
alternative light and appropriate power supply in the event
of a failure of the local supply.
b) Uninterrupted power supply is provided for life support
systems, essential lights in operating theatres and rooms
for interventional procedures.
2.6.2.14 There is evidence that the Facility has equipped safety stores,
cold rooms and plant rooms with self-closing doors or safety
latches, where appropriate.
2.6.2.15 There are adequate signs which are clearly displayed,
prominently visible and easy to follow throughout the Facility.
2.6.2.16 There is evidence of implementation of policies on:
a) managing the motor vehicles provided for staff and patient
use;
b) proper maintenance documented in a log book;
c) competency of drivers with valid licences.

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2.6.2.17 There is documented evidence that levels of noise, smoke, foul
odour or dust are monitored and action taken to minimise if
excessive.

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2.6.3 Disaster Plan
The Facility has written plans to deal with internal and
external disasters. Plans are coordinated with statutory and
civil authorities as appropriate.
2.6.3.1 External Disaster Plans
There is evidence that the Facility has an external disaster plan
appropriate to its capabilities which has taken into consideration
the following:
a) The disaster plan is developed in consultation with
statutory and civil authorities, emergency services, and
representatives of other health service agencies. The plan
is to establish an effective chain of command, clarify
matters of jurisdiction, and coordinate the Facility‟s
activities with the activities of these agencies.
b) The scope of the Facility‟s roles and resources are made
known to the local police, fire brigades, the state
emergency services, ambulance teams, and the
community.
c) The disaster plan provides for:
i) consideration of the type of disasters likely to occur;
ii) effective communication systems within and outside
the Facility;
iii) availability of adequate basic utilities and supplies
including gas, water, electricity, food, and essential
medical and support materials;
iv) assignment of staff to specific tasks and
responsibilities;
v) an efficient system of notifying staff;
vi) defined authority and control;
vii) conversion of all appropriate spaces into clearly
defined areas for efficient triage, patient
observation, and immediate care;
viii) transportation arrangements when necessary for
prompt transfer of casualties to the Facility most
appropriate for administering definitive care, after
preliminary emergency medical or surgical services
have been rendered;

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ix) making available a list of casualties and
appropriately designed tags to accompany each
casualty;
x) arrangements for the prompt discharge or transfer
of current inpatients who can be moved without
harm;
xi) maintaining security in order to keep unauthorised
persons away from the triage area;
xii) some form of visual identification for staff involved in
the plan;
xiii) the establishment of a public information centre and
assignment of public relation duties to a suitable
person; a media communication plan will help to
provide organised dissemination of information;
xiv) debriefing and disaster plan review procedures.
d) The external disaster plan is tested for its capability at
least once a year in order to:
i) ensure that all staff are provided with training to
enable performance of assigned tasks;
ii) evaluate the effectiveness of the plan;
iii) evaluate and document the exercise;
iv) review and revise the plan as necessary.
e) The external disaster drill is preferably coordinated with
the participation of other community emergency services.
However, if this is not practicable, at least the local
aspects of the plan are rehearsed.
f) Drills involved the medical practitioners, administrative,
nursing, and other staff and external agencies as
appropriate.
g) Each department in the Facility is aware of its function.
2.6.3.2 Internal Disaster Plan
There is evidence that the Facility has an internal disaster plan
based on the type of internal disasters likely to occur and its
capabilities which has taken into consideration the following:
a) Plans for fire, internal disasters, and emergency situations
incorporating evacuation procedures are developed with

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the assistance of qualified fire, safety, and other
appropriate experts. Emergency situations may include
bomb threats, hostage taking, attempted suicides, drug
demand, provision of medical services in areas other than
wards (for example, kitchens, laundry, workshops),
explosion, and loss of vital services such as IT.
b) Plans include:
i) the assignment of personnel to specific tasks and
responsibilities;
ii) instructions for the use of alarm systems and
signals;
iii) information concerning methods of hazards
management, e.g. fire containment;
iv) information concerning the location of equipment,
e.g. fire fighting equipment;
v) systems for notification of appropriate persons;
vi) specification of evacuation routes, assembly points,
and contingency procedures;
vii) other provisions as the local situation dictates;
viii) emergency resuscitation e.g. Code Blue (adults),
Code Pink (children).
c) The internal disaster plan is tested for its capability at least
once a year in order to:
i) ensure that all staff are provided with training to
enable performance of assigned tasks;
ii) evaluate the effectiveness of the plan;
iii) evaluate and document the exercise;
iv) review and revise the plan as necessary.
d) Staff are familiar with disaster plans that are readily
available and displayed throughout the Facility.
2.6.4 Waste Disposal
Waste disposal is carried out in accordance with
environmental, statutory and legislation requirements.
2.6.4.1 There is evidence that all types of waste (clinical, cytotoxic,
radioactive, spent oil etc) have been defined, identified and
labelled appropriately according to the Scheduled Waste
definitions.

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2.6.4.2 There is documented evidence that staff handling waste have
been trained on proper handling and disposal of the waste.
2.6.4.3 There is evidence that the process of segregation at the point of
origin of general waste and waste requiring special processing
has been implemented.
2.6.4.4 There is evidence that the labelling and disposal of all waste are
according to the relevant Acts.
2.6.4.5 There is evidence that the disposal of sharps is in accordance
with the requirements of relevant Acts. Needles are not
recapped.
2.6.4.6 Waste requiring special processing is handled safely including
the use of approved bags for contaminated waste, protective
clothing, and appropriate collection and storage facility prior to
incineration or removal from the site and a mechanism for
monitoring such handling.
2.6.4.7 There is evidence that the clinical waste storage room is
refrigerated if the waste is not removed for more than 24 hours.
2.6.4.8 There is evidence that there are dedicated transportation
vehicles for general waste and waste requiring special
processing from the point of origin to a central collection point.
2.6.4.9 There is documented evidence that general waste is removed
daily and the area is kept clean.

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2.6.5 Security Services
Security measures are taken to ensure the protection of
patients and staff from assault and loss of property; and the
Facility from damage and loss.
2.6.5.1 There is documented evidence of security risk assessment done
to identify potential security risk in the Facility.
2.6.5.2 There is evidence that appropriate security measures have
been implemented to ensure the protection of patients, staff and
visitors. These measures include:
a) control of access;
b) closed-circuit television (CCTV) monitoring;
c) key control;
d) alarm systems;
e) adequate lighting;
f) security protection for personal belongings, payroll, drugs,
and other assets of the Facility.

ENVIRONMENTAL AND SAFETY SERVICES
HOSPITAL COMMENTS
Std. No: __________

SURVEYOR COMMENTS
Std. No: __________

SURVEYOR RECOMMENDATIONS
Std. No: __________

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