SAFETY MANAGEMENT PROGRAM FOR MEDICAL FACILITIES

SAFETY MANAGEMENT PROGRAM FOR MEDICAL
FACILITIES
SAFETY MANAGEMENT PROGRAM
1.0 Purpose
Provide our patients, personnel and visitors a physical environment that is free from hazards and to
manage activities pro-actively through risk assessment in order to reduce the risk of injuries.
1.1 Objective:
The objective of the Safety Management Program is to control known and potential safety hazards to
our patients, personnel and visitors.
1.2 Goals:
1.2.1. To provide education to all personnel on the elements of the Safety Management Program.
1.2.2. To ensure safe work practices and conditions.
1.2.3. To reduce the risk of safety related incidents by pro-actively evaluating systems in place and
making necessary changes through the Safety Committee, TAGs, Administration and department
participation.
1.2.4. To ensure compliance with the Joint Commission of International Accreditation (JCIA) - Facility
Management and Safety (FMS) Standards & (CBAHI) Central Board accreditation for Health Care
Institutions.
2.0 Definitions
2.1. LSO Laboratory Safety Officer
2.2. EC Environment of Care
2.3. ER Emergency Room
2.4. ERTL Environmental Round Team Leader
2.5. JCIA Joint Commission International Accreditation
2.6. MN Management Notification
2.7. MSDS Material Safety Data Sheet
2.8. NFPA National Fire Protection Association
2.9. PFI Plan for Improvement

2.10. PIS Performance Improvement Standards
2.11. PPE Personal Protective Equipment
2.12. OVR Occurrence Variance Report
2.13. TAG Technical Advisory Group
2.14. Joint Commission of International Accreditation (JCIA) is the organization that surveys
operations and facilities. The JCIA is a subsidiary of the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO).
2.15. Facility Management and Safety Standards (FMS) are listed and defined by the JCIA and are
endorsed in this Program and its supplements.
2.16. FMS Programs are:
2.16.1.Safety
2.16.2.Security
2.16.3.Hazardous Materials and Waste
2.16.4.Emergencies
2.16.4.1. External Emergency Preparedness
2.16.4.2. Internal Emergency Preparedness
2.16.5.Fire Safety
2.16.6.Medical Equipment and Devices
2.16.7.Utility Systems
2.17. Performance Improvement Standards (PIS) are recognized standards that the Safety
Committee has identified as a high priority program element that will be monitored for
implementation.
2.18. Technical Advisory Group (TAG) is a multidisciplinary group that replaces a subcommittee.
There are eight groups, one for each of the FMS Standards.
2.19. Environmental Rounds are HOSPITAL-wide rounds to ensure the safety of staff, patients and
visitors through the level of their education, awareness, and implementation of their knowledge,
which will be reflected on their performance.
2.20. Facility Tour is a HOSPITAL-wide tour inspecting for the potential life safety hazards and the
physical presentation of the services delivered to the end user.
3.0 Responsibility

3.1. Chief, Operations Officer shall:
3.1.1. Review and approve the Safety Programs
3.1.2. Appoint, in writing, the Chairperson to the Safety Committee
3.1.3. Review reports provided by the Chairperson, Safety Committee and, when necessary and
appropriate, direct the allocation of resources or emphasis to fulfill program requirements.
3.1.4. Report annually, or as frequently as necessary the Chief Executive Officer on the activity of
the safety committee.
3.2. Chairperson, Safety Committee shall:
3.2.1. (PIS) Convene the Safety Committee at least ten times a year (see APP Safety Committee).
3.2.2. Direct the formation of each TAG, designate (with the approval of Directors and Managers)
TAG leaders and members, and assign a task to each TAG to ensure compliance with the respective
FMS Standard (see Attachment B).
3.2.3. Approve and monitor PIS for each of the Safety Standards.
3.2.4. Accept and approve periodic and annual summary reports from each TAG, to include the
status of implementation and attainment of PIS.
3.2.5. Examine safety management issues, seek resolutions, and report findings (i.e. Minutes of
Meetings, to relevant Department Heads/ Executive Directors.
3.2.6. Report annually, or as frequently as necessary, the Safety Program status to the COO.
3.3. TAG Leaders shall:
3.3.1. Write and submit to the Safety Committee, for approval, the Programs / APPs for respective
EC (safety) standards. (See Attachment C).
3.3.2. Write and submit for approval the APP Safety Committee.
3.3.3. Specify, review and make suggestions for the approval of recommendations that support the
Programs/APPs developed by the TAG.
3.3.4. Take action on specific problem areas based on the approved recommendations and report to
the Safety Committee.
3.3.5. Write and submit for approval, an Annual Summary Report and Plan for Improvement (PFI) to
the Chairperson, Safety Committee.
3.3.6. Develop a training program for members of the Medical Management Department / Unit
Safety Liaison Officers and designees as selected by Department Heads.
3.3.7. Present as a team, the EC (Safety) PFI to the JCIA Survey Team.

3.3.8. Maintain technical references and serve as technical advisors in respective areas of expertise
to all operational areas of the Health Facility.
3.3.9. Develop an overview of the Safety Program for new staff at the New Hire Orientation sessions,
as presented by the Safety Department.
3.3.10.(PIS) Meet when needed and issue a brief summary report of each meeting. The summary
report will be submitted to the secretary of the Safety Committee one (1) week prior to the Safety
Committee Meeting, for inclusion in the agenda.
3.3.11.Conduct project reviews to ensure that adequate fire protection, safety, health and
environmental design and controls are addressed.
3.4. TAG Members shall:
3.4.1. Assist TAG leaders in their assigned responsibilities.
3.4.2. Oversee development, implementation and monitoring of the Safety Programs and report to
the TAG leader.
3.4.3. Advise the TAG leader on the development or maintenance of Safety Programs.
3.5. Security & Safety Director shall:
3.5.1. Direct a facility-wide process to collect information on deficiencies and opportunities for
improvement in the healthcare environment through the following:
3.5.1.1. Occurrence Reports
3.5.1.2. Minutes of the Unit Safety Communications Meetings
3.5.1.3. Environmental Rounds
3.5.1.4. Facility Tour
3.5.1.5. Quarterly Environment of Care Executive Summary Reports
Note: See Attachment E for all items listed above.
3.5.2. Review summaries of occurrences, deficiencies, problems, failures and user errors related to
the FMS Standards and report findings and trends, if any, to the Safety Committee.
3.5.3. Coordinate with the appropriate staff to implement recommendations and monitor their
effectiveness.
3.5.4. Intervene whenever conditions pose an immediate threat to life or health, or threaten damage
to equipment, buildings or the environment.
3.5.5. Utilize the resources of published information on product hazards or recalled products.
3.5.6. Report to the Safety Committee on findings, recommendations, actions taken and results of

measurement.
3.5.7. Safety Manager serves as Leader, Internal Emergency Preparedness TAG.
3.5.8. Designate a member of the Safety Department to attend all Environmental Rounds.
3.6. Total Quality Management (TQM) Director shall:
3.6.1. Designate a TQM representative to monitor the implementation of the Safety Program
elements of compliance with JCIA Standards.
3.6.2. Submit a monthly report (confidentiality ensured) of all occurrences to the Security & safety
Director.
3.6.3. Designate a member of TQM to lead, control and review all Environmental Rounds Programs.
3.6.4. Submit Environment of Care Annual Summary Reports and Plan for Improvement to the Safety
Committee.
3.6.5. Call the Security & Safety Director, or a TAG Leader, immediately upon notification of an
occurrence. E.g. fire, smoke, hazardous material spill, medical device or equipment failure, major
utility system failure, etc.
3.7. Environmental Rounds, and Facility Tour Teams shall:
3.7.1. (PIS) Conduct scheduled environmental rounds and facility tour inspections of patient care
areas every 3 months, and non-patient care areas and grounds every six months (minimum).
3.7.2. Environmental rounds reports issued directly to the concerned units and copy to the Head of
the Department and Safety Committee.
(See attachment D).
3.7.3. Facility Tour inspection reports issued directly to concerned section/ department, with a copy
to the Safety Committee. (see Attachment F)
3.8. Safety Committee Chairman shall:
Designate a member the committee to be a team leader of Environmental Rounds.
3.9. Environmental Rounds Team Leader shall:
Ensure that the environmental round team has the following members:
3.9.1. Infection Control Representative
3.9.2. Security Representative
3.9.3. Safety Representative
3.9.4. Nursing Services Representative

3.9.5. Biomedical Engineering Representative
3.9.6. Maintenance Department Representative
3.9.7. Housekeeping Services Unit Representative
3.9.8. TQM Representative
3.10. Individual Units Safety Liaison Officer shall:
3.10.1. Accompany staff from the Environmental Team during Environmental Rounds, and take
necessary actions to correct noted deficiencies on inspection reports. Submit a statement of
compliance to Environmental Round Team Leader (ERTL).
3.10.2. Monitor corrections of any deficiencies noted during Environmental Rounds.
3.10.3. Monitor contractual maintenance work or other activities' in his unit to ensure compliance
with safe operational procedures and report any remarks to the safety.
3.11. Directors shall:
3.11.1. (PIS) Require that, at a minimum, a Unit Safety Communication Meeting convene at least 10
times per year with members from the unit level.
3.11.2.Designate a department Safety Liaison Officer to present department concerns on Safety
issues.
3.11.3.Maintain detailed Safety Programs (see Attachment D).
3.11.4.Ensure that each department head/supervisor is evaluated on safety performance.
3.11.5.Review projects in their areas for new construction, renovation and remodeling to ensure that
fire protection, safety, health, infection control and environmental features are addressed.
3.11.6.Enforce FMS standards, CBAHI standards, job procedures, standard safe practices, and
safety rules.
3.12. Department Head shall:
3.12.1.Enforce the Unit Safety Communication Meeting and forward minutes after approval to the
Department Director.
3.12.2.Attend at least one Unit Safety Communication Meeting each month.
3.12.3.Review summaries of Minutes of Unit Safety Communication Meetings and report significant
finding to the department director on quarterly basis.
3.12.4.Designate Safety Liaison Officer (SL)) and alternate.
3.12.5. (PIS) Specify that Environment of Care Safety be a standing agenda item at the Unit Safety
Communication Meeting, and Minutes will be forwarded to the Department Director.

3.12.6.Review projects in their areas for new construction, renovation and remodeling to ensure that
fire protection, safety, health, infection control and environmental features are addressed.
3.12.7.Enforce FMS standards, CBAHI standards, job procedures, standard safe practices, and
safety rules.
3.13. Supervisors/ Safety Liaison Officer shall:
3.13.1. Report immediately hazards judged to be serious to the Department Head, Security & safety
Director, Safety Committee Chairperson, a TAG Leader, or TQM Director.
3.13.2. Report accidents involving patients, staff or visitors (see APP- Occurrence Variance Report),
and direct employees to the Family Medicine or Emergency Room.
3.13.3. Coordinate with Department Head on EC (Safety) issues.
3.13.4. Train new employees on Safety Program elements, workplace hazards, emergency
procedures and the location of Material Safety Data Sheets (MSDS) within 15 days of assignment
and ensure that new employees attend the New Hire Orientation within 30 days of employment.
3.13.5. Conduct quarterly inspections of respective workplaces using Attachment D. If necessary,
request support from the Safety Officer or (for a purely technical consult) from a TAG Leader
through the Department Head.
3.13.6. Assign the roles and duties of their staff in the event of fire or disaster as specified within the
unit level fire plans.
3.13.7. Distribute EC Awareness letters, Safety letters and Hazard Alerts to their respective
employees.
3.13.8. (PIS) Ensure that all department employees attend R.A.C.E. for Fire Safety training annually,
and show them the locations of fire alarm stations, fire extinguishers, evacuation routes, and oxygen
valve locations (if applicable).
3.13.9. Accompany staff from the Environmental Team during Environmental Rounds, and take
necessary actions to correct noted deficiencies on inspection reports. Submit a statement of
compliance to ERTL.
3.13.10. (PIS) Chair Unit Level Safety Communications meetings with EC as a standing agenda item
and forward a copy of Minutes to the Department Head. Items of consideration include training,
safety letters, Hazard Alerts, Management Notification (MN), Awareness bulletins, published
articles, posters, Fire and Safety bulletin boards, pamphlets, suggestions, problem areas, emergency
procedures, reporting procedures, roles in emergencies, occurrences, etc.
3.13.11. Maintain accessible, neat & orderly, monthly bulletin boards in their areas, and post Fire &
Safety Alerts / Posters, Safety Letters, Management Notifications (MN), etc. and invite employees to
participate in providing information suitable for posting.
3.13.12. Issue formal written warnings to employees who have repeated poor safety performances or
who deliberately disregard the safety of others. Termination should be considered for those who fail
to respond.

3.14. Employees shall:
3.14.1.Report immediately all unsafe conditions (hazards), injuries, or illnesses, to their supervisor.
3.14.2.Observe and practice all safety procedures and use assigned personal protective equipment
(PPE).
3.14.3.Attend all required fire safety, safety, hazardous materials, and EC (Safety)-related training
sessions.
4.0 Policy
The Safety Management Program shall be used initially, and referred to, in conjunction with existing
department maintenance programs.
Note: Forms shown in Attachment D of this Program may be photocopied for use in each
department's Safety Program.
4.1. The principles of the Safety Management Program shall be practiced and adhered to by all
members of the staff, volunteers, patients, visitors and contract services personnel.
4.2. The safety committee chairperson/ security and safety director have the authority to intervene
whenever conditions pose an immediate threat to life, health or property.
4.3. 5.2 Upon full and continued implementation of the Safety Management Program elements, it is
anticipated that:
4.3.1. Effectiveness of the Program shall be measured through Performance Improvement Standards
marked as (PIS) in this program and its supplements (see Attachment A).
4.3.2. The Safety Committee shall monitor the implementation and attainment of Performance
Improvement Standards (PIS).
4.3.3. Teamwork and allocation of resources shall be maximized.
4.3.4. Use of computer systems shall be maximized.
4.3.5. Areas for improvement and cost savings shall be identified and included in annual summary
reports and plans for improvement.
4.3.6. Serious occurrences shall be minimized, reduced or eliminated.
5.0 Procedure:
5.1New Projects
All designs for new construction, renovation and remodeling will be thoroughly reviewed for fire
protection, safety, health, infection control and environmental criteria to eliminate, control or reduce
hazards in the design phase. End users will always be involved in the review process prior to letting
of contracts and will review the 100% Design Package to include drawings, specifications and
equipment lists.

5.2 Hazard Identification
Hazard identification will be an on-going process carried out through the following formal
mechanisms.
5.2.1. Immediate reporting of hazards by employees to supervisors.
5.2.2. Employee suggestions submitted at unit level.
5.2.3. Quarterly inspections conducted by supervisors / safety liaison officers.
5.2.4. Scheduled Environmental Rounds conducted by the Environmental Team (ET) as follows:
5.2.4.1Every 3 months inpatient care areas by the following representatives:
Infection Control Team Leader (ERTL)
Security Representative
Safety Representative
Nursing Services Representative
Biomedical Engineering Representative
Maintenance Department Representative
Housekeeping Services Unit Representative
TQM Representative.
Note: Area Supervisor/ Safety Liaison Officer should be available during the rounds.
5.2.4.2Annually in non-patient care areas by:
Infection Control Team Leader (ERTL)
Area Supervisor/ Safety Liaison Officer
Maintenance Department Representative
TQM Representative

5.2.4.3With noted deficiencies entered on the checklist (see
Attachment D).
Scheduled Facility Tour (FT) for fire protection, and life safety potential hazards as follows:
5.2.5.1Every 3 months inpatient care areas by the following representatives:
Facility Management Director Team Leader (FT)
Maintenance Representative
Infection Control Representative.
5.2.5.2Annually in non-patient care areas by:
Facility Management Director Team Leader (FT)
Infection Control RepresentativeMaintenance Representative
5.2.5.3With noted deficiencies entered on the Checklist (see Attachment F).
5.3 Control of Hazards:
5.3.1 Hazards which pose an immediate threat to life or health, or threaten damage to equipment,
buildings, or the environment, i.e., imminent danger, will be immediately reported by whatever
means available to the Department Head, Safety Manager, Safety Committee Chairperson, a TAG
Leader, or TQM Director
5.3.2 Support will be requested from the Safety Committee when hazards cannot be corrected at the
unit or department level.

5.3.3 Equipment or facilities requiring maintenance or repair, and unsafe conditions requiring repair
for correction are reported using the form as specified in Medical Equipment/Devices Management
Program
5.4 Workplace Accidents, Injuries and Illnesses
5.4.1 Any staff member, sub-contractor, construction worker or visitor injured/involved in an
accident or conceived to contact an infection or an illness should be directed to Family Medicine or
the Emergency Room
5.4.2 Accidents which meet the definition of an Occurrence (formally called incident) involving
patients, visitors or staff will be reported using the Occurrence Variance Report form as instructed
in OVR-APP
5.5 Operational Requirements
Each TAG will specify, review and make recommendations for the approval of relevant
Recommendations at the department and unit levels, as applicable, to ensure full implementation of
the Safety Management Programs and elements.
6.0 Format (AS applicable)
6.2 Performance Improvement Standards (PIS) for each of the Facility Management and Safety
Standards.
6.3 Safety Committee Organization Chart and TAG Leaders
6.4 Guidance for Revision and Maintenance of Safety Management Programs
6.5 Environmental Rounds Checklist
6.6 Report Required and Routing Procedure for the Safety Management Program
6.7 Facility Tour Checklist
6.8 Multidisciplinary Environmental Rounds and monthly self-inspection checklist
6.9 Report required and routing procedure for the Safety Management Program
7.0 References
Comprehensive Accreditation Manual for Hospitals (CAMH), Joint Commission for the Accreditation
of Healthcare Organizations (JCAHO), 1999/2001.
National Electrical Code, 1997 (US).
National Fire Codes, National Fire Protection Association (NFPA), US, 1997.
Saudi Arabia Standards Organization (SASO).
Sanitary Code, G1-151.006, 1996.

The Guidelines for the Construction and Equipment of Hospitals and Medical Facilities, 1996,
American Institute of Architects.
APP - Occurrence Variance Report (OVR).
PART 1 - FIRE SAFETY MANAGEMENT PROGRAM
FIRE SAFETY MANAGEMENT PLAN
Scope and Program Coordination
The Fire Safety Management Plan defines processes through which the Hospital/Dispensary
provides a fire-safe environment for patients, visitors, staff, and protects Hospital property from fire
and smoke damage. This plan covers all Hospital facilities and occupancies.
Coordination of the Fire Safety Management Program is a shared responsibility of the Hospital
Safety Officer, and the General Maintenance Department. All Hospital employees participate in the
Fire Safety Management Program.
The Hospital has established programs and practices, including
a Building Maintenance Program
an Interim Life Safety Management Program
a Statement of Conditions (SOC) coordination program, and
a facility fire plan to maintain the facilities in compliance with the Life Safety Code (LSC) and to
comply with National Fire Protection Association (NFPA) standards. In compliance with JCAHO, the
Hospital has adopted LSC NFPA 101 2000 as its standard, except when Building Code or other state
and local requirements are more stringent. The Hospital Safety Officer evaluates all proposed
changes to facility life safety features and is involved in the planning of all construction and
renovation projects. (Note: The Interim Life Safety Program is outlined in a separate document.) The
state fire marshal or his/her designee reviews and inspects all changes to the facility that affect life
safety.
Objectives
The processes included in the Fire Safety Management Plan are designed to meet specific
objectives.
o Ensure proper operation of fire detection, alarm, and suppression systems through a program of
inspection, testing, and maintenance
o Ensure proper maintenance of other built and installed life safety features, such as fire and smoke
walls, and fire doors.
o Provide and maintain portable fire extinguishers according to established criteria for type,
placement, inspection, maintenance, and use.
o Ensure that acquisitions such as curtains, furniture, waste baskets, bedding, and other equipment

meet established fire safety criteria.
o Investigate and recommend actions to correct deficiencies, failures, and user errors that may
impact fire prevention or safety.
o Ensure that all employees and others working within the building understand the building's life
safety features and their roles in fire prevention and response.
o Ensure that fire response procedures address institutional and departmental/area needs.
o Establish processes for identifying deficiencies and collecting data regarding fire prevention and
life safety processes and staff compliance.
Fire Alarm Systems
The fire alarm system is inspected, tested, and maintained through a service contract. The
established program includes, but is not limited to 1) quarterly testing of all circuits and 2) annual
preventive maintenance of all components.
Fire Detection System
The Hospital has a fire detection system that minimizes smoke transmission by controlling
designated fans and dampers in air-handling and smoke-management systems. All fire alarms are
monitored by the Maintenance Department and transmitted to the local fire department. The alarms
are also received in PPD dispatch and announced to the facility.
General Maintenance Department maintains the fire detection system. The system is tested in
accordance with NFPA 72 during regular quarterly inspections.
Automatic Fire Extinguishing Systems
The Hospital maintains outside contracts for inspecting, testing, and maintaining the automatic fire
extinguishing systems. The Preventive Maintenance Manager oversees the program and maintains
documentation.
Portable Fire Extinguishers
The Fire Marshal's Office provides portable fire extinguishers for Hospital facilities. The portable
fire extinguisher program has been established in compliance with NFPA standards. Fire
extinguishers within the Hospital are identified, placed, maintained, and used in compliance with
these standards.
The Fire Marshal services all fire extinguishers annually. Hospital representatives inspect all fire
extinguishers monthly.
System Monitoring and Transmission of Signal
Maintenance Department monitors the fire alarm system for the purposes of identifying location of
alarm, reset, and other internal functions.
Built and Installed Life Safety Features

The Hospital's built and installed life safety features, such as fire and smoke walls and fire doors are
inspected and maintained by the Maintenance Department as a part of the building maintenance
program. In addition, the safety surveillance team inspects such features as a part of the routine
inspection of the Hospital and submits work orders to PPD for all deficiencies noted.
Flame Resistance Requirements for Room Furnishings and Other Items
All room furnishings used in the Hospital must meet certain flame-resistance standards. These
standards, established by Life Safety Code, are detailed in the operating manuals of these
departments or offices designated as ordering consultants.
Fire Drills
Fire drills, totaling at least 1 per shift per quarter, are conducted in all Hospital healthcare
occupancies, according to an established schedule. All fire drills are unannounced. Only trained
evaluators from each service area have access to the established schedule. Fire drills exercise all
primary elements of the fire plan, including employee knowledge of:
Use and function of fire alarm systems
Transmission of alarms
Containment of smoke and fire
Transfer to area of refuge
Fire extinguishers and other life-safety features
Fire response duties
Extinguishing fires
Building evacuation
All fire drills are evaluated by trained monitors at the drill site, a smoke compartment on the same
floor and adjacent to the drill site, and a smoke compartment either immediately above or below the
drill site. Safety Training Coordinators or their designees evaluate other areas as deemed necessary
by past performance or the need for performance improvement. Hospital-owned or -operated
business occupancies conduct and evaluate fire drills at least annually.
Building Maintenance Program
The Hospital has an ongoing building maintenance program designed to resolve life safety code
deficiencies as they are identified whenever possible, rather than creating projects for their long
term resolution.
The goal of the building maintenance program is to ensure that at least 95% of the life safety
features function properly at all times. The inspection schedules for each life safety feature have
been established based on historical maintenance data to help ensure at least 95% compliance rate
for that item. The program's effectiveness is evaluated by regular inspections and by monitoring the
work order documentation.

The building maintenance program checklist includes, but is not limited to:
- 1 1/2-hour FRRA door and 1-hour FRRA doors (including occupancy separation doors, stair doors,
horizontal exit doors, and hazardous area room doors)
o positive latching
o self-closing or automatic closing devices in proper working order
o no more than 1/8 inch gap between edges of door pairs
o no more than ¾ inch undercut
- Smoke barrier doors
o Self-closing or automatic closing devices in proper working order
o Maintained to prevent spread of smoke
- Corridor doors
o Positive latching
o Maintained to prevent spread of smoke
- Smoke and fire walls
o Free of penetrations
o Properly sealed
- Egress illumination devices functioning (battery operated only)
- Exit signs lighted
- Grease producing devices (exhaust hoods, exhaust duct system, grease removal devices)
o Clean
o Maintained according to schedule
Reporting and Investigating Deficiencies, Failures, and User Errors
Maintenance Department has an established reporting and work order system that allows users to
report deficiencies, failures and other problems with the facility or its systems directly to
Maintenance Office. Dispatch personnel establish a work order for each report made, based on
established criteria. Once a work order is generated, area mechanics and other specialized
maintenance personnel are dispatched to investigate and reconcile, if possible, problems reported.
Maintenance personnel are required to close a work order when investigation and reconciliation are
complete. Maintenance Department dispatch personnel send notice that the work order has been
closed and how the problem was resolved to the individual who submitted the report.

In addition, the Hospital has a multi-faceted risk assessment program, designed, in part to
proactively evaluate the life safety features/systems of Hospital buildings.
That program includes, but is not limited to:
o Regular inspections/surveillance
o Random inspections/surveillance
o Construction/renovation meetings and site inspections
o Reportable occurrence reports
o False fire alarm reports
o Established periodic testing of mechanical life safety systems
o Fire drills and evaluations
The Hospital Environment of Care Committee and its subcommittees are actively involved in
evaluating safety trends and issues, recommending action, and monitoring implementation.
All hospital areas are evaluated on their compliance with life safety/fire prevention standards as a
part of the semi-annual inspection. Each area is expected to score 95% or above on life safety
standards. The results of the inspection are reported to the service director, manager, and
administrator.
The Safety department and designated Security and Maintenance employees respond to all fire
alarms. Only the ranking Safety department officer can authorize a system reset after the alarm is
activated. The reset is authorized after the cause of the alarm is identified.
Fire Prevention/Life Safety Education and Training
The Hospital Safety Officer develops the safety curriculum for 1) Hospital orientation and other
orientation programs for special audiences (i.e., residents, volunteers, teen volunteers, contractors),
2) supervisory training program, and 3) continuing education programs.
Based on JCAHO standards and identified institutional need, the safety officer has identified the
following issues to be included in life safety/fire prevention orientation:
o Roles and responsibilities of personnel at the fire's point of origin
o Roles and responsibilities of personnel away from the fire's point of origin
o Use and functioning of fire alarm systems
o Roles and responsibilities in preparing for and executing building evacuation
o Location and use of evacuation equipment
o Building compartmentalization and procedures for containing smoke and fire

Employees who have specific fire response assignments are educated and trained as a part of their
departmental orientation and continuing education.
Hospital employees are required to attend Hospital Orientation and must participate in
departmental orientation and continuing safety education programs.
Educational materials and/or education/training sessions tailored to the needs of volunteers,
physician staff, students, contract staff, and other personnel include information about fire
prevention and life safety. The Hospital Safety Officer and others participate in the development,
review, and evaluation of these materials.
Staff knowledge of fire response procedures is evaluated by the following:
o Annual safety survey--Hospital employees surveyed will be able to answer 95% of the fire
prevention questions accurately. The survey is conducted by area Safety Training Coordinators.
o Questions during Safety Surveillance--Hospital employees are questioned about fire response
procedures and are rated on their ability to respond accurately.
o Fire drills--Trained evaluators observe and question employees during each fire drill. Performance
and knowledge is documented and sent to area leaders for reconciliation of problems.
Performance Monitoring
The Hospital Environment of Care Committee and/or its subcommittees have established the
following performance standards related to fire safety management.
1. The Hospital will demonstrate a state of readiness for fire prevention and response by scoring
95% or above on all sections of the semi-annual fire drill evaluation.
2. Hospital areas will demonstrate a state of readiness for fire prevention and response by scoring
95% or above on life safety/fire prevention during each safety inspection.
3. The Hospital will have no more than 25 false fire alarms per year. This standard was established
based on comparison with benchmark institutions.
4. All fire extinguishers will be inspected monthly and inspections will be appropriatel documented.
5. The Hospital will resolve all life safety code deficiencies listed on the SOC within the time frame
specified.
Emergency Procedures
The Hospital has established a fire plan and an evacuation plan, documented in Hospital Policy and
in the Emergency Management Plan. These plans are tested as a part of routine fire drills and
emergency response exercises.
o The fire plan outlines the facility-wide fire response needs and roles and responsibilities of
staff at and away from the fire's point of origin.

o The evacuation plan outlines the roles and responsibilities of staff in preparing for transfer to area
of refuge or building evacuation.
In cases in which departmental or unit needs require more detailed instructions, the
department/unit has developed departmental policies and emergency procedures.
Emergency exit routes, established in consultation with the fire marshal, are posted in the Hospital
lobby, elevator lobbies, and public waiting areas. The Physical Plant Division updates emergency exit
route postings when construction or renovation causes a change to the facility.
Program Review and Evaluation
The Fire Safety Management Plan and related plans are evaluated annually by the Hospital
Safety Officer, the Maintenance Department, and other Hospital/Dispensary representatives who
have functional responsibility for life safety, using established questions/criteria. Results of this
annual evaluation are presented to the Hospital Environment of Care Committee for review,
recommendation, and approval.
All Hospital safety policies are reviewed at least bi-annually by the Hospital Safety Officer and other
appropriate bodies or individuals. Results of this evaluation are presented to the Hospital
Environment of Care Committee for review and recommendation. Hospital policies are distributed to
staff on line or in hard copy.
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