FMS PPT 6

Dr.
Ehab
DR-EHAB Hospital Management
2
Consultant & T.Q.M Consultant
3
Staff
Safety
Patients
Visitors

4
• FMS.1
• The Hospital Administration Supports
And Establishes A Safety
Management Program That Covers
The Following Seven Important Plans:

5
FMS.1.1 Safety of the Building. (0.5 score)

6
FMS.1.2 Security. (0.25 score)

7
FMS.1.3 Hazardous materials and waste disposals.
(0.5 score)

8
FMS.1.4 Emergencies

9
FMS.1.4 Emergencies
FMS.1.4.1 Internal Plan (0.25 score)

10
FMS.1.4 Emergencies
FMS.1.4.2 External Plan (0.25 score)

11
FMS.1.5 Fire Safety (0.5 score)

12
FMS.1.6 Medical Equipment (0.25 score)

13
FMS.1.7 Utility System. (0.5 score)

14
15
• FMS.2
• The Hospital Administration
Establishes A Budget To Support The
Safety Management Programs.

16
• FMS.3
• There is an Orientation on the
Facility Management and Safety Plans
conducted for new hires.

17
• FMS.4
• There is a No Smoking policy and
it is enforced.

18
How the standards will be identified
Document Review
Observation
Coding Scoring Criteria
Score 0 (NM)
There is no policy for No Smoking
Score 1 (MM)
Policy not approved.
Score 2 (PM)
Policy approved but not implemented.
Score 3 (FM)
There is a policy for no smoking and no evidence of any smoking in non designated
areas

19
20
• FMS.5
• The Safety Of The Building Plan
Covers The Following And Is
Implemented As Appropriate:

21
Establishing A Safety Committee Consisting Of The Following
Representatives
Head Of Safety,
Head Of Security,
Head Of Housekeeping,
Head Of ER,
Head Of Biomedical,
Head Of Maintenance Department,
Representative From Lab, Infection Control, Nursing, TQM And
Radiation Safety Officer

22
Safety Committee
FMS.5.1 Meets At Least 10 Times/Year On A Monthly

Schedule, Minutes Documented.

23
Safety Committee
FMS.5.2 Discusses And Analyzes All Safety Issues.

24
Safety Committee
FMS.5.3 Reviews Summary Of The Incidents/ OVR Reports

And Errors With High Level Of Occurrence And Suggests The
Appropriate Solution.

25
Safety COMMITTEE
FMS.5.4 Reports Safety Committee Minutes To The Hospital

Director.

26
Safety Committee
FMS.5.5 Communicates In Writing With All Heads Of

Departments About The Risk Issues In Their Areas.

27
• The Safety Committee Schedules
And Conducts The Following:

28
FMS.6.1 Environmental Rounds To Check Staff
Knowledge And Implementation Regarding The
FMS Plans (Quarterly).

29
FMS.6.2 Facility Tours To Check The Facility/
Physical Plant (Quarterly).

30
• Appointing A Full Time Trained
Safety Officer With A Minimum
Of 5 Years Experience

31
FMS.7.1 Communicates In Writing With All Department
Heads And Chiefs Of Units To Assign Safety Liaison Officers,
To Liaise The Safety Issues With The Safety Officer.
It Is A Requirement Of Civil Defense Aimed To

Provide The Professional Support For The Hospital

32
• Hospitals Greater Than 150 Beds
Required Additional Staff Trained In
Safety That Work With The Safety
Officer To Implement The Safety Plan.

33
FMS.9
The Hospital Has Civil Defense Gulf Countries Council (GCC) Guidelines
For The General Safety In The Building And The Guidelines Are In Part
1 Chapter#7. (Http://Www.998.Gov.Sa/) Or The Equivalent Guidelines.

34
• Warning Signs Are Posted Inside The
Hospital As Appropriate And Includes
But Not Limited To.

35
FMS.10.1
Hazardous Signs. (0.5 Scoring)

36
FMS.10.2
Signs Of The Radioactive Material As Dangerous.
(0.5 Scoring)

37
FMS.10.3
Signs Of Wet Floors During Cleaning.
(0.5 Scoring)

38
FMS.10.4
Signs For X-ray.
(0.5 Scoring)

39
FMS.10.5
No smoking signs. (0.5 scoring)

40
FMS.10.6
Signs To Restrict Cellular Phones In Sensitive Areas,
E.G. MRI Or Critical Care Units As Appropriate.
(0.5 Scoring)

41
• Directive Signs Are Posted As
Appropriate:

42
FMS.11.1
Fire Exit Signs. (0.5 scoring)

43
FMS.11.2
Directional Exit Signs.

(0.5 scoring)

44
FMS.11.3
Signs To Direct Staff And Patients To The
Different Services In The Hospital.
(0.5 scoring)

45
FMS.11.4
Signs To Direct Patients And Visitors To The
Emergency Room.
(0.5 scoring)

46
FMS.11.5
Signs To Identify Floor Level At Staircases, And In
Front Of Elevators.
(0.5 scoring)

47
FMS.11.6
Signs To Instruct Staff, Patients And Visitors In
Restricted Areas.
(0.5 scoring)

48
• Patients Bathrooms And Showers Are
Provided With The Following Safety
Measures:

49
FMS.12.1
Non-slipping Floors Surfaces. (1.0 scoring)

50
FMS.12.2
Bars To Support Patients. (0.5 scoring)

51
FMS.12.3
Bell Or A System To Call For Help. (1.0 scoring)

52
FMS.12.4
Lock System To Allow For Opening From Outside.
(0.5 scoring)

53
• Fire Safety Is Implemented In The Lab
And Includes, But Not Limited To:

54
FMS.13.1
Eye Wash Stations. (0.5 scoring)

55
FMS.13.2
Emergency Shower (0.5 scoring)

56
FMS.13.3
Fire Blankets. (0.5 scoring)

57
FMS.13.4
First Aid Kit.

(0.5 scoring)

58
FMS.13.5
Fire Extinguishers
(0.5 scoring)

59
FMS.13.6
Fire Resistant Storage Safety Cabinet.

(0.5 scoring)

60
• The Kitchen Has Safety
Equipment That Includes:

61
FMS.14.1
Eye Wash Stations.

(1.0 scoring)

62
FMS.14.2
Fire Blankets.
(0.5 scoring)

63
FMS.14.3
First Aid Kit.
(0.5 scoring)

64
FMS.14.4
Fire Extinguishers
(1.0 scoring)

65
• There Are No Obstructions To Exits,
Fire Extinguishers, Fire Alarm Boxes,
Emergency Blankets, Safety Showers
And Eye Wash Stations, And:

66
FMS.15.1
Emergency Lighting Is Adequate For Safe

Evacuation Of The Laboratory.
(0.5 scoring)

67
FMS.15.2
All Exits Are Maintained Free Of Obstructions. All Exits Are

Free Of Locks Or Fastening Devices That Could Prevent Free
Escape.
(1.0 scoring)

68
FMS.15.3
All Rooms In The Laboratory Have Direct And
Unimpeded Access To The Outside Corridor Or A
Second Exit.
(1.0 scoring)

69
FMS.15.4
All Doors Leading To Laboratories Are Marked To

Indicate The Fire Hazards Of Materials Used Within
This Area.
(0.5 scoring)

70
• The Laundry Has Safety Equipment
That Includes:

71
FMS.16.1
Eye Wash Stations.

(1.0 scoring)

72
FMS.16.2
Fire Blankets.
(0.5 scoring)

73
FMS.16.3
First Aid Kit.

(0.5 scoring)

74
FMS.16.4
Fire Extinguishers
(1.0 scoring)

75
• The Reverse Osmosis (RO) plant has
safety equipment that includes

76
FMS.17.1
Eye wash stations.
(1.0 scoring)

77
FMS.17.2
Fire blankets.
(0.5 scoring)

78
FMS.17.3
First Aid Kit.

(0.5 scoring)

79
FMS.17.4
Fire Extinguishers
(1.0 scoring)

80
• All Units Or Services Using Lasers
Have Written Laser Safety Policies
And Procedures, And They Are
Implemented.

81
• Flammable liquids are stored
according to the Materials Safety
Data Sheet (MSDS) guidelines.

82
• Occurrence, Variance Report (Incident
Reports) Are Used To Report Safety
Of The Building Related Incidents,
And Corrective Actions Taken.
• .

83
• SECURITY
• (FMS.21 – FMS.30)
• The Security Plan covers the
following aspects and is
implemented as appropriate:
84
• Identification Of All Of The Following
By The I.D. Badge:

85
FMS.21.1 Hospital Staff (2.0 scoring)
FMS.21.2 Temporary Employees (0.5 scoring)
FMS.21.3 Contractor Staff (0.5 scoring)

86
87
• Restricting Access To Sensitive Areas
By Security Personnel / Security
System, Like:
To protect patients on those units
and provide them with privacy

88
Restricting access to sensitive areas by Security
Personnel / Security System, like:
FMS.22.1
Delivery
(0.5 scoring)

89
FMS.22.2
NICU (0.5 scoring)

90
Restricting Access To Sensitive Areas By
Security Personnel / Security System, Like:
FMS.22.3
Nursery (0.5 scoring)

91
FMS.22.4
Female Floors (0.5 scoring)

92
FMS.22.5
Operating Room (0.5 scoring)

93
FMS.22.6
CSSD (0.5 scoring)

94
There Are Written Policies On •
Preventing Abduction Of Children,
And Neonates.

95
This Will Lead To High Awareness Among Staff
Which Will Protect Neonatal, Infants And
Children From Theft

96
• There are written policies on the
following that includes but not limited
to:
• To insure getting fast police assistance,
protect patient and others belongings

97
FMS.24.1
Lost And Found Items

(1.0 scoring)

98
FMS.24.2
Safe Keeping Of Patient Belongings

(1.5 scoring)

99
FMS.24.3
How To Contact The Local Police, In Case Of

Need.
(0.5 scoring)

100
• There Is A Written Policy On How
To
• Handle The Following:
• To clarify to the on duty ER staff the role of police
•
•

101
FMS.25.1
Involvement Of Police In Trauma, Motor

Vehicle Accidents & Similar Incident
(0.5 scoring)

102
FMS.25.2
Drug Addicts Cases

(1.0 scoring)

103
FMS.25.3
Manslaughter cases
(0.5 scoring)‫قتل غير متعمد‬

104
FMS.25.4
Violent Patient (MR. STRONG)

(1.0 scoring)

105
• There Is A Written Policy On How To Deal
With A Bomb Threat (Code White) In The
Hospital And The Policy Includes:

106
FMS.26.1
Defining The Role Of Person Receiving Threat.

107
FMS.26.2
Defining The Response Team.

108
FMS.26.3
Defining The Duties And The Responsibilities

Of All Staff Involve And Their Action Cards.

109
FMS.26.4
Defining The Responsible Person Who Announces

The Emergency Status And Calls The Local
Authorities.

110
FMS.26.5
How To Contact The Local Police.

111
FMS.26.6
The Command Centre Location.

112
FMS.26.7
Defining The Steps To Be Taken During The

Bomb Threat.

113
• The Security Rules Are Clearly
Defined In The Following:

114
FMS.27.1
External Plan. (0.5 scoring)
FMS.27.2
Internal Plan. (0.5 scoring)
FMS.27.3
No smoking policy. (2.0 scoring)

115
• There Are Specific Personnel Assigned
To Take Care Of Security, As
Appropriate To The Size Of The
Hospital And:

116
FMS.28.1
Security Personnel Have A Written

Job Description.
(0.5 Scoring)

117
FMS.28.2
Security Personnel Are Oriented On Their Scope Of

Work And Location Of Job Description
(0.5 Scoring)

118
FMS.28.3
Security Personnel Are Oriented On The Emergency

Codes.
(0.5 Scoring)

119
FMS.28.4
Security Personnel Are Oriented On Fire Safety.

(0.5 Scoring)

120
FMS.28.5
Security Staff Are Trained On How To Extinguish

Fires
(0.5 Scoring)

121
FMS.28.6
Security Personnel Are Properly Dressed.

(0.5 Scoring)

122
• Security Conducts Security Rounds
Hospital-wide 3 Times/Day And
Rounds Are Documented.
• To provide patient, staff with the sense of security,
provide assistance to outpatient and visitors,
correct security deficiencies that get noticed during
their rounds

123
OVRs Are Used To Report Security •
Related Incidents, And Corrective
Actions Taken.
• In Order To Properly Document Incidents, Involve

The Proper Parties, And Prevent Reoccurrence Of
Similar Incidents

124
OVRs Are Used To Report Security •
Related Incidents, And Corrective
Actions Taken.
• In Order To Properly Document Incidents, Involve

The Proper Parties, And Prevent Reoccurrence Of
Similar Incidents

125
• HAZARDOUS MATERIALS
AND WASTE DISPOSAL
(FMS.31– FMS.37)

126
• The Hazardous Materials Plan Covers The
Following And Are Implemented As
Appropriate:

127

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Dr.

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

FMS.1.4.2 External Plan (0.25 score)

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

FMS.5.1 Meets At Least 10 Times/Year On A Monthly

DR-EHAB Hospital Management

FMS.5.2 Discusses And Analyzes All Safety Issues.

DR-EHAB Hospital Management

FMS.5.3 Reviews Summary Of The Incidents/ OVR Reports

DR-EHAB Hospital Management

FMS.5.4 Reports Safety Committee Minutes To The Hospital

DR-EHAB Hospital Management

FMS.5.5 Communicates In Writing With All Heads Of

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

It Is A Requirement Of Civil Defense Aimed To

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

Fire Exit Signs. (0.5 scoring)

DR-EHAB Hospital Management

Directional Exit Signs.

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

Non-slipping Floors Surfaces. (1.0 scoring)

DR-EHAB Hospital Management

Bars To Support Patients. (0.5 scoring)

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

DR-EHAB Hospital Management

Eye Wash Stations. (0.5 scoring)

DR-EHAB Hospital Management