Comprehensive training programs and certification courses designed to enhance facility management skills, safety protocols, and professional development. Our programs cover building operations, safety management, emergency preparedness, and specialized facility training.
Comprehensive documentation and guidelines for facility management and safety protocols
The mission of Team One is to provide the highest level of respect and patient-driven care in a safe and healing environment; also deliver an exceptional education and research. To reach this mission, Team One, Administration provided all necessary supports and resources to this Facility Management and Safety (FMS) Programs in order to properly manage the environment and physical facility, utility systems, medical equipment, and its people.
Written management plans are develop through this facility management and safety programs in order to manage effectively the Facility Management and Safety (FMS) Program seven primary functions are:
2.1. The purpose of this Facility Management and Safety Program is to provide an environment that is safe, functional and a supportive facility, equipment's and vehicles for patients, staff and visitors.
2.2. FMS Program establishes the parameters within which a safe environment of care are plan, maintain, monitor, improve and also addresses specific responsibilities, awareness, training and education to all Team One employees.
3.1. Facility Management and Safety (FMS) Program: The organization's written document describing the process it has in place for the following areas of its operations: safety and security, hazardous materials, disaster preparedness, fire safety, medical equipment, and utility systems. The plan identifies specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities.
3.2. Safety: The degree to which the organization's buildings, construction areas, grounds, vehicles and equipment do not pose a hazard or risk to patients, staff, or visitors.
3.3. Security: Protection from loss, destruction, tampering, or unauthorized access or use.
3.4. Hazardous Materials: Handling, storage, and use of radioactive and other materials are controlled and hazardous waste is safely disposed.
3.5. Vehicle Inspection and Maintenance: Maintain vehicles and equipment in order to provide safe, comfortable, and reliable transportation to patients, and effective and efficient service to the community.
3.6. Fire Safety: Conducting ongoing assessment of risks to enhance protection of property and occupants from fire and smoke.
3.7. Medical Equipment: Equipment are selected, maintained, and used in a manner to reduce risks.
3.8. Utility Systems: Electrical, water, and other utility systems are maintained to minimize the risks of operating failures.
3.9. Plan: A method for outlining detailed strategies and resource needs for meeting short- and long-term goals and objectives.
3.10. Preventive Maintenance: The planned, scheduled, visual, mechanical, engineering, and functional evaluation of facility, systems, vehicles and equipment conducted before using and at specified intervals throughout the lifetime. The purpose is to maintain performance within manufacturers' guidelines and specifications and to help ensure accurate diagnosis, treatment, or monitoring. It includes measuring performance specifications and evaluating specific safety factors.
3.11. Qualified Individual: An individual or staff member who can participate in one or all of the organization's care activities or services. Qualification is determined by the following, as applicable: education, training, experience, competence, applicable licensure, laws or regulations, registration, or certification.
3.12. Environment of Care: refers to a variety of "key elements and issues" that contribute in creating the way the space, fleet feels and works for patients, families, visitors, and staff experiencing the health care delivery system.
4.1. The scope of this program is to outline the responsibilities of the facility management and safety primary functional plans in order to provide all Team 1 patients, families, staff and visitors a physical environment that is free from hazards and also to manage activities pro-actively through risk assessment in order to reduce the risk of injuries.
4.2. Facility Management and Safety Program covers the following written and approved plans:
5.1. The goal and objectives of the FMS Program is to deliver a safe, functional, and effective environment for patients, staff members and other individuals in order to achieve this goal, this FMS program must perform the processes of:
6.1. The Facility Management and Safety Department shall oversee the management of FMS Program and receives regular reports on the activities of the Facility Management & Safety Plans. It shall review reports and, as necessary, communicates concerns about key issues and regulatory compliance to the Administration to establish or approve resources and capital budgets to operate and maintain a safe and compliant environment of care.
6.2. Manager Facility Management and Safety Department shall be responsible to manage and develop plans for improvement.
6.3. Supervisor Facility Engineering shall be responsible to manage and develop plans for improvement on
6.4. Supervisor Environmental Services shall be responsible to manage and develop plans for improvement on
6.5. Supervisor Biomedical Engineering shall be responsible to manage and develop plans for improvement on
6.6. Supervisor Security shall be responsible to manage and develop plans for improvement on
6.7. Supervisor Transportation shall be responsible to manage and develop plans for improvement on
7.1. The Facility Management and Safety Department provides oversight and management of the program and reports are submitted to the Team governing bodies. The FMS Program shall comply with all applicable local, state, and federal laws, and meet the requirements of relevant accrediting agencies.
7.2.1. The Facility Management and Safety Department manages the performance measurement and improvement process for the Facility Management and Safety Program.
7.2.2. Designated members are responsible for preparing quarterly reports of performance of the programs. These reports include ongoing measurements of performance, and summary reports of incidents, including the results of any risk assessments.
7.2.3. The Facility Management and Safety Department establishes performance indicators to measure objectively the effectiveness of Utility Systems Management Program, Safety Management Program, Fire Management and Life Safety Management Program, Hazardous Materials and Waste Management Program, Medical Equipment Management Program, Security Management Program, Vehicle Inspection and Maintenance Program
7.2.4. Additionally, they determines appropriate data sources, data collection methods, data collection intervals, analysis techniques, and report formats for the performance improvement standards. Human, equipment, and management performance are evaluate to identify opportunities to improve the FMS Management Programs.
7.2.5. The performance measurement process is one part of the evaluation of the effectiveness of the FMS Program. A performance indicator has been established to measure at least one important aspect of each FMS Management Programs. The current performance improvement indicator for each FMS Management Program services are:
7.2.5.1.1. Compliance of Utility System Preventive Maintenance - Annual target of Ninety (90%) percentage.
7.2.5.2.1. Safety Risk Assessment Corrective Action Closure Rate. Measure the percentage of identified hazard or deficiencies that has been appropriately addressed or controlled or closed within specified timeframe - Annual Target of Ninety (90%) percentage.
7.2.5.3.1. Compliance Fire Safety Training Conducted - Annual Target of Ninety-Five (95%) percentage.
7.2.5.4.1. Medical Waste Staff Training Conducted - Annual target of Ninety-Five (95%) percentage.
7.2.5.5.1. Compliance of Medical Equipment Preventive Maintenance - Annual target of ninety (90%) percentage.
7.2.5.6.1. Maintain Zero Percent (0%) Event for security issues - Annual Target of Zero (0%) percentage.
7.2.5.7.1. Compliance of Vehicle Inspection and Maintenance - Annual target of ninety five (95%) percentage.
7.3.1. FMS Program effectiveness shall be monitored regularly using significant incidents as well as trending of performance measures to indicate the effectiveness of the processes and/or systems in place.
7.3.2. Performance monitoring and assessments of program effectiveness shall be reported to the Team One Governing body.
7.3.3. Significant events and outcomes of regular trending are report by the responsible members to the Manager Facility Management and Safety at least quarterly or immediately as an exception for serious events.
This Facility Management and Safety Program will be address to all staff and entities within the administration of Team One.
9.1. Human Resources Departments mandate orientation, education and training for FMS Program to all staff. This training includes, but is not limited to:
11.1. Annual evaluations of the FMS Program will include a review and examine the scope, objectives, key performance indicator and effectiveness of each program in accordance to the current regulatory standards to evaluate the degree in which the program meets accreditation standards. The report provides a summary of the FMS Management Programs performance over the preceding 12 months. Strengths are noted and deficiencies are evaluated to set goals for the next year.
11.2. The annual evaluation report shall be presented to the Team One governing body. All deliberations, actions, and recommendations are document in the minutes. Once the evaluation is final, the CEO, Team One and Manager Facility Management and Safety are responsible for implementing the recommendations in the report as part of the performance improvement process.
Comprehensive documentation and guidelines for utility systems management and maintenance protocols
In line with the vision, mission and value of Team One to provide respectful patient-driven care in a safe, healing environment and contribute to learning and sharing in healthcare practice, education and research for the benefit of the people it serves. Consistent with this, the administration and Facility Engineering has established and provided ongoing support for the Utility System Management Program described in this document.
2.1. The purpose of the Utility Systems Management Program is to support and provide a safe facility system environment at Team One by managing risks associated with the safe operation and functional reliability of its utility systems.
2.2. This program includes processes for selection, preventive or corrective maintenances, utility system emergency response, training and education that are design to promote safe and effective use of utility systems while minimizing risks.
3.1. Facility Management and Safety (FMS) Program: The organization's written document describing the process it has in place for the following areas of its operations: safety and security, hazardous materials, disaster preparedness, fire safety, medical equipment, and utility systems. The plan identifies specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities.
3.2. Utility System: Organization wide systems and equipment that support the following: electrical distribution, emergency power, water, vertical and horizontal transport, heating, ventilating, and air conditioning, plumbing, medical gases, or communication systems including data exchange systems. May also include systems for life support, surveillance, prevention, and control of infection, and environment support.
3.3. Routine Maintenance: The performance of basic safety checks—that is, the visual, technical, and functional evaluations of facility systems — to identify obvious deficiencies before they have a negative impact. It normally includes inspections of the case, power cord, structural frame, enclosure, controls, indicators, etc.
3.4. Maintenance Program, Preventive: The planned, scheduled, visual, mechanical, engineering, and functional evaluation of facility systems conducted before using and at specified intervals throughout the lifetime. The purpose is to maintain facility systems performance within manufacturers' guidelines and specifications and to help ensure accurate diagnosis, treatment, or monitoring. It includes measuring performance specifications and evaluating specific safety factors.
4.1. The scope of Utility Systems Management Program is to monitors and evaluates the utility systems in use at Team One facilities in accordance with all applicable local and international laws and regulations
5.1. The goals of this Utility Systems Management Program includes the following:
5.2. The objectives of Utility Systems Management Program includes the following:
6.1. The Facility Management and Safety Department delegated the Supervisor Facility Engineering or Designees to be responsible of developing, implementing, monitoring and managing the utility system management program.
6.2. The Supervisor Facility Engineering or Designees shall also be responsible for operation and maintenance of all utility systems and management of contractors working on the utility systems, collecting data, performing or overseeing repairs / corrective maintenance activities, preventive maintenance (PM) works, utility system inspection and testing, utility systems emergency failures, including all utility system improvement projects and other aspects required of this Utility Systems Management Program.
7.1.1. Utility system risk assessment and hazard surveillance reporting system is designed to proactively evaluate and identify deficiencies in the Teamone facility, knowledge and work practices of occupants.
7.1.2. The utility system risk assessment and hazard surveillance reporting system includes, but is not limited to regularly scheduled inspections, random inspections, and a reportable issue related hazardous materials and waste.
7.1.3. The Maintenance technician with the Environmental Facility Rounds Team shall conduct the utility system risk assessment inspections to identified risks, hazard and issues, shall recommend action or control measure and monitor implementation and compliance.
7.1.4. Utility System Risk assessment inspection reports issues are directly forward to the concerned department /section, copy to the Head of the Department for rectification and uses the resulting information for corrective and preventive actions, planning, and budgeting of long-term upgrading and replacement.
7.2.1. All essential services that support physical environments are consider as a Utility System, which include:
7.3.1. Facility Engineering Section have all schematic drawings (mapping) on the distribution of utility systems, which indicate the controls for partial or complete shutdown of each utility system.
7.3.2. All emergency shut-off controls for the utility systems components shall be labeled clearly, visibly and permanently throughout the facility.
7.3.3. Power supply is available 24 hours per day all the year, coming from Saudi Consolidated Electric Companies (SCECO).
7.3.4. Uninterrupted Power Supply (UPS)
7.3.4.1. Uninterruptible Power Supply (UPS) System and Automatic Generators covering dispatch center, ambulance shorelines, IT data room (1 UPS socket, 1 emergency socket).
7.3.4.2. All Power Supply Outlet Are Labeled and Cored Coded:
7.4.1. The sources of portable water is National Water Company.
7.4.2. Alternative Water Supply
7.4.2.1. In case of total failure of water in all lines contractor Company will be contacted to deliver within 2 to 4 hours' portable water.
7.4.2.2. The Facility Engineering section ensure it has conducted and documented the water supply test very six (6) month and to document the contractor response.
7.5.1. The Facility Engineering section, in conjunction with the Safety and Infection Prevention and Control, will develop policies and procedures for the inspection, testing and maintenance of all water systems and domestic hot/cold water systems to minimize pathogenic biological agents.
7.5.2. Water is tested and documented on a monthly basis for mineral (solids) and microbial level. Chemical analysis and other Chemical Contaminations and other essential parameters as required will be conducted every six (6) months.
7.5.3. The Facility Engineering section manage all water testing. Result will be forwarded to the Infection Control.
7.6.1. All HVAC system are tested and maintained as per Period Preventive Maintenance (PPM) System.
7.6.2. Air filter are change regular as required by the manufacturer.
7.6.3. All HEPA filters in ambulances are continuously monitored through and replacement as require by system manufacturer. Testing are conducted as per require base on manufacturer recommendation.
7.7.1. Portable cylinders will be provided as per submitted requirements.
7.7.2. Cylinders are stored and managed in an appropriate way by the Facility Engineering.
7.7.3. Medical gas room and components are tested in accordance with the Period Preventive Maintenance (PPM).
7.8.1. All elevators are maintain in accordance with the manufacturer recommendation and Period Preventive Maintenance (PPM).
7.9.1. All communication system like digital phones and public address system are maintain by I.T Department.
7.10.1. Discharged water to municipality drainage is tested and document semiannually.
7.11.1. The utility system incident reporting process is the responsibility of the Facility Engineering Section or his designee. Staff who identify any utility related issue should be reported it to the head of section or immediate supervisor who in turn is responsible for filling an incident report. Incident reporting will be forwarded to the Quality Department for analysis and treading.
7.11.2. A Utility system failure report shall be completed for any problem failure or user error of a vital or essential system.
7.11.3. The Facility Engineering Section will respond to and correct all identified problems within the scope of their operations in a timely manner. Evidence of the actions taken to resolve identified problems can be located in the daily log, the completed work orders file, the utility system management failure user error log and additionally the problem resolution log.
7.11.4. The Supervisor Facility Engineering or his designee shall submit a summary of all utility system incidents to Manager Facility Management and Safety.
7.12.1. There is a scheduled maintenance system, which is use to schedule, monitor and documents the inspection, testing and maintenance of each utility system based on the manufacturer's recommendation.
7.13.1. The Supervisor Facility Engineering or his designee is responsible for coordinating activities and ensuring procedures are during the failure of major utility services at great risk. Emergency procedure include:
7.14.1. A comprehensive preventive maintenance program, which includes written testing and maintenance programs for all utility components shall help to ensure reliability, minimize risks and reduce failures of utility systems. It is the responsibility of the Maintenance and Project Management Section to keep the preventive maintenance program accurate and ongoing at the established intervals. Preventive maintenance includes the following maintenance techniques metered, corrective and interval-based. Other techniques that may be used are predictive maintenance and reliability-centered maintenance.
1.1.1. The Director of Engineering and Support Services and Buildings Operations Management Section shall make plans and budgets for upgrading or replacing utility systems or components based on inspection body, environmental audits or findings through PPM in accordance to local and international standard and regulations.
This Utility Management Program will be address to all staff and entities within the administration of Team One.
9.1. Human Resources Departments mandate orientation, education and training for Program to all staff. This training includes, but is not limited to:
N/A
11.1. Annual evaluations of the Program will include a review and examine the scope, objectives, key performance indicator and effectiveness of each program in accordance to the current regulatory standards to evaluate the degree in which the program meets accreditation standards. The report provides a summary of the Program performance over the preceding 12 months. Strengths are noted and deficiencies are evaluated to set goals for the next year.
11.2. The annual evaluation report shall be presented to the Team One governing body. All deliberations, actions, and recommendations are document in the minutes. Once the evaluation is final, the Manager, Facility Management and safety is responsible for implementing the recommendations in the report as part of the performance improvement process.
Comprehensive documentation and guidelines for hazardous materials and waste management protocols
The mission of Team One is to provide the best healthcare services standard for its patients / staff and visitors by meeting their expectations, full commitment to the principles of total quality management, providing the optimum support to all employees through effective training, improving the management operations efficiency, and to ensure a continuous improvement work culture.
The Hazardous Materials & Waste Management Program shall provide criteria and processes to ensure safe, functional and supportive facilities for patients, families, staff and visitors.
2.1 The purpose of the Hazardous Materials and Waste Management is to define the program to identify and manage materials known to have the potential to harm humans or the environment. This includes processes designed to minimize the risk of harm. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures.
2.2 The Hazardous Materials and Waste Management Program provides a programmatic framework to reduce risk and includes processes that are designed to evaluate risks that may adversely affect the life or health of patients, visitors, staff and volunteers.
3.1. Hazardous Materials and Waste Materials: "Chemicals or any Materials that would be a risk to employees, patients and visitors if they are exposed to those materials in the workplace."
3.2. Safety Data Sheet (SDS): A formal document with information about the characteristics and actual or potential hazards of a substance; includes instructions related to first aid, spills, and safe storage, among other information. Previously named material safety data sheet (MSDS).
4.1. The scope of the Hazardous Materials and Waste Management Program processes by which Team One utilizes to provide a safely controlled environment where hazardous materials are used in the facility and vehicles by proactive risk assessments to reduce the risk of injury as well as a program that includes selecting, handling, storing, transporting, using and disposing of health care waste. This also takes into consideration staff orientation, education and monitoring.
4.2. Hazardous materials and waste risks are continually assessing and review during hazard surveillance and environmental rounds, the collection of information through incident reports, product management and review as well as risk assessment results by the Environmental Services Section. Risks levels are determined by the level of potential consequences that are associated with the types, quantities, inherent physical and chemical properties of the hazardous materials utilized.
5.1. The goals of the Hazardous Materials and Waste Management Plan includes the following:
5.2. The objective of the Hazardous Materials and Waste Management Plan is to develop a system that addresses the identification, selection, handling, storage, use and disposal of hazardous materials and wastes based on the results of the risk assessment.
6.1. The Manager Facility Management delegated the Supervisor Environmental Services Section or Designees to be responsible for developing, implementing, monitoring and managing the Hazardous Materials and Waste Management Program.
6.2. Supervisor Environmental Services Section or Designees have the authority to take action when hazardous conditions or potential hazardous conditions exist.
6.3. Environmental Services Section will monitor the staff compliance to the Key Performance Indicators (KPI) and report the findings to the Management.
7.1.1. Team One has a multi-faceted Hazardous materials and waste management risk assessment and hazard surveillance reporting system, designed to proactively evaluate and identify deficiencies in the Teamone facility, knowledge and work practices of occupants.
7.1.2. The risk assessment and hazard surveillance reporting system includes, but is not limited to regularly scheduled inspections, random inspections, and a reportable issue related hazardous materials and waste.
7.1.3. The Representative from the Environmental Services Section with the Environmental Facility Rounds Team; shall conduct hazardous material risk assessment inspection to identified risks, and related issues, they shall recommend action, and monitor implementation and compliance.
7.1.4. Risk assessment inspection reports issues are directly forward to the concerned department /unit, copy to the Head of the Department for rectification and Safety Management Committee uses the resulting information for corrective and preventive actions, planning, and budgeting of long-term upgrading and replacement.
7.2.1. Environmental Services Section will keep a list of materials classified by local and international law, i.e., Gulf Cooperation Council Unified Law of Healthcare Waste Management (GCC), Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA) as being hazardous materials and these organizations will be reference. A copy of the Hazardous Materials list will be kept in each department who use the hazardous material or waste for their reference.
7.2.2. Each department will be responsible for identifying and labeling all hazardous materials and waste within their department after the Environmental Services Section approval.
7.2.3. A Safety Data Sheet (SDS) is to be obtained for every chemical used and identified as hazardous. A master file of all Safety Data Sheets will be kept in the Environmental Services Section as well as in the user department for the employees who handle hazardous materials.
7.3.1. A system has been developed that addresses the identification of hazardous materials and waste from selection to the point of final disposal.
7.3.2. The safety liaisons will review the use of hazardous materials in their departments annually and submit the findings to the Environmental Services Section, which in turn submit these findings to the Management.
7.3.3. Upon ordering the hazardous materials, the Purchasing Department should review the list of special handling requirements, restricted storage quantities and the Environmental Services Section requirements for the specific hazardous material. In general, the Environmental Services must receive notification at the time of purchase for any all materials considered hazardous material.
7.3.4. In an effort to reduce the use of hazardous materials, the Environmental Services Section, Safety and Security, Purchasing, and other related Department shall review all literature referencing the reduction of hazardous materials. They will have provided recommendations regarding less hazardous products to the Management for the purpose of replacement also the Environmental Services will implement several programs for targeted hazardous chemical and waste reduction.
7.3.5. Inventory levels of all hazardous materials will be routinely reviewed for appropriateness as a part of the overall inventory management program. Safety liaison is responsible for keeping a current inventory of hazardous materials at least annually with a report to the Environmental Services Manager.
7.4.1. Environmental Services routinely coordinates the collection of all unwanted chemicals waste that contains solid, liquid or gaseous chemicals resulting from cleaning and disinfecting procedures. Solid chemicals and pharmaceutical drug waste will be disposed in yellow bag with phrase chemical waste medications (Arabic & English) with "bio-hazard" waste" logo. On the other hand, the Liquid Chemicals waste will be disposed in yellow thick air tight sealed, leak proof containers, bearing the phrase "Chemical Waste" in (Arabic and English).
7.4.2. Environmental Services is responsible for the monitoring of the disposal any residual cytotoxic drug that remains following patient treatment and any materials or equipment (decide to be considered waste) potentially contaminated with cytotoxic drugs. This type of waste will be disposed in yellow container with a phrase "Cytotoxic Waste" with cytotoxic hazard logo and Biohazard logo.
7.4.3. Infectious Waste that might spread any of the infectious diseases due to its load of bacteria, viruses, parasites, and fungi are monitored by Environmental Services through providing technical assistance and support regarding occupational health and safety matters, this type of waste will be disposed in yellow bag with a phrase" hazardous waste" (Arabic & English) with Bio-Hazard logo.
7.4.4. Pathological Waste (waste of body parts and organs) will be disposed in red bag with a phrase "hazardous waste" (Arabic &English) with Bio Hazard logo as well as will be treated in specific method accordance to Islamic Sharia (law).
7.4.5. Environmental Services has the responsibility to train individuals involved with managing the sharp waste containers, educate the staff regarding what containers are acceptable and to ensure that they are properly sealed and labeled. The sharp waste will be disposed in yellow container with a phrase" sharp waste only" (Arabic & English) with Biohazard logo.
7.4.6. Pharmaceutical waste (medications and vaccines) are wastes resulting from preventive, therapeutic activities, or from production and preparation of pharmaceutical products, and medications including expired drugs must be disposed in leak proof containers under the Environmental Services Supervision.
7.4.7. Compressed gas cylinders'/containers wastes, must be handled and disposed only by experienced and properly instructed personnel. Information on the chemical nature of the materials and the appropriate response necessary in the event of the fire, leak or spill must be available and provided by Environmental Services in coordination with the Safety and Security.
7.5.1. All hazardous materials are receiving in the department by appropriate staff and stored in a designated supply closet for chemicals only. Chemicals are properly label with a description of the hazard they represent.
7.5.2. Exposure to hazardous materials shall be minimized through primary prevention measures, such as engineering controls, administrative controls and personal protective equipment (PPE).
7.5.3. Materials, which ignite easily under normal condition (flammable), are consider fire hazards and will be stored in a cool, dry, well-ventilated storage space, away from areas of fire hazard.
7.5.4. Highly flammable materials will be kept in an area separate from oxidizing agents (material susceptible to spontaneous heating, explosives etc.).
7.5.5. The storage area for flammables should be equipped with firefighting equipment either automatic or manual. There will be "flammable material" signs posted in and around the storage area.
7.5.6. Oxidizers will not be stored close to liquids of low flash point. E.g. Oxygen
7.5.7. Acids and acid-fume-sensitive materials will be stored in a cool dry well-ventilated area, preferably wooden.
7.5.8. Materials which are toxic or which can decompose into toxic components from contact with heat, moisture, acids or acid fumes will be stored in a cool, well ventilated place out of the direct rays of the sun. Incompatible toxic materials will be isolated from each other.
7.5.9. Corrosive materials will be stored in a cool, well-ventilated area (above their freeze point). The containers will be inspected at regular intervals to ensure they are labeled and kept closed. Corrosives will be isolated from other materials.
7.5.10. Environmental Services assesses each department's workplace to determine if hazards are present, or likely to be present1 in order to identify areas and work activities where personal protective equipment should be used. All purchase requests for PPE must be forwarded to Safety & Security Department prior to purchasing the equipment.
7.5.11. There is a list of approved storage areas for hazardous materials and waste describing their location and features kept in the Environmental Services (Purchasing Department, Safety & Security).
7.6.1. Environmental Services and Safety & Security Section are responsible for the training of staff involved in the use and transport of compressed gas in the proper handling of cylinders, cylinder trucks and supports and cylinder valve protection caps. All cylinder storage areas, outside and inside, shall be protected from extremes of heat, cold and from access by unauthorized individuals.
7.6.2. Regular visual inspections of compressed gas cylinders are performed to ensure cylinders are in safe condition.
7.6.3. All pressure relief safety devices must meet the local and international safety standard such as the Compressed Gas Association (CGA) requirements and Civil Defense Regulations.
7.6.4. Storage areas for gaseous and liquefied hydrogen systems must be well ventilated. Storage of oxygen will be kept away from electric power lines, flammable or liquid gases, ignition sources, flammable and combustible materials and populated areas. Oxygen storage is located in outside and isolated area next to Service Entry.
7.6.5. Oxygen cylinders must be stored a minimum of 20 feet (6 meters) apart from Fuel-gas cylinders or combustible materials.
7.6.6. Oxygen equipment must not come in contact with any form of grease or oil.
7.6.7. Storage of up to 300 cubic feet (91.44 cubic meters) of oxygen (up to 12 "E'' sized cylinders) is permitted without regulation.
7.6.8. The requirements below apply to the storage of more than 300, but less than 3000 cubic feet (914.4 cubic meters) of oxygen:
7.6.9. The requirements below apply to the storage of more than 3,000 Cubic Feet (914.4 cubic meters):
7.7.1. The Environmental Services shall investigate all hazardous materials and waste spills and exposure. The incident report will be reviewed and studied to determine the cause of the incident.
7.7.2. The Environmental Services will make recommendations to the Management to prevent the reoccurrence of related incidents as well as Environmental Services will provide the department will meet the departments' demand in terms of spill kits.
7.8.1. If a leak or spill is found, the following actions shall be taken:
7.9.1. Management has to determine/identify quantity generator of hazardous waste. Hazardous/medical waste generated does not exceed determined parameters. Hazardous waste generation will be tracked, controlled and managed according to related local and international regulations.
7.9.2. Medical waste is picked-up once per day or per request by a licensed medical waste hauler and is taken to a certified off-site medical waste treatment facility for treatment and disposal in accordance with federal and state laws.
7.9.3. Required manifests for hazardous materials and waste are maintained.
7.9.4. A component of the management and disposition of hazardous wastes is the removal of these materials from the point of generation to a specified treatment, storage or disposal facility.
7.9.5. Records will be maintained, with copy of completed documents to Environmental Services identifying the generator, submitted quantity, types and disposal action of the hazardous material or waste.
7.9.6. The Environmental Services will maintain hazardous waste manifests. They are the responsible for maintaining all documents; including tracking records (submitted by Housekeeping, The hauler certificate of treatment or disposal for all hazardous materials removed from the facility for a minimum of five (5) years.
7.9.7. The Environmental Services is responsible for maintaining documentation including tracking records and shipping documents for all medical waste removed from the facility.
7.9.8. Both hazardous and medical waste records will be retained on file according to law for a period of five (5) years by the Environmental Services.
7.10.1. Containers of hazardous chemicals must be labeled by the chemical manufacturer, importer or distributor with the following information prior to leaving the workplace:
7.10.2. Labels must be legible and prominently displayed on the container.
7.10.3. Labels and other forms of warnings are legible in English and pre- dominate second language of staff, if applicable.
7.11.1. All hazardous medical waste will be segregated and contained separately from other waste at the point of generation. Environmental Services and the related department is responsible for ensuring there is appropriate separation and the waste is placed in properly constructed and labeled containers.
7.11.2. Trained housekeeping staff will utilize rigid containers to transport bio-hazardous waste bags from the various departments. All containers will be labeled with the universal biohazard symbol. Trained housekeeping staff will wear the appropriate personal protective equipment when handling and transporting bio hazardous waste.
7.11.3. The designated Supervisor will inspect hazardous medical waste holding areas on a daily basis. Any deficiencies found will be documented and prompt action will be taken to address any handling, segregation and containment or storage issues. Monthly rounds will be made by the Environmental Services to ensure compliance.
7.12.1. It is the responsibly of the related Departments such as Safety and Security Maintenance, Infection Control, Purchasing and others whom are signing agreement, approvals and contracts to ensure that contractors and other entities are aware of the Teamone Hazardous Materials and Waste Management plan, attend hazard communication orientation and comply with the aspect of this plan.
7.13.1. There is a planned, systematic, interdisciplinary approach to process design and performance measurement, analysis and improvement related to organization wide hazardous materials and waste management. The Management will develop and establish performance measures and related outcomes, in a collaborative fashion, based on those priority issues known to be associated with the healthcare environment. Performance measures and outcomes will be prioritized based upon high-risk; high volume, problem-prone situations and potential or actual sentinel event related occurrences. Criteria for performance improvement measurement and outcome indicator selection will be based on the following:
7.13.2. The Management monitors performance regarding actual or potential risk related to one or more of the following:
7.13.3. Based on the criterion listed above, will establish other performance measures and outcomes. The Environmental Services will determine data sources, frequency of data collection, individual responsible for data collection, aggregation and reporting.
7.13.4. Performance improvement monitoring and outcome activities will be presented to the Management by the Environmental Services at least on a quarterly basis, with a report of performance outcome forwarded to the CEO quarterly.
7.13.5. The following is the Key Performance Indicator:
An Orientation and Education Program for employees who manage or have contact with hazardous materials and wastes is in place:
8.1. All persons required managing or handling hazardous chemicals, materials or waste will be provided with appropriate orientation, personal protective equipment and on-the-job training. The Environmental Services is responsible for training each individual handling hazardous materials and waste. A master file of the training records will be kept in the Environmental Services, user departments for the employee's annual review and a copy will be kept in the Human Resources Department.
8.2. Employee orientation and education shall include the following;
8.2.1. Identification of the hazardous materials in their workplace and the health hazards associated these materials.
8.3. The employee will be in-serviced on the location of the following:
8.4. SDS
8.5. Retraining will be done annually and wherever the hazard changes of a new hazards is introduced to the environment.
8.6. The department manager will evaluate the effectiveness of all staff training, and additional training will be supplied to the employee if he/she does not the required level of competence.
8.7. Mass media such as signs and posters will be used to educate the public such as visitors and families on the importance of health care waste management, the coding system and what type of waste is to be placed in a particular type of bags and containers.
N/A
Annual evaluation of the Hazardous Materials and Waste Plan's Objectives, Scope, Performance and Effectiveness:
10.1. The annual evaluation of the Hazardous Materials and Waste Management Program will include a review of the scope according to the current local and international regulations to evaluate the degree in which the program meets accreditation standards and the current risk assessment of the hospital.
10.2. A comparison of the expectations and actual results of the program will be evaluated to determine if the goals and objectives of the program were met. The overall performance of the program will be reviewed by evaluating the results of performance improvement outcomes. The overall effectiveness of the program will be evaluated by determining the degree that expectations were met.
10.3. The Management and Administration shall review the performance and effectiveness of the Hazardous Materials and Waste Management Program.
10.4. The Environmental Services, with approval from the Management, will incorporate changes in the plan into an updated Hazardous Materials and Waste Management Plan.