1. Joven Botin Bilbao, RN, MAN
Deputy Chief Nurse Officer
Clinical and Accreditation Educator

2. The Chapter Addresses 9 Topics
1. Leadership and Planning,
2. Safety and Security,
3. Hazardous Materials,
4. Disaster Preparedness,
5. Fire Safety,
6. Medical Technology,
7. Utility Systems,
8. Facility Management Program
Monitoring,
9. Staff Education.

3. Leadership and Planning

4. • Hospital leadership, including governance and senior
management, are responsible for knowing what national
and local laws, regulations, and other requirements
apply to the hospital’s facilities; implementing the
applicable requirements or approved alternative
requirements; and planning and budgeting for the
necessary upgrading or replacement as identified by
monitoring data or to meet applicable requirements and
providing evidence of progress toward implementing the
improvements.
• When the hospital has been cited for not meeting
requirements, hospital leadership takes responsibility for
planning for and meeting the requirements in the
prescribed time frame.

5. • To manage the risks within the environment in which patients are treated
and staff work requires planning.
• The hospital develops one master program or individual programs that
include;
a. Safety and Security Safety—the degree to which the hospital’s
buildings, grounds, and equipment do not pose a hazard or risk to
patients, staff, and visitors Security—Protection from loss, destruction,
tampering, or unauthorized access or use;
b. Hazardous materials—Handling, storage, and use of radioactive and
other materials are controlled, and hazardous waste is safely disposed;
c. Emergencies—Response to epidemics, disasters, and emergencies is
planned and effective;
d. Fire safety—Property and occupants are protected from fire and smoke;
e. Medical technology—Technology is selected, maintained, and used in
a manner to reduce risks;
f. Utility systems—Electrical, water, and other utility systems are
maintained to minimize the risks of operating failures.

6. Program oversight includes:
a.planning all aspects of the program, such as development of
plans and providing recommendations for space, technology,
and resources;
b.implementing the program;
c. educating staff;
d. testing and monitoring the program;
e. periodically reviewing and revising the program; and
f. providing annual reports to the governing body on the
effectiveness of the program.
Depending on the hospital’s size and complexity, a
facility/environment risk committee may be formed and given
responsibility for overseeing the program and program continuity.

7. Safety and Security

8. • Safety refers to ensuring that the building, property, medical
and information technology, equipment, and systems do not
pose a physical risk to patients, families, staff, and visitors.
Security, on the other hand, refers to protecting the
organization’s property and the patients, families, visitors, and
staff from harm. Prevention and planning are essential to
creating a safe and supportive patient care facility. Effective
planning requires the hospital to be aware of all the risks
present in the facility.
• The goal is to prevent accidents and injuries; to maintain safe
and secure conditions for patients, families, staff, and visitors;
and to reduce and to control hazards and risks. This is also
important during periods of construction or renovation.

9. • As part of the safety program, the hospital develops and
implements a comprehensive, proactive risk assessment to
identify areas in which the potential for injury exist. Examples
of safety risks that pose a potential for injury or harm include
sharp and broken furniture, linen chutes that do not close
properly, broken windows, water leaks in the ceiling, and
locations where there is no escape from fire.
• Construction and renovation pose additional risks to the
safety of patients, families, visitors, and staff, and include risk
related to infection control, ventilation, traffic flow,
garbage/refuse, and other risks. A pre-construction risk
assessment is helpful in identifying these potential risks, as
well as the impact of the construction project on services
provided. The risk assessment should be performed during all
phases of construction.

10. • In addition to the safety program, the hospital must have a
security program to ensure that everyone in the hospital is
protected from personal harm and from loss or damage to
property. Staff, vendors, and others identified by the hospital,
such as volunteers or contract workers, are identified by
badges (temporary or permanent) or other form of
identification. Others, such as families or visitors in the
hospital, may be identified depending on hospital policy and
laws and regulations.
• Restricted areas such as the newborn nursery and the
operating theatre must be secure and monitored. Children,
elderly adults, and other vulnerable patients unable to protect
themselves or signal for help must be protected from harm.
In addition, remote or isolated areas of the facility and
grounds may require the use of security cameras.

11. Hazardous Materials

12. • A hazardous materials program is in place that includes identifying and safely
controlling hazardous materials and waste throughout the facility. World Health
Organization (WHO) identifies hazardous materials and waste by the following
categories:
a. Infectious waste;
b. Pathological and anatomical waste;
c. Hazardous pharmaceutical waste;
d. Hazardous chemical waste;
e. Waste with a high content of heavy metals;
f. Pressurized containers;
g. Sharps;
h. Highly infectious waste;
i. Genotoxic/cytotoxic waste; and
j. Radioactive waste.
The hospital considers these categories identified by WHO when developing an
inventory of hazardous materials and waste.

13. • Documentation of this search should include information
about the locations, types, and quantities of hazardous
materials and waste being stored and should be updated
when the location, storage, type, and quantities of hazardous
materials has changed.
• The hazardous materials program includes processes for the
inventory of hazardous materials and waste that includes the
material, the quantity, and the location; handling, storage,
and use of hazardous materials; proper protective equipment
and procedures during use, spill, or exposure; proper labeling
of hazardous materials and waste; reporting and investigation
of spills, exposures, and other incidents; proper disposal of
hazardous waste; and documentation, including any permits,
licenses, or other regulatory requirements.

14. • Information regarding procedures for handling or working
with hazardous materials in a safe manner must be
immediately available at all times and includes
information about the physical data of the material (such
as its boiling point, flash point, and the like), its toxicity,
what effects using the hazardous material may have on
health, identification of proper storage and disposal after
use, the type of protective equipment required during
use, and spill-handling procedures, which include the
required first aid for any type of exposure. Many
manufacturers provide this information in the form of
Material Safety Data Sheets (MSDS).

15. Disaster Preparedness:

16. • The development of the program should begin by identifying the types of
disasters that are likely to occur in the hospital’s region and what the
impact of these disasters would have on the hospital.
• The program provides processes for:
a. determining the type, likelihood, and consequences of hazards, threats,
and events;
b. determining the hospital’s role in such events;
c. communication strategies for events;
d. the managing of resources during events, including alternative sources;
e. the managing of clinical activities during an event, including alternative
care sites;
f. the identification and assignment of staff roles and responsibilities during
an event; and
g. the process to manage emergencies when personal responsibilities of
staff conflict with the hospital’s responsibility for providing patient care.

17. • The disaster preparedness program is tested by an
annual test of the full program internally or as part of a
communitywide test; or testing of critical elements c)
through g) of the program during the year. If the hospital
experiences an actual disaster, activates its program,
and debriefs properly afterward, this situation represents
the equivalent to an annual test.

18. Fire Safety:

19. • A hospital establishes a program in particular for the prevention of fires
through the reduction of risks, such as safe storage and handling of
potentially flammable materials, including flammable medical gases such
as oxygen; hazards related to any construction in or adjacent to the patient-
occupied buildings; safe and unobstructed means of exit in the event of a
fire; early warning, early detection systems, such as smoke detectors, fire
alarms, and fire patrols; and suppression mechanisms, such as water
hoses, chemical suppressants, or sprinkler systems.
• The hospital’s fire safety program identifies the frequency of inspecting,
testing, and maintaining fire protection and safety systems, consistent with
requirements; the program for safely evacuating the facility in the event of a
fire or smoke; the process for testing all portions of the program during
each 12-month period; the necessary education of staff to effectively
protect and to evacuate patients when an emergency occurs; and the
participation of staff members in at least one fire safety test per year.

20. Medical Technology:

21. • To ensure that medical technology is available for use
and functioning properly, the hospital performs and
documents an inventory of medical technology; regular
inspections of medical technology; testing of medical
technology according to its use and manufacturers’
requirements; and performance of preventive
maintenance. Qualified individuals provide these
services.
• Medical technology is inspected and tested when new
and then on an ongoing basis, according to the
technology’s age, use, and manufacturers’ instructions.
Inspections, testing results, and any maintenance are
documented.

22. • The hospital has a system in place for monitoring and
acting on medical technology hazard notices, recalls,
reportable incidents, problems, and failures sent by the
manufacturer, supplier, or regulatory agency. Some
countries require reporting of any medical technology
that has been involved in a death, serious injury or
illness.
• Hospitals must identify and comply with the laws and
regulations pertaining to reporting of medical technology
incidents. The medical technology management program
addresses the use of any medical technology with a
reported problem or failure, or that is the subject of a
hazard notice or is under recall.

23. Utility Systems:

24. • Utilities can be defined as the systems and equipment that
support essential services that provide for safe health care.
Such systems include electrical distribution, water, ventilation
and airflow, medical gases, plumbing, heating, waste, and
communication and data systems. Effective utility function
throughout the hospital creates the patient care environment.
• A good utilities management program ensures the reliability of
the utility systems and minimizes the potential risks. For
example, waste contamination in food-preparation areas,
inadequate ventilation in the clinical laboratory, oxygen cylinders
that are not secured when stored, leaking oxygen lines, and
frayed electrical lines all pose hazards.

25. • To avoid these and other hazards, the hospital has a process
for regularly inspecting such systems and performing
preventive and other maintenance. During testing, attention is
paid to the critical components (for example, switches and
relays) of systems. Hospitals should have a complete
inventory of all utility systems components and identify which
components have the greatest impact on life support, infection
control, environmental support, and communication.
• The utility management program includes strategies for utility
maintenance that ensure that these key systems components,
such as electric, water, waste, ventilation, and medical gas,
are regularly inspected, maintained, and, when necessary,
improved. Patient care, both routine and urgent, is provided
on a 24-hour basis, every day of the week in a hospital.

26. • The hospital establishes and implements a program to
ensure that all utility systems operate effectively and
efficiently.
• Utility systems are inspected, maintained, and improved.
• The hospital utility systems program ensures that
potable water and electrical power are available at all
times and establishes and implements alternative
sources of water and power during system disruption,
contamination, or failure.
• The hospital tests its emergency water and electrical
systems and documents the results.
• Designated individuals or authorities monitor water
quality regularly.

27. Facility Management Program
Monitoring:

28. • Monitoring each of the facility management programs
through data collection and analysis provides information
that helps the hospital prevent problems, reduce risks,
make decisions on system improvements, and plan for
upgrading or replacing medical technology, equipment,
and utility systems. The monitoring requirements for the
facility management programs are coordinated with the
requirements. Monitoring data are documented and
quarterly reports are provided to hospital leadership.

29. Staff Education:

30. • Staff are the hospital’s primary source of contact with patients,
families, and visitors. Thus, they need to be educated and trained
to carry out their roles in identifying and reducing risks, protecting
others and themselves, and creating a safe and secure facility.
• The program can include group instruction, printed educational
materials, a component of new staff orientation, or some other
mechanism that meets the hospital’s needs.
• The program includes instruction on the processes for reporting
potential risks, reporting incidents and injuries, and handling
hazardous and other materials that pose risks to themselves and
others.
• Staff responsible for operating or maintaining medical technology
receive special training. The training can be from the hospital, the
manufacturer of the technology, or some other knowledgeable
source.

31. • The hospital plans a program designed to periodically test staff
knowledge on emergency procedures, including fire safety
procedures; the response to hazards, such as the spill of a
hazardous material; and the use of medical technology that
poses a risk to patients and staff. Knowledge can be tested
through a variety of means, such as individual or group
demonstrations, the staging of mock events such as an epidemic
in the community, the use of written or computer tests, or other
means suitable to the knowledge being tested. The hospital
documents who was tested and the results of the testing.