MSQH 4th Edition: Standard 2- Environment and Safety Services Survey Questionnaires

Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013

Service Std 2: Environmental and Safety Services

SERVICE STANDARD 2: Environmental and Safety Services

Standard No. Survey Item Hospital Rating

Surveyor Rating

2.1

ORGANISATION AND MANAGEMENT

2.1.1

Each activity is organised and administered to provide optimum support to the goals, objectives and values of the Facility and to meet the needs of the Facility, patients, staff and visitors.

2.1.1.1

Based on the complexity of the facilities, there are designated

committees on safety, health and environment issues with

clearly defined:

Appointment of a Chairperson

Terms of Reference

Committee members

Tenure of membership

Frequency of meetings

2.1.1.2

Each designated committee ensures and documents the

following:

a) action plans indicating the persons responsible;

b) activities with input from patients, community, medical

practitioners, service staff, and in consultation with other

relevant services;

c) monitoring and compliance with Terms of Reference;

d) practice is consistent with professional standards,

guidelines and relevant legislation;

e) review and revise action plans as required, signed and

dated accordingly.

2.1.1.3

There is an organisation chart which:

a) represents the structure, function and reporting

relationships between the Person In Charge (PIC) and the

staff of the Environmental and Safety Services;




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b) is accessible to all staff;

c) includes off-site services if applicable;

d) is revised when there is a major change in any of the

following:

organisation;

functions;

reporting relationships;

goals and objectives;

staffing patterns.

2.1.1.4

Regular committee meetings are held to discuss issues and

matters pertaining to the operations of the Environmental and

Safety Services and minutes are available and made accessible

to relevant staff.

2.1.1.5

There is documented evidence that where more than one

committee have interests in the issues of the Environmental

and Safety Services:

a) There is clear committee structure that shows line of

reporting.

b) There is coordination of the actions undertaken or

proposed by the committees.

c) Records are kept on actions taken to identify and correct

the cause of any problem.

2.1.1.6

The Head of Environmental and Safety Services is involved in

the planning, management and justification of the budget and

resource utilisation of the services.

2.1.1.7

The Head of the Environmental and Safety Services ensures

that the staff of Environmental and Safety Services complete

incident reports with evidence that these are discussed by the

services with learning objectives. These reports are forwarded

to the Person In Charge (PIC) of the Facility.




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2.1.1.8

There is documented evidence that Root Cause Analysis of all

incidents have been done and action taken to prevent

recurrence.

2.1.1.9

There are appropriate statistics and records maintained on the

provision of Environmental and Safety Services and there is

evidence that these are used for managing the services and

patient care purposes.

2.1.1.10

Where services are provided by an external source, there is a

written agreement between the external service provider and the

Facility stating the requirements for service delivery, including the

following:

a) formal lines of communication and responsibilities between

the external service provider and the Facility;

b) provision of adequate numbers of appropriately qualified

personnel to perform their duties;

c) participation, as appropriate, of the external service

provider in committees of the Facility;

d) arrangement for adequate pick up and delivery;

e) arrangements for after-hours and emergency services;

f) mechanisms for dealing with problems in service delivery;

g) adequate facilities and equipment for providing the

services at the Facility and at the site of the external

service;

h) involvement of the external service provider in safety and

quality improvement activities of the Facility, as

appropriate;

i) comply with the appropriate MSQH Standards of

Accreditation for Environmental and Safety Services.




Surveyor Rating

2.2

HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

2.2.1

The Environmental and Safety Services are directed by and staffed with adequate numbers of appropriately qualified staff as required under relevant regulations and statutory requirements to achieve the objectives of the services.

2.2.1.1

The Head and staff of each service fulfil the educational

qualification, training, experience and certification required to

meet the demands of the various positions and to achieve the

objectives of the services. These requirements are documented.

2.2.1.2

The Head of Environmental and Safety Services has a letter of

appointment which delineates the authority, responsibilities and

accountabilities of the position.

2.2.1.3

The number of personnel and support staff with the appropriate

qualifications employed are sufficient to enable the services to

meet the documented purposes.

2.2.1.4

There is evidence that a structured orientation programme

where new staff are briefed on their services, operational

policies and relevant aspects of the Facility to prepare them for

their roles and responsibilities has been implemented.

2.2.1.5

There is documented evidence of implementation of a staff

development plan which provides the knowledge and skills

required for staff to maintain competency in their current

positions as the demands of the positions evolve.

2.2.1.6

There are continuing education activities for staff to pursue

professional interests and to prepare for current and future

changes in practice as evidenced by:

a) Records on staff education and development needs being

appraised and identified are available.

b) Records on continuing education activities for staff are

available.




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c) A programme for on-the-job training, in-service education,

and continuing education for all staff appropriate to their

work has been implemented. These should include:

i) additional training to staff in the execution of

procedures unique to special areas, such as the

operating rooms, obstetrical units, emergency

services, special care units, and isolation rooms;

ii) instructions on environmental control in the

prevention of healthcare associated infections and

the roles of the employee in this control;

iii) safety measures in hazardous areas such as the

central sterilising supply services, operating

theatres, kitchens, workshops, laundry, laboratories,

and radiation emission areas.




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2.3

POLICIES AND PROCEDURES

2.3.1

Documented policies and procedures reflect the current

knowledge and practice of Environmental and Safety

Services, and they are consistent with the objectives of

each service and relevant regulations and statutory

requirements.

2.3.1.1

There is an Environmental, Health and Safety Policy statement

that is displayed throughout the hospital. There are documented

specific policies and procedures to support the Environmental,

Health and Safety Policy statement.

2.3.1.2

There is documented evidence that policies and procedures are

developed in collaboration with staff, medical practitioners,

Management and where required with other external service

providers and with reference to relevant sources involved.

2.3.1.3

Policies and procedures are dated, authorised, signed and

reviewed at least once every three years and revised as

required.

2.3.1.4

There is evidence of staff acknowledgement that policies and

procedures including new and revised ones are communicated

to all staff.

2.3.1.5

There is evidence of compliance with policies and procedures.

2.3.1.6

Copies of policies and procedures, relevant Acts, Regulations,

By-Laws and statutory requirements are accessible to staff.

2.3.1.7

Current reference manuals, pamphlets, journals, and books as

well as information and scientific data from manufacturers

concerning their products are readily available for reference and

guidance.




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2.4

FACILITIES AND EQUIPMENT

2.4.1

Adequate facilities and equipment are available to enable

the Environmental and Safety Services to meet its goals,

objectives and ensure safety.

2.4.1.1

There is adequate and proper utilisation of space and

equipment to enable staff to carry out their professional and

administrative functions.

2.4.1.2

There is documented evidence that equipment complies with

relevant national/international standards, e.g. those set by

SIRIM Berhad (Standards and Industrial Research Institute of

Malaysia) and current statutory requirements.

2.4.1.3

There is evidence that the Facility has a comprehensive

maintenance programme such as predictive maintenance,

planned preventive maintenance and calibration activities, to

ensure the facilities and equipment are in good working order.

The maintenance programme and budget are reviewed.

2.4.1.4

There is evidence that specialised equipment is operated by

staff with appropriate qualification and privileged by the Facility.

2.4.1.5

There is evidence that provisions are made for the personal

comfort of staff and patient. This includes:

clean and hygienic facilities;

room temperatures are kept at comfortable levels and

adequately ventilated;

steps taken for reduction of noise in patient and staff work

areas.




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2.5

SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

2.5.1

The Head responsible for environmental and safety

activities ensures the provision of quality performance with

staff involvement in the continuous safety and quality

improvement activities of the Services.

2.5.1.1

There is evidence that the Head of the Service has in a written

document assigned responsibilities to appropriate

individuals/committees for safety and quality improvement

activities within the services.

2.5.1.2

There are documented plans for systematic safety and quality

improvement activities that include:

a) Planned activities

b) Data collection

c) Monitoring and evaluation of the performance

d) Action plan for improvement

e) Implementation of action plan

f) Re-evaluation for improvement

2.5.1.3

There are safety and quality improvement activities in place that

include tracking and trending of specific performance indicators

not limited to but at least two (2) of the following:

a) percentage of staff (includes all on-site outsourced service

providers) given orientation and training in Health and

Safety requirements

b) percentage of high level risks identified and corrected

2.5.1.4

There is evidence that feedback on results of safety and quality

improvement activities are regularly communicated to the staff.




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2.5.1.5

Records on safety and quality improvement activities are kept

and confidentiality of staff and patients is preserved.

2.5.1.6

There is documented evidence of safety and quality

improvement activities that address staff safety.




Surveyor Rating

2.6

SPECIAL REQUIREMENTS

2.6.1

Fire Safety

The Facility is constructed, equipped, operated and

maintained in a manner that ensures the safety of and

protects its patients, visitors, staff and property from fire.

2.6.1.1

Fire Safety : Building and Fire Alarm

a) There is evidence that all buildings comply with relevant

legislation relating to fire safety.

b) All fire alarm systems are integrated and linked to the

nearest fire station or fire station designated by fire

authorities.

2.6.1.2

There are documented reports of fire safety inspection by the

fire authorities (BOMBA) available. Fire inspection should be

performed within the last one year, and more recently in the

event of a major building renovation, development or service

alteration.

2.6.1.3

There is documented evidence of planned timetable for

compliance and implementation of recommendations made by

the fire authorities.

2.6.1.4

There is written evidence of approval from the appropriate

government and fire authorities for all new buildings, renovation

works and service alterations. Drawings and design calculations

to be endorsed by certified professional bodies.

2.6.1.5

There is evidence of automatic fire suppression systems (for

example, sprinkler, deluge or clean agent systems) installed

where required based on recommendations of the local fire

authority.

2.6.1.6

Fire fighting equipment (for example, fire extinguishers,

hydrants, hose reels, fire blankets) are located appropriately.




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2.6.1.7

Fire Safety : Systems and Equipment

a) All fire fighting systems and equipment are appropriate to

the type of fire most likely to occur in the area where they

are located;

b) There is documented evidence of regular testing and

maintenance of the systems being performed at least

annually.

2.6.1.8

There are approved fire detection and alarm systems (such as

smoke detectors or manual fire alarms) throughout the Facility

and are in working order.

2.6.1.9

There are clear signs for the location of fire fighting equipment.

„EXIT (KELUAR)‟ signs are prominently displayed at the main

corridors and exit doors in accordance with regulations.

2.6.1.10

There are adequate “No Smoking” signs displayed throughout

the Facility.

2.6.1.11

There are appropriate systems in the design and construction of

buildings to minimise the risk of the spread of fire and smoke.

(E.g. ventilation systems, compartmentalisation).

2.6.1.12

Doors to patient rooms and exit doors are not locked from the

inside except where specifically required (for example,

psychiatric units). In such cases, there are documented policies

and procedures to ensure adequate access and egress.

2.6.1.13

Fire Safety: Egress

a) There is adequate means of egress from all parts of the

building in compliance with requirements of local fire

authorities and building regulations.

b) There should be clear signs to indicate dead-end

corridors.




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2.6.1.14

Doorways, corridors, ramps, and stairways for egress in case of

fire are:

a) kept free of obstruction at all times;

b) wide enough for the evacuation of non-ambulatory

patients.

2.6.1.15

Fire and smoke doors which can be opened and closed

manually are kept closed at all times (no door stopper allowed)

except doors which are held open by electric hold-open devices

set to release upon activation of the fire detection system.

2.6.1.16

There is a letter of appointment for a designated fire safety

officer who is trained to be responsible for fire safety issues.

2.6.1.17

Fire Safety : Fire Evacuation Plan

a) Fire evacuation floor plan including assembly area

locations are displayed prominently in all areas.

b) The Facility has written fire emergency plans and

procedures which include:

i) the assignment of personnel to specific tasks and

responsibilities;

ii) instructions for the use of alarm systems and

signals;

iii) information concerning methods of fire containment;

iv) information concerning the location of fire fighting

equipment;

v) systems for notification of appropriate persons;

vi) specification of evacuation routes, assembly points,

and procedures;

vii) other provisions as the local situation dictates;

viii) emergency resuscitation e.g. Code Blue (adults),

Code Pink (children).

2.6.1.18

Fire Safety : Fire Drills

a) There are written reports on fire drills held regularly to

accommodate staff working at different times (day/night)




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and under varied conditions. These reports include

evaluations on all drills, and documentation of staff

attendances.

b) The drills ensure:

i) all staff are trained in fire procedures including fire

alarm or notification procedures, and are familiar

with the use and operation of the fire fighting

equipment available;

ii) all staff are aware of the method and route of

evacuation from their area;

iii) designated staff are trained to physically evacuate

non-ambulant patients;

iv) there is a written plan available throughout the

Facility detailing action to be taken in the event of

patients having to be moved.




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2.6.2

Safety Programmes

The management of the Facility promotes occupational

safety and health programmes that ensure a safe and

healthy environment for patients, staff and visitors.

2.6.2.1

Safety Programmes: Committee

a) There is a multidisciplinary committee(s) formed for the

purpose of implementing and maintaining a

comprehensive safety programme for patients, staff and

visitors and for monitoring and reporting on occupational

health matters.

b) Minutes of these committee meetings are available and

decisions made are implemented.

c) In a small Facility, safety matters may be dealt with as

items on the agenda in a committee whose terms of

reference encompass various aspects of safety and

patient care.

2.6.2.2

There is documented evidence that programmes for

occupational safety and health are being implemented in

accordance with statutory regulations.

2.6.2.3

There is documented evidence of planned safety activities that

monitor and evaluate the performance of safety programmes

which includes: a) reporting of activities as required by law and regulation;

b) conducting risk management activities such as risk

assessment, risk registration and risk prevention has been

implemented, monitored and evaluated. The evidence

includes:

i) Data collection

ii) Monitoring and evaluation of the performance

iii) Action plan for improvement

iv) Implementation of action plan

v) Re-evaluation for improvement




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2.6.2.4

There are reports on regular safety inspections to monitor

compliance to indoor air quality, health surveillance and

hazardous and chemical risk assessment requirements

according to the Safety Programme.

2.6.2.5

The designated safety officer who is trained has a letter of

appointment which clearly delineates his authority,

responsibilities and accountabilities for safety related activities

2.6.2.6

There is evidence that all staff are familiar with safety

programmes.

2.6.2.7

There are written environmental, occupational safety and health

policies and procedures and implemented throughout the

Facility.

2.6.2.8

There are written safety procedures specific to potentially

hazardous areas, and for hazardous substances (for example,

central sterilising supply services, food services areas,

laundries, laboratories, operating suites, radiation emission

areas, special units, and workshops) and implemented

throughout the Facility.

2.6.2.9

There is evidence that special safety measures in the form of

policies and procedures, facilities and equipment have been

implemented for hazardous areas in accordance with applicable

standards and the requirements of national and local statutory

authorities.

2.6.2.10

There is evidence that personal protective clothing and

equipment are provided where required, and their usage

monitored.

2.6.2.11

All portable gas cylinders are stored, restrained, and secured in

accordance with applicable standards and the requirements of

national and local statutory authorities. The requirements are:

a) Oxygen and flammable gases are stored separately from

each other.




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b) Storage areas are ventilated, built of non-combustible

material, and secured as appropriate.

c) All full gas cylinders are restrained and stored in an upright

position.

d) Flammable anaesthetic gases are not used in piped

systems.

e) Storage areas are appropriately sign posted including “No

Smoking” signs in accordance with statutory requirements.

2.6.2.12

There is provision of emergency suction apparatus and medical

gas supplies in key areas such as operating suites, special care

units, emergency services etc.

2.6.2.13

Safety Programmes: Power Supply

a) There is evidence that the Facility has provision for

alternative light and appropriate power supply in the event

of a failure of the local supply.

b) Uninterrupted power supply is provided for life support

systems, essential lights in operating theatres and rooms

for interventional procedures.

2.6.2.14

There is evidence that the Facility has equipped safety stores,

cold rooms and plant rooms with self-closing doors or safety

latches, where appropriate.

2.6.2.15

There are adequate signs which are clearly displayed,

prominently visible and easy to follow throughout the Facility.

2.6.2.16

There is evidence of implementation of policies on:

a) managing the motor vehicles provided for staff and patient

use;

b) proper maintenance documented in a log book;

c) competency of drivers with valid licences.




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2.6.2.17

There is documented evidence that levels of noise, smoke, foul

odour or dust are monitored and action taken to minimise if

excessive.




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2.6.3

Disaster Plan

The Facility has written plans to deal with internal and

external disasters. Plans are coordinated with statutory and

civil authorities as appropriate.

2.6.3.1

External Disaster Plans

There is evidence that the Facility has an external disaster plan

appropriate to its capabilities which has taken into consideration

the following:

a) The disaster plan is developed in consultation with

statutory and civil authorities, emergency services, and

representatives of other health service agencies. The plan

is to establish an effective chain of command, clarify

matters of jurisdiction, and coordinate the Facility‟s

activities with the activities of these agencies.

b) The scope of the Facility‟s roles and resources are made

known to the local police, fire brigades, the state

emergency services, ambulance teams, and the

community.

c) The disaster plan provides for:

i) consideration of the type of disasters likely to occur;

ii) effective communication systems within and outside

the Facility;

iii) availability of adequate basic utilities and supplies

including gas, water, electricity, food, and essential

medical and support materials;

iv) assignment of staff to specific tasks and

responsibilities;

v) an efficient system of notifying staff;

vi) defined authority and control;

vii) conversion of all appropriate spaces into clearly

defined areas for efficient triage, patient

observation, and immediate care;

viii) transportation arrangements when necessary for

prompt transfer of casualties to the Facility most

appropriate for administering definitive care, after

preliminary emergency medical or surgical services

have been rendered;




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ix) making available a list of casualties and

appropriately designed tags to accompany each

casualty;

x) arrangements for the prompt discharge or transfer

of current inpatients who can be moved without

harm;

xi) maintaining security in order to keep unauthorised

persons away from the triage area;

xii) some form of visual identification for staff involved in

the plan;

xiii) the establishment of a public information centre and

assignment of public relation duties to a suitable

person; a media communication plan will help to

provide organised dissemination of information;

xiv) debriefing and disaster plan review procedures.

d) The external disaster plan is tested for its capability at

least once a year in order to:

i) ensure that all staff are provided with training to

enable performance of assigned tasks;

ii) evaluate the effectiveness of the plan;

iii) evaluate and document the exercise;

iv) review and revise the plan as necessary.

e) The external disaster drill is preferably coordinated with

the participation of other community emergency services.

However, if this is not practicable, at least the local

aspects of the plan are rehearsed.

f) Drills involved the medical practitioners, administrative,

nursing, and other staff and external agencies as

appropriate.

g) Each department in the Facility is aware of its function.

2.6.3.2

Internal Disaster Plan

There is evidence that the Facility has an internal disaster plan

based on the type of internal disasters likely to occur and its

capabilities which has taken into consideration the following:

a) Plans for fire, internal disasters, and emergency situations

incorporating evacuation procedures are developed with




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the assistance of qualified fire, safety, and other

appropriate experts. Emergency situations may include

bomb threats, hostage taking, attempted suicides, drug

demand, provision of medical services in areas other than

wards (for example, kitchens, laundry, workshops),

explosion, and loss of vital services such as IT.

b) Plans include:

i) the assignment of personnel to specific tasks and

responsibilities;

ii) instructions for the use of alarm systems and

signals;

iii) information concerning methods of hazards

management, e.g. fire containment;

iv) information concerning the location of equipment,

e.g. fire fighting equipment;

v) systems for notification of appropriate persons;

vi) specification of evacuation routes, assembly points,

and contingency procedures;

vii) other provisions as the local situation dictates;

viii) emergency resuscitation e.g. Code Blue (adults),

Code Pink (children).

c) The internal disaster plan is tested for its capability at least

once a year in order to:

i) ensure that all staff are provided with training to

enable performance of assigned tasks;

ii) evaluate the effectiveness of the plan;

iii) evaluate and document the exercise;

iv) review and revise the plan as necessary.

d) Staff are familiar with disaster plans that are readily

available and displayed throughout the Facility.

2.6.4

Waste Disposal

Waste disposal is carried out in accordance with environmental, statutory and legislation requirements.

2.6.4.1

There is evidence that all types of waste (clinical, cytotoxic,

radioactive, spent oil etc) have been defined, identified and

labelled appropriately according to the Scheduled Waste

definitions.




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2.6.4.2

There is documented evidence that staff handling waste have

been trained on proper handling and disposal of the waste.

2.6.4.3

There is evidence that the process of segregation at the point of

origin of general waste and waste requiring special processing

has been implemented.

2.6.4.4

There is evidence that the labelling and disposal of all waste are

according to the relevant Acts.

2.6.4.5

There is evidence that the disposal of sharps is in accordance

with the requirements of relevant Acts. Needles are not

recapped.

2.6.4.6

Waste requiring special processing is handled safely including

the use of approved bags for contaminated waste, protective

clothing, and appropriate collection and storage facility prior to

incineration or removal from the site and a mechanism for

monitoring such handling.

2.6.4.7

There is evidence that the clinical waste storage room is

refrigerated if the waste is not removed for more than 24 hours.

2.6.4.8

There is evidence that there are dedicated transportation

vehicles for general waste and waste requiring special

processing from the point of origin to a central collection point.

2.6.4.9

There is documented evidence that general waste is removed

daily and the area is kept clean.




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2.6.5

Security Services

Security measures are taken to ensure the protection of

patients and staff from assault and loss of property; and the

Facility from damage and loss.

2.6.5.1

There is documented evidence of security risk assessment done

to identify potential security risk in the Facility.

2.6.5.2

There is evidence that appropriate security measures have

been implemented to ensure the protection of patients, staff and

visitors. These measures include:

a) control of access;

b) closed-circuit television (CCTV) monitoring;

c) key control;

d) alarm systems;

e) adequate lighting;

f) security protection for personal belongings, payroll, drugs,

and other assets of the Facility.



ENVIRONMENTAL AND SAFETY SERVICES

HOSPITAL COMMENTS

Std. No: __________




SURVEYOR COMMENTS

Std. No: __________




SURVEYOR RECOMMENDATIONS

Std. No: __________

MSQH 4th Edition: Standard 2- Environment and Safety Services Survey Questionnaires

Healthcare

Transcript of MSQH 4th Edition: Standard 2- Environment and Safety Services Survey Questionnaires