Facility Management and Safety (FMS)

Standard, Intents, and Measurable Elements SCORE ANALYSIS

Gap Action Plan PIC Due date
Leadership and Planning "10" "5" "0"
FMS.1 The hospital complies 1 Hospital leadership and those
with relevant laws, responsible for facility management
regulations, and facility know what laws, regulations and
inspection requirements other requirements apply to the
organization's facilities
2 The leaders implement the
applicable requirements or
approved alternatives
3 Hospital leadership ensure the
organization meets the conditions of
facility inspection report or citations
from infections by local authorities.

FMS.2 The hospital develops 1 There are written plan(s) that

and maintains a written address the risk area a) through f)
plan(s) describing the in the intent .
process to manage risks 2 The plan(s) are current and are fully
to patient, families, implemented.
visitors and staff. (P) 3 The hospital has a process to review
and update the program(s) when
changes in the hospital's
environment occur or at a
minimum, on annual basis.
4 When independent entities are
present within the patient care
facilities to be surveyed, the
hospital ensures thet the entities
comply with all aspects of the
facility management programs
identified in a) through d) of the
intent.
FMS.3 One or more qualified 1 Program oversight and direction are
individuals oversee the assigned to one or more individuals
planning and
implementation of the 2 The individual(s) is qualified by
program to manage the experience or training
risks in the care 3 The individual(s) is plans and
environment implements the program including
elements a) through g) of the intent
Safety and Security
FMS.4 The hospital plans and 1 The hospital has a program to
implements a program provide a safe and secure physical
to provide a safe facility
physical through 2 The hospital has a documented,
inspection and planning current, accurate inspection of its
to reduce risks. (P) physical facilities.
3 The program includes safety and
security during times of
construction and renovation and
implementing strategies to reduce
risks. ( Also see PCI 7.5)

FMS.4.1 The hospital plans and 1 The hospital plans and implements
implements program to program to provide a secure
provide a secure environement, including monitoring
environement for and securiing areas identified as
patients, families, staff, security risks
and visitors (P)

2 The program ensures that all staff,

contract workers, and vendors are
identified.

3 All scurity risk areas and restricted

areas are identified, documented,
monitored, and kept secure.

FMS.4.2 The hospital plans and 1 The organization plans and budgets
budgets for upgrading to meet applicable laws, regulation,
or replacing key and other requirements
systems, buildings, or
components based on
the facility inspection 2 The organization plans and budgets
and in keeping with law for upgrading, or replacing system,
and regulation. buildings or component needed for
the continued operation of a safe
and effective facility.

3 The hospital leadership applies the

budgeted resources to provide for a
safe and secure facility in
accordance with approved plans.
Hazardous Materials
FMS.5 The hospital has a plan 1 the hospital identifies the type,
for the inventory, location, and quantities of all
handling, storage and hazardous materials and waste and
use of hazardous has a complete and current
materials. (P) inventory of all such materials
within the hospital.
2 The program establishes and
implements safe handling, storage,
and use hazardous materials and
waste.
3 The program establishes and
implements the proper protective
equipment and procedures required
during use. (Also see AOP.6.3, ME
3)

4 The program establihes and

implements proper labeling
hazardous material and waste

5 The program established and

implements documentation
requirements including any permits,
licenses, or other regulatory
requirements.

FMS.5.1 The hopital has The program established and

1
program for the control
and disposal of
hazardous amterials
and waste. (P)
implements a reporting and
investigation mechanism for spills,
exposures, and other incidents.

2 The program established and

implements aprocedures for the
management of spills and
exposures, including the use of
proper protective equipment.

3 Information about the hazardous

material related to safe handling,
spill-handling procedures, and
procedures for managing exposures
are up to date and available at all
time.

4 The program established and

implements the disposal of
hazardous waste in a safe and legal
manner.
Disaster Preparedness
FMS.6 The hospital develops 1 The hospital has identified the
and maintains an major internal and external and
emergency external disasters and major
management program epidemic events which pose
to respond to significant risks of occurring, taking
emergencies, into consideration the hospital's
epidemics, and natural geografic location.
or other disasters that
have the potential of 2 The hospital identifies the probable
accuring within their impact that each type of disastere
community. (P) will have on all aspects of care and
services.
3 The hospital established and
implements a disaster program that
identifies its response to likely
disasters, including items a)
through g) in the intent.

4 The entire program, or at least

critical elements c) through g) of
the program, is tested annually.

5 The conclusion of every test,

debriefing of the test is conducted.

Fire safety
FMS.7 The hospital establihed 1 The hospital established and
and implements a implements a program to ensure
program for the that all occupants of the hospital's
prevention, early facilities are safe from fire, smoke,
detection, suppression, or other non-fire emergencies
abatement, and safe
exit from the facility in
response to fires and 2 The program includes the
nonfire emergencies. documented assessment of fire
risks, including when construction is
present in or adjacent to the
facility.
3 The program includes the early
detection of fire and smoke.

4 The program includes the

abatement of fire and containment
of smoke
5 The program includes the safe exit
from the facility when fire and non-
fire emergencies occur
FMS.7.1 The hospital regularly 1 All staff participate in at least one
tests its fire and smoke fire and smoke safety program test
safety plan, including per year. ( also see, FMS.11-FMS
any devices related to 11.2)
early detection and
suppression, and 2 Staff can demonstrate how to bring
documents the results. patients to safety.
(P)

3 Fire detection and abatement

equipment ans systems are
inspected, tested, and maintained
according to manufacturers'
recommendations.

4 Inspection, testing, and

maintenance of equipment and
systems are documented

FMS.7.2 Te fire safety program 1 The hospital safety program

includes limiting addresses eleminating or limiting
smoking by staff and smoking within hospital facility.
patients to designated
non-patient care areas 2 The program applies to patients,
of the facility. (P) families, visitors, and staff

3 the program identifies who may

grant patient exceptions for
smoking and when those exceptions
apply.
Medical Technology
FMS.8 The hospital establihed 1 The hospital establihed and
and implements a implements a medical technology
program for inspecting, program throughout the hospital.
testing, and maintaining 2 There is an inventory of all medical
medical equipment and technology
documenting the 3 Medical technology is inspected and
results. (P) tested when new and according to
age, use, and manufacturers'
recommendations thereafter.

4 The medical technology program

includes preventive maintenance.

5 Staff providing these services are

qualified and trained for the
services being provided.

FMS.8.1 The hospital has system 1 The hospital has system in place for
in place for monitoring monitoring and acting on medical
and acting on medical technology hazard notices, recalls,
technology hazard reportable incidents, problems, and
notices, recalls, faliure.
reportable incidents,
problems, and faliure. 2 When laws and regulations require,
(P) the hospital reports any deaths,
serious injuries, or illness that are a
result of medical technology.

3 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.
Utility Systems
FMS.9 The hospital established The hospital inventories its utility
and implements 1 systems components and maps the 5
program to ensure that distribution of them
all utility systems Cek dokumentasi & SAMRS
operate effectively and The hospital identifies, in writing,
effeciently. inspection and maintaince activities
for all operating components of
2 5
utility systems on the inventory

Cek dokumentasi & SAMRS

The hospital identifies, in writing, in
intervals for inspecting, testing, and
maintaining all operating
components of utility systems on
the inventory, based on criteria
3
such as manufacturers'
recommendations, risk levels, and
hospital experience

The hospital labels utility system

controls to facilitate partial or
4 complete emergency shutdowns.

Utility sistems are Utility systems and components are

inspected, maintained, 1 inspected based on hospital-
and improved. developed criteria.

Utility systems and components are

2
tested based on hospital criteria.
FMS.9.1 Utility systems and components are
3 maintained based on hospital
criteria.

Utility systems and components are

4
improved when necessary

FMS.9.2 The hospital utility 1 Potable water is available 24 hours

systems program a day, 7 days a week
ensure that potable
water and electrical 2 Electrical power is available 24
power are available at hours a day, 7 days a week
all times and
3 The hospital has identified the areas
established and
and services at greatest risk when
implements alternative
power fails or water is contaminated
sources of water and
or interrupted.
power during system
distruption, 4 The hospital seek to reduce the
contamination, or risks of such events.
failure.
5 The hospital plan alternative
sources of power and water in
emergencies.
FMS.9.2.1 The hospital test its 1 The hospital test alternative sources
emergency water or of water quarterly or more
electrical system and frekuently if required by local laws
documents the result. and regulations or conditions of the
source of water.

2 The hospital documents the results

of such tests.

3 The hospital test alternative sources

of electricity quarterly or more
frekuently if required by local laws
and regulations, manufacturers'
recommendations, or conditions of
the source of electricity.

4 The hospital documents the results

of such tests.

5 When emergency resources of

FMS.9.3 Designed individuals or 1 water quality is monitored at least
outhorities monitor
water quality regulary
power require a fuel source, the
hospital established and has
available, the necessary amount of
on-site fuel stored.
quarterly or more frekuently based
on local laws and regulations or
conditions of the source of water,
and previous experience with water
quality problems. The monitoring is
documented.

2 Water used in renal dialysis is

tested and testing is documented
according to industry standards at
least quarterly or more frekuently
based on local laws and regulations
or conditions of the source of water,
and previous experience with water
quality problems.

3 Actions are taken and documented

when water quality is found to be
unsafe.
Facility Management Program Monitoring

FMS.10. The hospital collects 1 Monitoring data are collected and

and analyzes data from
each of the facility
management program
to support planning for
replacing or upgrading 2 Monitoring data are used to support
medical technology,
equipment, and
systems, and reducing
risks in the
environment.
analyzed for each of the facility
management programs
palning for replacing or upgrading
medical technology, equipment, and
systems, and reducing risks in the
environment

3 Report or monitoring data and

recommendations are provided to
hospital leadership on quarterly
basis.
Staff Education
FMS.11 The hospital educates, 1 Education is provided on an annual
trains, and test all staff basis for each component of the
about their roles in hospital's facility management and
providing a safe and safety program, to ensure that all
effective patient care staff on all shifts can effectively
facility carry out their responsibilities. (also
see AOP.5.3 ME 4 and AOP 6.3 ME
4)

2 The education includes visitors,

vendors, contract workers, and
others as identified by the hospital.

3 Staff knowledge is tested regarding

their role in each of the facility
management programs.
4 Training,testing and the resuls of
testing are documented for each
staff member.
FMS.11.1 Staff members are 1 Staff member can describe and/or
trained and demonstrate their role in response
knowledgeable about to a fire
their roles in the 2 Staff can describe and/or
hospital's programs for demonstrate actions to eliminate,
fire safety, scurity, minimize, or report safety, security,
hazardous materials, and other risks
and emergencies.
3 Staff can describe and /or
demonstrate precautions,
procedures and participation in the
storage, handling, and disposal of
medical gases, and hazardous
waste and materials.
4 Staff members can describe and/or
demonstrate procedures and their
role in internal and community
emergencies and disasters.
FMS.11.2 Staff are trained to 1 Staff are trained to operate medical
operate and to maintain technology according to their job
medical technology and requarments
utility systems.
2 Staff are trained to operate utility
systems according to their job
requirements
3 Staff are trained to maintain
medical technology according to
their job requarments
4 Staff are trained to maintain utility
systems according to their job
requirements

Total 880